Plastic Bodies by Emilia Sanabria

8/19/2019 Plastic Bodies by Emilia Sanabria

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P l a s t i c B o d i

e s

S e x

H o

r m o n

e s a n d

M e n s t r u a l S u p p r e s s i o n i n

B r

a z i l

E m i l i a

S a n a b r i a


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P L A S T I C

B O D I E S


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E X P E R I M E N TA L F U T U R E S

Technological Lives, Scientific Arts, Anthropological Voices

A series edited by Michael M. J. Fischer and Joseph Dumit

D U K E U N I V E R S I T Y P R E S S

Durham and London

2016


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PlasticBodies

SexHormones

and Menstrual

Suppression

in Brazil

Emilia

Sanabria


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© 2016 Duke University PressAll rights reserved

Printed in the United States o America on acid-free paper ♾Designed by Natalie F. Smith

ypeset in Quadraat Pro by seng Information Systems, Inc.

Library o Congress Cataloging-in-Publication DataNames: Sanabria, Emilia, [date] author.

itle: Plastic bodies : sex hormones and menstrualsuppression in Brazil / Emilia Sanabria.

Other titles: Experimental futures.Description: Durham : Duke University Press, 2016. |

Series: Experimental futures: technological lives,scientic arts, anthropological voices | Includes

bibliographical references and index.Identiers: 2015039926|

9780822361428 (hardcover : alk. paper) | 9780822361619 (pbk. : alk. paper) |

9780822374190 (e-book)Subjects: : Menstruation—Brazil—Salvador—Prevention. |Hormones, Sex. | Contraceptive drugs—Health aspects—Brazil—

Salvador. | Menstruation—Social aspects—Brazil—Salvador. |Menstrual regulation—Brazil—Salvador.

Classication: 263 . 263 2016 | 612.6/62098142—dc23

record available at http://lccn.loc.gov/2015039926

Cover art: David P. Wagner, Pill dispenser prototype fororal contraceptives, 1962. Metal, plastic, wood, ⁄ in. × 3 ⁄ in.Gift o David P. Wagner. Image courtesy o National Museum o

American History, Kenneth E. Behring Center.


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TO M Y M O T H E R


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C O N T E N T S

Acknowledgments ix

Introduction Plastic Bodies 1

1. Managing the Inside, Out Menstrual Blood and Bodily

Dys- Appearance 43

2. Is Menstruation Natural? Contemporary Rationales ofMenstrual Management 71

3. Sexing Hormones 105

4. Hormonal Biopolitics From Population Control to Self-Control

129

5. Sex Hormones

Making Drugs, Forging Efficacies 159

Conclusion Limits That Do Not Foreclose

187

Notes 207References 223

Index 241


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A C K N O W L E D G M E N T S

Tis book has been in the making for seven years. Its form has both enduredand evolved through the encounters that continue to shape my thinking.

Bringing it to completion has been a paradoxical process, one that—in a way—stands contra to its central thesis concerning the plasticity o things.

Its present form is enmeshed in a lively web o conversations for which I amdeeply grateful.

In Bahia, I was lucky to benet from the support o the Gender andHealth program ( ) at the Instituto de Saúde Coletiva () o the Fed-eral University o Bahia. Tanks in particular to Cecilia McCallum, EstelaAquino, Greice Menezes, Ana Paula dos Reis, Jorge Iriart, Jenny Araújo, and

Ulla Macêdo. Tanks also to João de Pina Cabral for transmitting his loveo ethnography; to Luisa Elvira Belaunde, Elena Calvo-Gonzalez, Silvia DeZordo, Luis Nicolau Parés, and Ana Regina Reis for the inspiring conversa-tions that helped shape this work; as well as to Rosário Gonçalves de Car-

valho, Míriam Rabelo, Cecília Sardenberg, Graciela Natansohn, and IleanaHodge. Tis work would not have been possible without the testimonieso the women who agreed to share their stories and insights with me, andI am deeply grateful for their generosity and openness. I am grateful for

the patience and interest shown by the sta in the di ferent medical andpharmaceutical sectors in which I was able to work, in particular,


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and , and to Flávio Costa Pereira and Mauro Bitencourt, as well asto the members o the Association o ravestis o Salvador. Josefa Pereirada Silva deserves special thanks, as does Dona Nancí for her stories. IvanaChastinet, Márcia Motta, Rose Rihan, Lise Silvany, Rose Silva, Rowney Scott,and the McCallum-eixeiras taught me about much more than Bahia, and Ithank them with all my heart for their friendship.

In the Department o Social Anthropology at the University o CambridgeI was lucky to benet from the support o Marilyn Strathern, who is an ex-ceptional teacher. I am deeply grateful for her patient guidance, care, andsupport. During my time in Cambridge I met wonderful scholars who wouldbecome dear friends, in particular, Charlotte Faircloth, Zeynep Gürtin, AnnKelly, Ashley Lebner, Ayesha Nathoo, and Signe Nipper Nielsen. My heart-felt thanks to them for their friendship. I am grateful for the institutionaland nancial support provided by King’s College Cambridge and the Eco-nomic and Social Research Council during my doctorate and the FyssenFoundation and the École des hautes études en sciences sociales ()during my postdoctorate at the Institut interdisciplinaire d’Anthropologiedu contemporain. At the École normale supérieure de Lyon, where I amnow based, Frédéric Le Marcis and Samuel Lézé have been wonderful inter-locutors. My thinking also owes much to the exchanges sustained with col-

leagues in the context o the Global Health: Anticipations, Infrastructures,Knowledge seminar at , Paris, as well as with colleagues o the edito-rial board oSciences sociales et santé .

Anita Hardon read multiple chapters and followed with astute questionsthat helped me sharpen my arguments in key places. Working with her andthe ChemicalYouth team at the Amsterdam Institute for Social Science Re-search has been a real pleasure and a marvelous opportunity to push mythinking about drugs and pharmaceutical efficacies further. I am particu-

larly grateful to Kaushik Sunder Rajan for his encouragement, kindness,and friendship and for helping me see more clearly the underlying logic othe book. My heartfelt thanks to Emily Yates-Doerr for her friendship, care,and unfailingly smart advice, as well as to Alex Edmonds for his encour-agement and for helping me clarify key ideas. I am grateful to the manypeople who read or listened and commented on versions o the chapters pre-sented here and with whom I exchanged ideas in the course o this project:Nathalie Bajos, Julien Barrier, Claire Beaudevin, Barbara Bodenhorn, Char-

lotte Brives, Maurice Cassier, Simon Cohn, Michèle Cros, Philippe Des-cola, Stefan Ecks, Sylvie Fainzang, Claude Fischler, Soroya Fleischer, Daniel


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Frandji, Sarah Franklin, Françoise Barbira-Freedman, Romain Garcier, Jean-Paul Gaudillière, Sahra Gibbon, Susan Golombok, Elena Gonzalez-Polledo,Françoise and Pierre Grenand, Miriam Grossi, Cori Hayden, Nick Hopwood,

Julia Hornberger, Stephen Hugh- Jones, Frédéric Keck, Guillaume Lachenal,Patricia Lambert, Anna Lavis, Nicolas Lechopier, Sabina Leonelli, IlanaLowy, Jonathan Mair, Daniela Manica, Daniel Miller, Annemarie Mol, Anne-Marie Moulin, Alex Nading, Haripriya Narasimhan, Yael Navaro-Yashin,Vinh-Kim Nguyen, Kristin Peterson, Maja Petrović-Šteger, EmmanuellePicard, Laurent Pordié, Marie-Christine Pouchelle, Fabiola Rohden, NickShapiro, Susan Leigh Star, Eduardo Viveiros de Castro, and Umut Yildirim.

Te insights, wisdom, teachings, and friendship o Bernadette Blin,Emilia Bucaretchi, Jan Day, Lily Defriend, Lucia Durante-Ringham, JosieFenton, and Roberta Rodriquez have been an invaluable source o supportand inspiration. I will never be able to thank my parents Laura Rival andEdgar Sanabria enough for enabling me to listen to and follow my heart. Iam lucky to count Francine Sanabria, Martin King, and Pierrette and DanielChartier as what, in French, we refer to asbeautiful parents, and I am deeplygrateful to them, as well as to my three wonderful sisters, Chloé Sanabria,Lison Sanabria, and Léa Rival, for their loving care and support. WithoutDenis Chartier’s love, wisdom, and boundless support I would not have been

able to write this book. I am so grateful to be walking this path by his side.Birthing and nurturing our daughter, Luce Isadora, helped me deepen myunderstanding o bodily plasticity. Te joy, light, and love she brings inspireme; I thank them both deeply for making the world so bright.

An earlier version o chapter 1 was published (in a di ferent form) as “TeBody Inside Out: Menstrual Management and Gynecological Practice in Bra-zil,”Social Analysis 55, no. 1 (2011): 94–112. An earlier version o chapter 3 was

published (in a di ferent form) in French as “Hormones et recongurationdes identités sexuelles au Brésil,” inClio. Femme, Genre et Histoire, no. 37 (2013):85–104. A shorter version o chapter 4 was published (in a di ferent form) as“FromSub- toSuper-Citizenship: Sex Hormones and the Body Politic in Bra-zil,”Ethnos 75, no. 4 (2010): 377–401. Small portions o an earlier version ochapter 5 were published in “‘Te Same Ting in a Di ferent Box’: Similarityand Di ference in Pharmaceutical Sex Hormone Consumption and Market-ing,”Medical Anthropology Quarterly 28, no. 4 (2014): 537–55.


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I N T R O D U C T I O N

P L A S T I C B O D I E S

In June 1975 theSan Francisco Chronicle and theSan Antonio Express ran articleson a young Brazilian scientist’s research on hormonal contraceptives. “I

have declared a war on menstruation,” Elsimar Coutinho, the Brazilian sci-entist, told theChronicle, “his dark eyes ashing.” Te press coverage ap-peared in the wake o a meeting o the World Health Organization ()task force on fertility regulation held in exas. Coutinho told theChronicle:“Before, we thought that lack o menstruation was a bad side e fect o thelong-term contraceptive pill. Now I consider it the main good e fect (sic).”Te Express reported that “he has patients in Brazil who have not had a men-strual cycle in 10 years.” Coutinho is a polemical and highly mediatized doc-

tor. Professor o human reproduction at the Federal University o Bahia’smedical school in Salvador da Bahia (in northeastern Brazil), and director oa private research center and clinic called (the Centre for Researchand Assistance in Human Reproduction), Coutinho derived much prestigefrom the international networks he partook in throughout the 1970s and1980s. Manica (2009) shows how he gained considerable local legitimacythrough his international connections with institutions such as the FordFoundation, Rockefeller Foundation, Population Council, and, while

opening up research hospitals (and their attending populations) in a stra-tegic region for these institutions interested in the “population problem.”


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For years, he appeared weekly on women’s television programs from wherehe professed advice about sexuality and family planning and found a uniqueplatform to air his provocative statements such as, “Menstruation is a use-less waste o blood” or “Eve did not menstruate.”

In 2005 I began eldwork in Salvador with the intent o studying therole that sex hormones play in contemporary social life. I gained access to

, where a wide array o di ferent hormonal regimens and treatmentscontinue to be administered to prevent unwanted pregnancies, suppressmenstruation, regulate moods, maintain youth, or assist reproduction.

is an atypical institution in the Bahian medical landscape, cateringsimultaneously—although in clearly di ferentiated spaces—to a clientele

with private health insurance while o fering a free, charitable family plan-ning service to the “poor.” On one o my rst days at , Dr. Paulo,one o the clinic’s directors, took me on a tour. We began downstairs in theambulatório (outpatient clinic), where a bustling crowd o women was wait-ing. “Tey come here from theperiferia [slums],” Dr. Paulo tells me. “We givethem high-qualityatendimento [care], entirely for free.” In the inrmary wemet the two nurses who weigh patients, apply the contraceptive injections,and “release” the drugs that the doctors have prescribed. An old-fashionedglass cabinet full o jumbled pill and hormonal injection boxes occupies

one wall, next to an imposing manually counterbalanced weighing scale.Faded advertisements for di ferent hormonal contraceptives representingtenderly embracing, white, fair-haired couples hang on the wall. A framedphotograph o a cesarean delivery sits on the desk next to a little gurine oa nurse holding a bottle labeledcarinho em gotas (care in drops). One o thenurses is drawing the air out o a syringe while joking with a young, high-heel-clad doctor. Dr. Paulo introduces me and they nod knowingly. We en-gage in small talk: Larissa, the nurse, tells us that menstruation isuma coisa

muito moderna (a very modern thing). Her grandmother only menstruatedthree times, she explains, her rst period came when she was eighteen, thenshe had seven children, and by the time she was done, she wasmenopausada (in menopause). “Just like as indias [indigenous women],” Dra Beatriz added,“they never menstruate either.”

Upstairs, functions as a state-of-the-art gynecological center, where women who subscribe to private health insurance are o fered a host odiagnostic exams and gynecological surgeries, and where doctors prescribe

the newest contraceptive technologies, including tailor- made hormonal im-plants. Te paint is fresher; there is air-conditioning and no crowds. A few


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days earlier, I met with Elsimar Coutinho in his office on the third oor. Itis spacious, and I count nine statues o naked women, some neoclassical in

varying shades o gold, several celebrating the pregnant form. I was invitedto sit on a predictably low-lying sofa at the other side o his desk, behind abarricade o papers and journals. An enormous three-dimensional modelo the female reproductive organs and a few glossy pharmaceutical mono-graphs on new hormonal regimens sit on the co fee table beside me. Afterreviewing my research proposal, Coutinho noted that they needed moreresearch on the “social” side o things.Crendices (beliefs) about menstrua-tion still inhibited the uptake o the new hormonal contraceptive methodsthey have been developing at . “You see, women don’t understand yet that they have a fake menstruation when they use the pill. Pill makersused to instruct women to take a pause every 21 days to produce an arti-cial withdraw bleeding episode that women think is menstruation. But it isnot menstruation, it is not natural and not necessary,” he told me in impec-cable English.

Menstrual suppression, or the idea that regular menstrual cycling is anew and potentially harmful phenomenon, received much attention glob-ally after the 2003 U.S. Food and Drug Administration ( ) approval oSeasonale, a contraceptive pill repackaged to produce only four menstrual

periods a year (“Seasonale®. Fewer Periods. More Possibilities.”), and thepublication o the English translation o Coutinho’s controversial book,Is Menstruation Obsolete? (1999). Widely discussed in medical publications(Association o Reproductive Health Professionals [] 2004a, 2004b,2006; den onkelaar and Oddens 1999; Edelman et al. 2007; Estanislau doAmaral et al. 2005; Ferreroa et al. 2006; Makuch and Bahamondes 2013;Tomas and Ellerston 2000) and global popular media (in particular, Glad-

well 2000), the menstrual suppression debate is founded on two intercon-

nected claims. Te rst consists in di ferentiating the menstrual bleedingpattern experienced by oral contraceptive pill users from “natural” men-struation and suggests that the former, because o its articial nature, isdispensable. Te second claim denaturalizes regular menstruation, arguingthat this is a “new biological state” ( 2004b), since “in the past” or in“tribal” contexts women reached menarche later, had more children, andbreastfed them longer than “modern” women do. Indirect evidence, this lit-erature argues, suggests that this increases the likelihood o gynecological

cancers and menstrual symptoms—problems purportedly overcome by theuninterrupted use o hormonal contraceptives.


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E fectively, Seasonale—like the extended-regime pills used in Brazil—isnothing more than the standard oral contraceptive pill, repackaged. Sinceits inception in the early 1960s, the pill—as a set o daily tablets—has been“unpacked,” and is better conceived in terms o the synthetic hormones thatcompose it. It has given way to a multitude o products in di ferent forms opackaging and with di ferent modes o administration. First, there is a pro-fusion o orally administered pills—combination (estrogen and progester-one), mini-pills, extended-regime, or “morning after” pills—associating any

variation o the plethora o synthetically produced hormones. Tese can inturn be brand-name drugs produced by international pharmaceutical labo-ratories, or copies o these (Sanabria 2014). In addition to this profusiono oral forms, contraceptive sex hormones may be injected (in monthly ortrimonthly doses, such as Depo-Provera); implanted subdermally (such asImplanon); or absorbed through the skin (via transdermal patches such asOrtho Evra, creams, or gels), the vagina (via the vaginal “ring” Nuvaring), orthe uterus (via the intrauterine hormone- releasing “system” Mirena). Tesechanges in modes o administration produce di ferent drug entities, but alsodi ferent kinds o consumers, bodily e fects, and subjectivities. Many long-acting hormonal methods intercede in the “normal” monthly bleeding epi-sodes experienced by women. Tis requires that women be “educated” or

“counseled,” to borrow the terms used by the (2004), to recognizethe positive benets o menstrual suppression, a task that Coutinho hascarried out with astonishing determination throughout his career. In thisbook I examine the ways in which “the” pill has been unpacked and turnmy attention to what is done with hormones as they are put to new uses, re-assembled and then released from their packages and ingested or otherwiseabsorbed into bodies.

Four in ve American women (82 percent) have used the pill at some

point (Daniels et al. 2013) and 23 percent have used the hormonal contra-ceptive injection Depo-Provera. In Brazil, 49 percent o sexually active ado-lescents use the pill (Rozenberg et al. 2013), as do 27 percent o womenin a relationship. Tis makes the pill the most used method, just ahead ofemale sterilization. oday over 100 million women worldwide use hormonalcontraceptives, and 80 percent o women o reproductive ages in WesternEurope and the United States are considered “ever-users,” making the pillone o the most widely prescribed drugs in the history o pharmaceuticals

(Brynhildsen 2014; one 2001). Sex hormones have become key therapeuticagents in women’s health and are central to contemporary understandings


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o the body, sex, and personhood. Yet, despite their ubiquity, sex hormoneshave seldom been studied ethnographically. Existing work on sex hormonestends either to be historical (Gaudillière 2004; Marks 2001; Oudshoorn1994; Soto Laveaga 2009), to focus solely on North American contexts(Jones 2011; Kissling 2013; Watkins 2012), or to focus on how knowledgeis constructed around sex hormones (Dos Reis 2002; Fausto-Sterling 2000;Löwy and Weisz 2005).

Plastic Bodies provides an ethnographic account o sex hormone use inBahia, examining how hormones are enrolled to create, mold, or disciplinesocial relations and subjectivities. Hormones are hybrid, complex objectsthat cut across political and sexual economies and sit at the boundary be-tween sex and gender. Tis book considers the way the scientic concepto “sex hormones” is materialized into pharmaceuticals and how, as drugs,hormones leave the laboratory and are taken up by users and absorbed intoeveryday understandings o the body. As an anthropologist, I am interestedin making visible the social relationships through which sex hormone usesare legitimized and in showing how these relations in turn mediate the livede fects o hormones.Plastic Bodies thus attends to the materiality o sex hor-mones while arguing that their efficacies cannot be reduced to their phar-macological properties.

Te book tells two intertwined stories: the story o hormonal menstrualsuppression and a story about bodily plasticity and malleability. Drawing onin-depth interviews with women, doctors, pharmacists, and health plan-ners, I show that the locally prevalent practice o menstrual suppressiongrew out o Cold War neo-Malthusian concerns with overpopulation in theGlobal South. In recent years it has been remarketed into a practice o phar-maceutical self-enhancement couched in neoliberal notions o choice andcontrol. I map the specicity o these coexisting biopolitical rationalities in

Bahia through an analysis o the peculiar local context o experimentality(Petryna 2009), aspirational class dynamics, and showbiz culture (Edmonds2010), and by reference to the role that consuming medical services andbeing knowledgeable about health play in constructing social relations. Tebook adopts an object-centered approach that enables me to study both private practice medicine and public health institutions and to examine thedi ferent ways hormones are prescribed and adopted by upper-middle-classor low-income women. Tese conversations are often kept apart in anthro-

pologies o Brazil (e.g., Biehl 2005; Scheper-Hughes 1992).Plastic Bodies

isconcerned with the way biomedicine and modernity are embroiled in Bra-


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zil (Browner and Sargent 2011; Caldeira 2000; Clarke et al. 2010). Inspiredby the pharmaceutical anthropology literature (Whyte, van der Geest, andHardon 1996, 2002), I followed hormones around, in women’s descriptionso menstruation and o the body, in ideas about blood, and in a variety omedical and pharmaceutical contexts. I set out to examine what happens when this biomedical concept travels, reconguring lay understandingso menstruation, reproduction, and the body. My questions abouthormô-nio—as it is referred to locally—were met with statements about sexuality,gender relations, and reproduction, and elicited discussions concerning hy-giene, bodily interventions, and modernity. Te ethnography opened intoa range o related questions concerning the role o medical institutionsand regimes in the making o citizenship. Adopting an object-centered or“follow-the-thing” approach (Appadurai 1986; Haraway 1991; Marcus 1995;Martin 1994), I traced the circulation o pharmaceutical sex hormones, asmanifestly material objects, and their associated discourses through a rangeo contexts. Tis study o sex hormones as “things medical” (Clarke et al.2010, 380) ormateria medica (Whyte, van der Geest, and Hardon 2002)—readthrough the stratied Brazilian biomedical system—sheds light on howhormones are mobilized within contemporary biomedical regimes (Fou-cault 1976). As contraceptives, sex hormones are central to demographic

interventions at the level o the population, and through the unfurling onew forms o administration, sex hormones are entangled in the individual-izing modes o biopolitics, concerned with the disciplining o subjectivitiesand the performance o the body at the molecular level.

Drawing on an analysis o local understandings o blood and menstrua-tion, and o the role o medical institutions in Brazilian social life,PlasticBodies examines why the body is so readily made open to biomedical inter-

vention in Brazil. Te book argues that this can be explained by the fact that

the body is understood to be malleable andplastic. It shows that, rather thanbreaching the body’s boundaries, medical interventions are integral to pro-ducing the body and its delimitations. In his ethnography o plastic surgeryin Rio de Janeiro, Edmonds (2010, 66) argues that Brazilian modernity is anaspirational process, perceived as always incomplete: “Te modern is notquite now, but rather a goal that is continuously receding.” Tis gives medi-cal techniques a particular “mystique” that Edmonds (2010, 67–68) qualiesas a fetishism o technological progress, often driven by mediatized doc-

tors. Malcolm Montgomery, who is famous for his cover stories in Brazil’sPlayboy magazine and regular appearances in people magazines, where he


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is presented as the gynecologist o the “stars,” is a fervent defender o hor-monal treatments. In an interview I carried out with him, he relayed to mehis tale o two sisters: thenatureba (a derogatory term for “naturalist”) andthehigh tech (in English, in our conversation). Te rst, who is a hippy, wentto live on a farm and had four home-births and breastfed for years. Te sec-ond is a “beautiful businesswoman,” had two elective cesarean births fol-lowed by plastic surgery, and did not breastfeed. Te latter is his patientand, at her fortieth birthday, he recently met her sister, younger by one yearbut “looking sixty, at least,” with her graying hair, collapsed breasts, and—he posited—prolapsed uterus andrasgada (torn) vagina. Natural births, hetold me, are violent and aggressive; they distend the vagina and damage theperineum. Tey are “um espetáculo de miséria estética [a spectacle o estheticmisery],” he concluded. He narrated to me his experience traveling to theUnited States for a medical conference in the 1980s, during which feministshad marched “against the pill.” Why would women march against them-selves, against their own autonomy, he had wondered?

Tis intrigued me. Such people have a very naïve view o nature. Nature isaggressive. We had to ght against nature to achieve our quality o life, tohave a better life. Tat thing that Rousseau said about living in harmony

with nature, I really don’t agree. . . . It is an error to think that, naturally, women should menstruate. It is biologically correct for women to have

roughly between forty and eighty cycles in her life. A modern woman like you will have an average o two children and menstruate uselessly around

400 times. And this is why it is medically interesting to useanticoncepcio-nais [hormonal contraceptives] to lower the doses o hormones that natu-rally occur when women cycle. Te doses administered in anticoncepcio-nais are immensely inferior to the natural peaks that occur when womencycle and which lead to a host o pathologies. echnology is important toadapt to the hostile natural world.

As I explore in this book, the appeal to the distinction between natureand artice carries, in Brazil, particular values concerning the moderniza-tion o the nation, a project intimately tied up with questions o reproduc-tion (Edmonds 2010). Writing from North American or Western Europeancontexts, some authors have argued that recent developments in the bio-technologies recongure or “denaturalize” the idea o biology in its relation

to the social. Tis book shows how, in Brazil, this is not new (Rohden 2003,2001), as nature is already understood to be plastic. Mapping the class and


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gendered distribution o the prescribed and improvised hormonal regimesadopted by people in Bahia, it opens up a series o questions concerning therelation between self- improvement, control, hygiene, biomedical citizen-ship, and the Brazilian project o modernity.

Unmaking “the” Pill: Sex Hormones and Menstrual Suppression

Historical analyses o steroid sex hormones’ disparate congurations in bio-medical practices past and present reveal that these are particularly uidobjects (de Laet and Mol 2000). In the mid-1920s sex hormones were involved in clinical trials for menstrual irregularities. In the initial market-ing strategy, the contraceptive qualities o hormones were presented asa side e fect. Te development o these therapies into “the” pill came lategiven the range o medical indications for which they were being used. Onecould argue that this played a signicant role in the establishment o exibletherapeutic indications for these newly developing pharmaceuticals. Tisdemonstrates the complexity involved in dealing with such objects. Te pill,hormonal therapies, or fertility treatments are not natural kinds or cate-gories that we can refer to without evoking their context. Sex hormones, intheir form as pharmaceuticals, are made into particular kinds o objects by

the social relations within which they exist.“Te” pill was initially dispensed in a glass bottle containing fty tab-

lets, and issued with directions on how many tablets to take and how longa pill-free interval to count in order to reproduce a monthly cycle. Couplesare reported to have placed the pills on calendars to facilitate counting, andin the early Puerto Rican trials “illiterate” women were issued rosaries ascounting aids (Gossel 1999). Te circular Ortho-Novum dispenser releasedin 1963 was based on the patent delivered to David Wagner for his pill ad-

ministration mechanism. Tis served to stabilize, within the pill’s design, aregular menstrual cycle o twenty-eight days. It is interesting that what Ak-rich (1996) terms the “temporal coordination apparatus” was built into thepill’s designafter the drug was launched as a contraceptive and is not intrin-sic to its design. Te consolidation o this articial bleeding episode was fur-ther stabilized through a series o changes that were made to the pill’s dis-pensing mechanism. Tus, the pill came to include dummy or placebo pills,often containing vitamins or minerals, during which women experienced

a “mock”—or fake—period. Historically, the monthly withdraw bleedingperiod experienced in the pill-free (or placebo) interval was considered im-


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Figure I.1 Enovid, the rst oral contraceptive pill approved by the in 1960, was dispensed in a bottle o fty tablets. Image credit: Smithsonian Institution,

National Museum o American History.


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portant for a variety o reasons, by both users (for whom regular bleeding

was a sign o nonpregnancy) and doctors who promoted the pill as a formo “natural” contraception in its early days (see Gladwell 2000). It is justanother step within this logic to move from scheduled monthly to seasonalbleeding intervals. As we have seen, the extended-regime pill Seasonaleprovides pills for a “3-month cycle”: eighty-four pink active pills and seven white inactive pills. Interestingly, in Brazil only a minority o oral contra-ceptives include placebo pills, and women are routinely instructed that theycan either take a seven-day break oremendar cartelas, which means beginning

the new pill pack immediately without taking a break. Tis is facilitated bythe fact that women can readily obtain pills over the counter in pharmacies

Figures I.2 and I.3 Te Ortho-Novum 21 DialPak (1963), and its patent, introducedthe notion o a cycle into the pill’s design. Image credit: Smithsonian Institution,National Museum o American History.


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without a prescription, giving them greater exibility in how they use thedrugs. Tis explains why Brazilian women have long been experimenting with extended regimens to skip a period at their convenience, for a party,carnival, or a beach holiday.

Te global circulation o sex hormones contributed to deconstructingthe pill as a unitary object, either through the development o new formso administration or packaging design, or through the widening o its eldo action to include new indications, such as hormone replacement ther-apy, skin treatments, and “emergency” contraception. Oudshoorn’s (1994,1996, 1997) historical work on hormonal contraception provides a contextto understand the dynamic o repackaging that I am foregrounding here.She argues that the history o sex hormones is a history o “Western sci-

ence ignoring the local needs to specic users” (Oudshoorn 1994, 150–51)and traces the demise o the “one size ts all” approach to contraception


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promoted by early developers o the pill (Oudshoorn 1996). Tis led to thedevelopment o a “cafeteria model” o hormonal contraceptive diversity.In the late 1970s the actively promoted research on long-acting hor-monal contraceptives such as hormonal injections and implants. Tese were seen as efficacious tools for population control programs because

they are provider-administered. Tis makes them good “technical dele-gates,” that is, artifacts that are “designed to compensate for the perceiveddeciencies o [their] users,” such as women’s tendencies to forget to taketheir pills daily (Oudshoorn 1997, 44). Te research and develop-ment program stemmed from the recognition that “the pill” had only beentaken up by “middle- and upper-class women in the western industrialized

world.” Injectable contraceptives such as Depo-Provera are described by the team in aScience publication as particularly “appropriate in develop-

ing countries” (Crabbé et al. 1980). Tis logic was particularly evident inthe Bahian publicambulatórios where I carried out my research, as I detail

Figure I.4 Elaní is a widely available, fourth-generation extended-regime pill pro-duced by the Brazilian pharmaceutical laboratory Libbs. “Non-Stop, Te evolutiono the pill through the evolution o woman” is a short information guide produced

by Libbs to relay the idea o the evolution o the pill’s design alongside women’s evo-lution in society. Photograph by Emilia Sanabria.


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in chapter 3. Te problem with long-acting hormonal methods is that theyinterfere with women’s menstrual cycles, which explains, I argue, how thestory o hormonal contraceptive development became entangled with thestory o menstrual suppression. Gradually, the menstrual-suppressive sidee fects o the new modes o administration developed for the Global South

were rescripted as desirable, primary e fects. “Menstruate: What For?” wasthe title o a recent pharmaceutical industry-funded electronic newsletter(SaberMulher) that pinged into my inbox, explaining the health benets ousing long-acting hormonal methods to mitigate premenstrual symptoms.As discussed in detail in chapters 2 and 5, the lifestyle and esthetic e fectso hormonal contraceptives gained much coverage in Brazil in recent years.

Contraceptive technologies, like any technology, are inscribed duringtheir development such that representations o future users are materializedinto the design o new products (Akrich 1996; Hardon 2006). Tey containa congured user (Oudshoorn 1996) that can inhibit their capacity to travel.For the object to travel, a certain amount o context must travel too, so tospeak. Failing this, the object is transformed as it is re-localized. For the pillto travel, it needed to be unpacked. As new objects were produced from sexhormones, their circulation worked to di ferentiate between di ferent con-sumer populations. Tis background is important for understanding how

choices are presented in reproductive health centers and clinics in Salvador.DeGrandpre (2006) argues that the efficacies o drugs are informed as

much by the cultural scripts that shape user expectations as by the drugs’pharmaceutical properties. As a pharmacologist he is uniquely placed toadvocate that his discipline is “not equipped to grapple with the powerfuldialectic that exist[s] between drugs, their users, and the historical and im-mediate contexts o use” (237). He argues that lay and expert understand-ings are infused with a kind o magicalism that assumes that the e fects o

drugs reside entirely in the substance, reducing understandings o phar-maceutical efficacy.Plastic Bodies examines the unwritten cultural scripts or“placebo texts,” as DeGrandpre refers to them, that accompany and shapesex hormones use in Brazil. It does so while simultaneously taking seriouslythe material efficacies o hormones, attending in ethnographic detail to howhormones “retool sensuousness” (Hayward 2010, 227) by immersing “thebody’s organs in a chemical bath such that one’s proprioceptive sense is . . .changed” (229). Te lived experiences o hormones related by people I en-

countered were widely shared, attesting to a particularly powerful conver-gence between such proprioceptive retoolings and their attendant cultural


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able .1 Menstrual Suppression Methods Available in Salvador

ype o method Brand name Active principles

Extended-regimeoral contraceptivepills

Elaní (Libbs Brasil) Drospirenone 3 mg andethinylestradiol 30 mcg

Gestinol 28 (Libbs Brasil) Gestoden 75 mcg andethinylestradiol 30 mcg

Any monophasic, combined oral contraceptive pilltaken without the 7-day pill-free interval. Options rangefrom Microvlar (Schering) and its “similar” Ciclo 21(União Quimica) (0.03 mg ethinylestradiol and 0.15 mg

levonorgestrel) to Yasmin (0.03 mg ethinylestradiol and3 mg drospirenone).

rimonthlyinjections

Depo-Provera (Pzer)or Contracep (SigmaPharmaceuticals), Depo-Provera’s Brazilian “similar”

Medroxyprogesteroneacetate: injectible suspensiono 150 mg/mL

Subdermalhormonalimplants

’s “tailor-made”implants

Presented in capsules otestosterone, estradiol,gestrinone, elcometrine,levonorgestrel combinedaccording to required dose.

Implanon (Organon) Single subdermal implantcontaining 68 mgetonogestrel

Intrauterine

“system” withhormones

Mirena (Schering Brasil) Intrauterine device (with

reservoir containing thehormone levonorgestrel)


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Cost/duration Availability in Salvador

US$18 for a pack o 28 Launched specically as an extended-regimecontraceptive, Elaní contains the hormone drospi-renone and is marketed as the “well-being” pill.

US$13 for a pack o 28 Marketed as an extended regime specically formenstrual disorders.

Varies with cost o individual pills (from US$1 to

US$20 for a 21-pill pack);one extra pack o 21 is re-

quired for every 3 monthso continuous use.

Widely available in public and private health centersor directly over the counter where prescriptions arenot always required for purchasing contraceptives.Most o the women interviewed who had used the

pill had at one point taken it continuously.

Prices range from US$10for Depo-Provera to US$5for Contracep (for a contra-ceptive efficacy o threemonths).

Widely distributed method in public health familyplanning dispensaries and readily available over thecounter in pharmacies, many o which apply the in-

jection for a small fee.

Prices range from US$200to US$900 for a contracep-tive efficacy o one to three

years, depending on thecombination.

Limited to private practices with doctors capaci-tated to insert the subdermal implants. Com-mon in Salvador because o the active presence o

, which provides and inserts implants onbehal o other doctors and trains doctors in im-plant insertion.

US$325 plus medical hono-rariums. Contraceptive effi-cacy o three years.

Far less common in Brazil than locally “manipu-lated” hormonal implants mixing di ferent hor-monal compounds.

US$350 plus medical hono-

rariums. Contraceptive effi-cacy o up to ve years.

Limited to private practices because o the high

cost. Brazil has the world’s highest rate o Mirenause according to several Schering informants.


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scripts. Interestingly, medical professionals did not always recognize theshared lived experiences widely imputed to sex hormones as hormonally in-duced. For example, many women experience headaches or weight gain, afact that was often rebutted by doctors with the refrain:Hormônio nao engorda,é comida que engorda. Fecha boca, querida [Hormone doesn’t cause weight gain,food does. Close your mouth, darling].

Martin (2006) calls attention to the displacements at work in assessments

o pharmaceutical e fects. She reviews how adverse side e fects are displacedto small print, how population-level e fects o clinical trials are o f-shoredto the developing world, or how marketing and clinical practice keeps theambivalence people may have about the limited or at times toxic efficacies othepharmakon at bay. While negative e fects are laboriously kept “over on ‘theside,’” Martin (2006, 282) reminds us that it is “a short step from side e fectsto ‘collateral damage.’” Drawing on Martin’s analysis, Masco (2013) asks:“what makes one outcome the benet o the drug, and another its nega-

tive side e fect? How is it that this powerful line is drawn, and what formso value are revealed in its calculus?” Te ways in which the potentially

Figure I.5 Te hormonal injections most commonly found in Salvador are Depo-Provera’s “similar” Contracep (medroxyprogeseterone acetate 150 mg/mL), Depo-Provera, and the monthly injection Mesigyna. Photograph by Emilia Sanabria.


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harmful e fects o sex hormones are assessed and regulated are variable andcontested (Löwy and Weisz 2005). A considerable epidemiological litera-ture on the risks o venous thrombosis in oral contraceptives users pointsto the increased risk for smokers or women using rst-generation pills that

were more highly dosed. While risks fell with second-generation pill use,controversies resurfaced in the wake o new studies into the increased riskscarried by third- and fourth-generation pills, which presented small butconsistent increased risks o thrombosis in relation to second-generationpills (see de Bastos et al. 2014; DeLoughery 2011; Marks 2001; and Stege-man et al. 2013 for a discussion o earlier risks). A recent Cochrane reviewcomparing extended-cycle with traditional cyclic dosing (a bleeding intervalevery three months versus monthly) is curiously contradictory on the topico safety (Edelman et al. 2014). Te widely available abstract states that evi-dence from randomized controlled trials “is o good quality” and that con-tinuous dosing is “a reasonable approach.” But buried in the full- text versionone nds the mention, almost in passing, that “the studies were too small toaddress efficacy, rare adverse events, and safety.” My own reading o the datareviewed in this meta-analysis (which includes a 1995 study conducted byCoutinho’s team in Salvador) reveals that more than hal the studies cited re-ported conicts o interest with the pharmaceutical industries whose drugs

are trialed. Endocrinologists Prior and Hitchcock (2014) note that with theextended-regime pill, women are exposed to 25–33 percent increased es-trogen exposure. A meta-analysis o cardiovascular risks showed that eventhe pills with the lowest dose cause a doubling o the risk for stroke andheart attack (Baillargeon et al. 2005). Existent studies are biased, Prior andHitchcock argue, because they compare risks with risks on standard regi-men pills and not with untreated menstrual cycles. Further, the continuouspill regimen causes more days o higher-than-normal estrogen concentra-

tions, which is likely to have an incidence on breast cancer.Depo-Provera, a popular method in my eld site, underwent numerouscontroversies in its career as a contraceptive. Te withheld approvalfor Depo-Provera in 1967, 1978, and 1983 and then approved it in 1992 de-spite outcry from women’s health movements. In 2004, concerns over losso bone density in Depo- Provera users led the to request a warninghighlighting concerns about loss o bone density and indicating that Depo-Provera should not be used for more than two years. Such warnings were

absent from the Depo- Provera applications that I observed. In Bahia, risk-benet analyses put forward the substantial personal and public health con-


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sequences o unwanted pregnancies or emphasize the reversibility o long-acting hormonal methods in relation to sterilization—the rates o whichare still very high.

I do not engage here in a debate over the relative safety o di ferent hor-monal methods, but rather attend to how the potential deleterious e fects ohormones are—or are not—raised in Bahia and how these inect patternso use. What is most striking about the question o the potential risks asso-ciated with hormonal methods is the absence o debate within the Bahianmedical community. Tis was evident both in the interviews I carried out with doctors and in the gynecological conferences I attended. Patientsoften did raise concerns, but these tended to focus more on experiencedside e fects rather than concerns with future health risks, such as thrombo-sis or cancer. Tese were routinely met with the ready-made, nely tuned,and locally sensitive counterarguments that pharmaceutical sales represen-tatives and doctors establish through their interactions. Oldani (2004) hasshown how these ground-level exchanges between pharmaceutical repre-sentatives and doctors can inect local marketing strategies, leading to ad-

justments in how a pharmaceutical is used and thought about in di ferentprescribing ecologies. In Bahia, I found that doctors’ risk–benet evalua-tions tended to downplay future health risks in order to ensure compliance

and the correct use o hormonal methods in a context where women areseen as switching and swapping erratically, without medical advice. Empha-sis was placed on nding the most adapted method, and this often meantbracketing potential health concerns. Women also were engaged in compli-cated risk–benet exercises. As I detail in chapter 3, these risk evaluationsdo not limit themselves to evaluations o health risks. Users’ cost– benetanalyses include thinking through the potential costs o not using hor-mones, which might range from unwanted pregnancy, incapacity to work

because o heavy menstrual symptoms, or loss o libido, leading one’s hus-band to stray. Returning to Masco’s question concerning how the line be-tween primary and side e fect is drawn, we can see the importance o con-text in shaping how benets and risks are evaluated. Bahia, with its specicforms o stratied reproduction (Ginsburg and Rapp 1995), has played animportant role in the development o the practice o menstrual suppression,that is, in the transmutation o what was initially perceived as a negative sidee fect o long-acting hormonal methods (the suppression o monthly men-

strual episodes) into a desirable end goal. Te cloaking o risks in Bahianmedical practices should be thought alongside the labor o making evidence


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about safety for markets in the Global North. Tey are part o a commonregime o value in which lively capital (Sunder Rajan 2012) is produced outo the circulations o pharmaceuticals and their attendant knowledges. Pro-ducing new efficacies for sex hormones is facilitated by what Lovell (2006)has aptly termed “pharmaceutical leakage.” Leakage describes how pharma-ceuticals are shaped by the movements o drugs through global spaces oresearch, development, production, marketing, and regulation. As sex hor-mones circulate globally they leak between official and unofficial prescrip-tion regimes, reconguring bodies and socialities by circulating “not onlythrough blood, brain, and other body sites but also through social settings”(Lovell 2013, 131).

Salvador da Bahia

Over the course o eighteen months, I attended several hundred familyplanning consultations at and in three health posts or maternityunits where hormonal contraceptives are dispensed. I interviewed doctorsabout their work in state-funded services and in their private practices. Dur-ing participant observation activities in these clinical contexts, I sat in onthe stages o triagem, observed the preinterview with the nurse and social

worker, as well as the consultation itself, during which methods are admin-istered, injected, or inserted. I also went out with ’s municipality-funded mobile unit ( -móvel) to several favelas and partook in a

variety o women-centered community activities in these peripheral neigh-borhoods. Access to gynecological consultations in the private sector wasmore limited than in the public sector, whose users are presented as appro-priate research subjects by medical professionals. My access to the privatesector was via the operating theater in two private institutions, where I was

able to observe hysteroscopies, laparoscopies, and a dozen births, o whichthe majority were by cesarean delivery. In and in a small neighbor-ing town’s maternity unit I was also able to observe three tubal ligations, adozen vasectomies, and one postabortion curettage. Tis enabled me tosituate hormone use as an engine o new sexual normativities in the chang-ing biopolitical arrangements that link national progress to the constitutiono a sexually healthy Brazilian population (Adams and Pigg 2005).

I also conducted over sixty in-depth interviews with women across the

class spectrum. Tese women were urban (although some were o rural ori-gin) and o mixed socioeconomic background. Te openness with which


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people in Brazil speak publicly about their bodies’ most intimate processeshas never ceased to amaze me—perhaps the product o having lived in Eng-land for so long. Not only are bodies publicly made visible in specic ways,but the women I encountered draw on an array o widely circulated tech-niques, health tips, pharmaceutical regimens, or physical exercises to modu-late their bodies and its processes and to monitor its metamorphoses. I feltmy own body scrutinized in particular ways as I entered into clinical spaces where class boundaries are reestablished through close attention to physical

appearance, dress, and presentation. But, more importantly, I began to feeldi ferently in my body, to pay attention to things I had never noticed before.Digestion and the specic e fects o foods, the embodied manifestations oemotions, the state o one’s blood pressure, the relative efficacy o di fer-ent brands o painkillers, or the reference values for a normal white bloodcell count formed part o everyday conversations across a range o socialcontexts and brought my attention to processes to which I realized I hadnever given much thought. I was surprised by the extensive knowledge many

women had o the di ferent contraceptive methods available, their recom-mended uses or side e fects, and often felt slightly inept when women were

Figure I.6 Waiting for contraceptive methods in the shade o ’s mobile unitin a low-income peripheral neighborhood. Photograph by Emilia Sanabria.


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surprised to discover that I was quite literally doing exploratory research andnot mysel always as biomedically versed as they were.

I did not deliberately discriminate between informants in function osociological categories, speaking to women o diverse backgrounds and with a broad range o views and attitudes toward menstruation and hor-mones. Within these discussions, I privileged questions about contraceptivechoice, experiences o menstruation, reproductive histories, gender rela-tions, and perceived generational shifts in these areas. Te topics o sexu-ality, body culture (narrated to me as a Brazilian specicity), “self-care,”medications, well-being, beauty, changing family structure, and abortionregularly arose, demarcating the discursive eld within which sex hormoneuse is commonly situated. During the initial period o eldwork (2005–6),and in four subsequent visits o three to six months between 2008 and 2013,I attended medical congresses and carried out several weeks o eldworkin three pharmacies catering to low-, middle-, and high-income neighbor-hoods. I met pharmacy sector regulators and members o pharmacist profes-sional organizations. I interviewed the national marketing directors o fourmajor pharmaceutical corporations in São Paulo (Schering, Pzer, Libbs,and Boehringer Ingelheim) and followed the work o Schering’s, Libbs’s,and Organon’s regional managers over the course o several months. I met a

number o other pharmaceutical representatives in doctors’ waiting rooms,some o whom allowed me to observe their work. Trough these contactsI was invited to several pharmaceutical promotion events (such as promo-tional dinners and in-congress events). Several informants suggested I goto the blood donation center to nd answers to my questions abouthormô-nio, blood, and menstruation. Tere I encountered patients who no longermenstruated and sought to alleviate themselves o the excess blood accu-mulated by this absence o menstruation (Sanabria 2009, 2011). For sev-

eral months I also participated in ’s (the Association o ravestis oSalvador) weekly meetings and organized group discussions ontravesti useso hormones. ravestis, as they refer to themselves, are physiological males

who use female sex hormones (among other techniques) to transform theirbodies. I had not initially anticipated to trace hormones all the way intothese sites but, as I detail in chapter 4, this enabled me to understand howhormones are rendered as a kind o substance in Bahia, not unlike blood.

Brazil’s rst capital and home to a large afro-descendent population, Sal-

vador counts nearly 3 million inhabitants ( 2013). Te city spans a vastheterogeneous urban space between the Bay o All Saints, the open sea, and


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inland hills. Recent modernization includes the renovation o the old colo-nial center (Pelourinho), the expansion o middle-class neighborhoods alongthe seafront, and development o vast tourism installations for both na-tional (Brazilian) and foreign tourists. Te Northeast is considered the poor-est o the ve Brazilian macro-regions, wherein wealth is disproportionatelyconcentrated in Salvador. Despite its size, Salvador has the feel o a smallcity, and it is often said that Salvador é um ovo (Salvador is an egg) when gossipgets around with astonishing velocity. Bahia occupies a place that is care-fully set apart as sensual, jovial, and backward by Southerners o São Pauloor Rio. Many have attempted to capture the core elements o thisbaianidade (Bahian-ity), which, aside from the slurry speak commonly associated byPaulistas (residents o São Paulo) with the purportedly “lazy” Northeasternerlaborers, includes the specic style o samba (di ferent from that practicedin Rio), the particular culinary tradition, or Bahian religiosity and “popu-lar culture.” Salvador is often characterized by itssincretismo (syncretism),a representation in the national Brazilian imaginary that owes much to theidea that Brazil is the product o the mixture o the three races: European,African, and indigenous. Te specicities that mark Bahia are often attrib-uted in popular representations to the strong presence o “Africa” in Bahia,a legacy o slavery. Parés (2006) and van de Port (2011) have noted the im-

portance o the colonial Baroque heritage to Bahian modes o being, sug-gesting that what is often taken for an African heritage is the product oa long history o hybridization and mixture that cannot be reduced to theproblematically bounded entities “Africa” or “Europe,” as they so often are. I

was in São Paulo in January 2006 when the case o Father Pinto’s excommu-nication from his Catholic parish in Salvador hit the national news. Te con-troversy began during the epiphany celebrations when the priest was saidin the national press to have “turned mass into a show” by staging a cele-

bration to, in his words, “honor the di ferent races o Brazil,” representingeach o the three kings as “white,” “black,” and “Indian.” What shocked wasthe fact that he appeared in full makeup, emulating an Amerindian danceand appearing as Oxum, a female Afro-Brazilian deity dressed in gold. Ar-riving from Bahia, people I met in São Paulo jokingly distanced themselvesfrom these Bahian extremes o cultural “miscegenation,” exclaiming: “Só naBahia, né !” (Only in Bahia, no?). Bahians often narrate Bahia as a particularly“spiritual” place. Among medical professionals I met many Kardecist spi-

ritists, a Christian- based religion founded on the channeling o predomi-nantly eighteenth- century European spirits, a doctrine o reincarnation, and


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Figure I.7 wo Mães-de-santo (Candomblé priestesses) share a joke atIemanja festival, Rio Vermelho (Salvador). Photograph by Emilia Sanabria.


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healing performed at a distance. A wide array o energy healing practicesgrew out o this rich polysemous context, and biomedicine is, in a sense,but one o many resources that people call on in their search for health. AsDra Eugenia, a gynecologist I interviewed in her private practice, explained:“Here everything is miscegenation. See that image o the Virgin behind you?Tat was given to me by Mãe Carmen do Gantois [a well-known Candomblépriestess], and in the bottom corner o the frame is Krishna. Here [shows

key ring] is Sai Baba. I love Candomblé, and I like to go to mass at Our Ladyo Conceção. You see, I’m Bahian, I’m genuinely ecumenical.”Many have attempted to characterize Brazil’s specic sexual culture, em-

phasizing the sensuality that marks many aspects o sociality and invites“passionate encounters” (Van de Port 2011, 48). Drawing on Freyre’s (1990)analysis o sexual miscegenation as foundational to the Brazilian nation,Parker (1991, 28) argued that, in Brazil, sexual life acquired a central im-portance at the sociocultural level, whereas in Euro-American contexts it

is treated as a private or individual phenomenon. In this reading, Brazilian

Figure I.8 Bahian “multiculturalism”: Candomblé folk and a white middle-class woman observing a ritual dance during Iemanja festival. Photograph by Emilia Sa-

nabria.


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society is heir to the social organization characteristic o the slave-owning fazenda (estate). Te fazenda connected the patriarch, his wife, and his legiti-mate o fspring to a network o relations that included the patriarch’s mis-tresses, illegitimate children, slaves, tenants, friends, and clients. Tis,Parker (1991, 31) argues, produced a notion o masculinity tied to the imageo the virile and hierarchically superior patriarch and a plural model o femi-ninity, as “legal wife and mother” or “concubine” (5). Te di ferent roles o

women as objects o desire or as respectable wife and mother are at timesdifficult to reconcile, and part o what Brazilian feminists denounce as thedouble standards o sexual morality, whereby male sexuality is encouragedand positively valued, whereas women are expected to elicit desire withoutcompromising their virtue. Parker’s analysis is focused almost exclusivelyon male sexual discourse, allowing him to capture the tenor omachismo ide-ology in a vivid way, using the crude, sexist language o his informants. Teextent to which this gloried sexual culture is actually reected in everydayintimate relations has, however, been questioned (Galvão and Diaz 1999).Drawing on a survey o 4,634 youths in three Brazilian capitals, the authorso the study o young people’s sexuality and reproductive trajecto-ries argue that this representation o Brazil as a sexually uninhibited societycoexists with a rigid system o gender relations and familial organization

that spans all classes (Aquino et al. 2003; Heilborn et al. 2006; Heilborn,Aquino, and Knauth 2006; Heilborn and Cabral 2013). Many o the doctorsand health practitioners I spoke with told me that a surprising number opatients consulted for sexual problems. In this context, the capacity attrib-uted to hormones to generate sexual e fects—both stimulating desire andprotecting from unwanted pregnancy—was particularly appreciated.

When my partner and I rst settled in Salvador, we opted for the2 de julho neighborhood, a lower-middle-class, slightly bohemian neighbor-

hood in the old center, lodged between the Campo Grande, the exclusiveseafront Vitoria avenue, andcrackolândia that gentrication and real estatepressure has yet to prevail over. Campo Grande is a central node for manyo Salvador’s convoluted bus routes. I spent hours negotiating these routeson my way to distant, painstakingly arranged appointments with doctors,health planners, or interviewees who had at times forgotten me by the timeI made it to their door. Riding the overpacked, overheated bus up to Fede-ração, where is located, one passes steep roads leading into some

o the neighborhoods that house the older Candomblé houses o the city.


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One spot just after the old cemetery always caught my attention; in the earlymornings there would often lie a fresh o fering to asanto (saint), a yellowceramic bowl left at the crossroad, the wings o the sacricial chicken ap-ping in the morning breeze. One morning I sat behind an ancient little lady

who boarded the bus at the large public hospital in Canela. She wore a fadedgreen dress, plastic shoes, and an old stained handkerchie to contain her

vibrant white Afro. She carried a battered plastic bag and multitudes o littlebags within it, full o treasures, buttons, a shredded identity card, papersthat had been folded so many times that it was not clear how they still heldtogether, a single white pill cut out o a blister pack, a little key, a rubberband. She shifted these from one plastic bag back to the other, reorganizingher world. Each o these possessions was manipulated with great care as she

knotted and unknotted the little bags and handled these documents, keysinto the labyrinthic bureaucracy that I found so challenging to negotiateand that can make citizenship a perpetually receding horizon for many Bra-zilians. I observed her as we rode downBarra avenida, with its Land Rovers;shiny, Lycra-clad, siliconed joggers hooked up to their iPhones; straight,blond, mega-hair extensions; arts cinema;sorveterias (ice cream parlors);top-end pharmacies with their imported pharmaceuticals and cosmetics;exclusive diagnostic imagery labs; andsalão de beleza (beauty parlors), struck

by the vivid contrasts so characteristic o Brazilian urban centers.Over the years I have come to love and long for this city like few other

places in the world, despite its intense inequalities, receding public space,and intense commercialism. Tere is something about the sensuousness andaliveness o Salvador that is hard to capture. A vibrancy in the way I observemy friends engaging in life with joy, letting things unfold even when theystruggle with nancial difficulties, the absence o the state or the violencethat marks the everyday. Te strange risk evaluations that shape existence,

as one crosses into the peaceful square where seniors gossip, in the earlyevening freshness, to the monotonous sound o chanting from the massheld on the corner, church doors wide open onto the world, where a shoot-ing occurred in broad daylight, only weeks before, killing three people, oneo whom was a pregnant woman. Feral bare- bottomed children play in theornamental vegetation, their mother lying, disheveled, on a length o card-board beneath a bench, having visibly made a visit to nearby crackolândia.A huge iguana with sharp teeth observes the scene as two men theatrically

exchange a verbal joust, cheered on by onlookers. On one corner a vendorsells pink, blue, and orange popcorn from an antique trolley, topped with


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condensed milk for an extrareal. Next to him a coconut water vendor and acorn-on-the-cob vendor are rehearsing the latest carnival hit’s suggestivechoreography, well aware o the attention their sensual dancing is eliciting.Buses, people, traffic. At the opposite corner a woman in a white lab coatand matching baseball cap has set up a white plastic chair and table and ismeasuring blood pressure and glucose plasma levels for a small fee. She is anursing auxiliary and tops up her earnings in this manner. Outside the bank

is a good spot to catch hypertension, she jokes, gesturing to the long queueo people waiting to pay bills or renegotiate a loan.In this book I show that the extreme incursion o biomedical interven-

tions into people’s lives in Brazil should be considered alongside other,older, or more mundane forms o bodily management, such as the regularmonitoring o blood pressure on a street corner between errands. Bodilyprocesses are o great interest toSoteropolitanos (inhabitants o Salvador).Clinical exams o all descriptions—from blood tests to scans, functional

magnetic resonance imaging or x-rays—are remarkably present in a con-text marked by such disparities in access to health care. Tese imaging

Figure I.9 Measuring blood pressure on a street corner. Photograph by Emilia Sa-nabria.


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techniques constitute a new set o tools to assess, measure, and quantifythe bodies’ internal metamorphoses. Tis marked attention to bodies isnot limited to the assessments made possible by these medical technolo-gies; rather, their astonishing prevalence attests to the fact that these re-spond to existing concerns. Dumit (2012, 181–96) has outlined three modeso biomedical living with mass health in the United States. Tese are “ex-pert patienthood,” “fearful subjects,” and “better living through chemistry.”Here, pharmaceuticals are mobilized to mitigate the risks generated by thenew regime o surplus health. Te statistical model o mass health is markedby an encroaching paradigm o treatment as prevention in which health andillness are no longer “states o being” (13) but recongured as epistemicclaims at the population level. Tis invites patients to become responsible,self-diagnosing experts o their own health, monitoring their blood levelsregularly, for example. As Dumit (2012, 192–93) notes, this mode o better(pharmaceutical) living “o fers a new choice through reconguring what isconsidered foundational and xed and what is changeable and can be coun-tered.” InPlastic Bodies I examine how biology and nature may also supplynotions o instability and changeability and show how human action is oftengeared to xing and stabilizing this ux. “Knowing your numbers” in this way takes on a magical quality, enabling expert patients to navigate dys-

functional health systems and make (new) sense o their bodies’ changinginternal balance.

While characterized by profound inequalities, statistics place Brazilamong the highest users o female sterilization, cesarean deliveries, andplastic surgery (Edmonds 2010). Te 2002 EngenderHealth publication onfemale sterilization reported Brazil as having the third highest internationalrate o female sterilization, placing it above China. Victora et al. (2011) re-port in Te Lancet that 47 percent o all births in Brazil were by cesarean de-

livery, a rate higher than has been reported in any other country. Cesareandeliveries are performed on 48 percent o primiparous mothers and ac-count for 35 percent o deliveries in the (Sistema Únicode Saúde, the pub-lic health service), where three-quarters o births take place. Te NationalAgency o Supplementary Health reported in 2008 that 85 percent o birthsin the Brazilian private health sector were by cesarean delivery, and one othe clinics in which I worked boasted a 99 percent rate. In an article ex-ploring the prevalence o cesarean deliveries in Salvador, McCallum (2005a,

226–27) argues that:


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Te sexually adapted, attractive and active female body—the proper con-dition o modern Brazilian women—is represented by untouched andaesthetically pleasing genitalia. Tese genitalia, i also used for givingbirth, lose their power to signify modernity and progress. On the con-trary, when sexuality and reproduction become inter-linked through

vaginal childbirth, the meanings attached to the genitalia’s referent (thefemale body) are inverted. Such a body is pre-modern, damaged. It is re-pulsive to others. . . . Tat this old-fashioned form o birth is also seen as“natural” confers no value on it whatsoever. On the contrary, nature itselis devalued, measured against the gains conferred by science and tech-nology. Abdominal birth lends modernity, and thus continued value, to

women’s bodies. . . . And women are agents only insofar as they “choose”the knife—and, by this token, “modernity.”Te relation between class, modernity, and practices o bodily modica-

tion and enhancement therefore needs to be carefully examined. Account-ing for the unusually high levels o biomedical interventions solely throughthe lens o medicalization—that is, the domestication o social inequities with medical solutions that conceal the sociopolitical roots o ill- health(see Scheper- Hughes 1992, for example)—seemed unsatisfactory to me.Troughout eldwork, in listening to the stories o women who activelysought out such interventions and in observing their engagements with bio-medical institutions, procedures, and technologies, it dawned on me thatalthough this was certainly an important part o the story, other things weregoing on.

Plastic Relations: Class, Race, and Bodies

Dr. Ricardo picked me up at 6 a.m., and we made it to the maternity unitby 7 a.m., at which time a long queue o patients had already formed. Teunit was small, making the process o triage explicit, that whole business ocounting people, turning their stories into ticked boxes, percentages, andpharmacological formulas. I was numb with that kind o numbness you get

when you ick through channels and hypnotize yourself. Faces, stories,questions all merged into each other. I had a revelation as I realized thatafter six hours o attending some fty patients, all these persons blendedinto one other, becoming a mass o cases. Tat experience was an unwit-ting moment o participation in what is often referred to in Bahia as the


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“dehumanization” o medical attention. It was the point at which my under-standing o medical practice shifted and came to include an understandingo how things felt for doctors in this context o scarce resources and the“social problem,” as Ricardo refers to it. We walked down a corridor, to the“private” part o the unit, newly built and latched onto the old crumblingpink colonial building. Several neatly dressed patients were waiting. He ex-changed caring words, hugs, kisses, and jokes with them. We took placein the very new, air-conditionedconsultório, where there was markedly moretime for listening and discussing, more space for negotiation, for nding a

way ( dar jeito). Te contrast, so proximate, was striking. Most o the gyne-cologists I met juggled several jobs, moving on the same day from the pri-

vate to the public sector ( ). Te typical pattern is attending patients ina health post or public maternity hospital in the morning and holdingprivate consultations in the afternoon.

We had a quick lunch in the hospital cafeteria, and idle talk rapidly gave way to sexist jokes exchanged between the hospital’s director, Mineiro the

anesthetist (a self-proclaimedpetista [ activist] studying for a law degree),and Ricardo. After a phenomenally sweet but much needed co fee, we wentstraight up to the labor ward where four young, heavily pregnant womenawaited “their [scheduled] surgeries.” We proceeded into the operating the-

ater for the rst delivery. I was impressed by how quick it was: twenty-sevenminutes from the rst incision to the nal stitch. Te baby was whisked oby the pediatric nurse and we moved on to the next surgery in the neighbor-ing, posher, and newer private operating theater. Te second baby was ex-tracted. We moved back into the rst, which had been cleaned up and wherepatient number three lay waiting. Everything stood out starkly with theother room: the electrosurgical scalpel was Cellotaped together, althoughit might now be considered a piece o 1950s design, the operating table

was rusty at the edges, and so on. Te surgical protocol swung into action,but this time things didn’t go smoothly. Te baby was ne but the patientstirred, and Mineiro kept having to leave his law books to increase the doseo anesthetic. ension rose. He and Ricardo exchanged stern words: “youdeal with your bit and leave the head to me [deixa a cabeça comigo],” Mineiro re-torted. Joking ceased. Tere was profuse bleeding and Ricardo and the nurse worked, silent, highly focused, their shoes splattered with birth blood. imedragged on, but the situation had come under control by the time the direc-

tor popped his head through the door and asked what on earth was goingon. Ricardo turned away from the operating table, exposing a long ow o


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blood that had stained his overalls from the crotch down. Catching sight othis, Mineiro burst out laughing and pointing to the blood exclaimed: “Tepatient started to whine and moan andRicardinho got so emotional that hemenstruated [ co menstruado]!”

Roughly 75 percent o Soteropolitanos rely on the (the nationalhealth service), which operates according to the principles o universality oservices, equality o all citizens, and integration o health actions. Foundedin 1988, the still faces major challenges and is marked by lack o re-sources, leading those who can a ford it to take out aplano de saúde (medi-cal insurance). wenty-ve percent o the population has private health in-surance, which gives them access to a range o services, including highlysophisticated, top-of-the-range medical services. Doctors, clinics, hospi-tals, and clinical laboratories haveconvênios (agreements) with di ferentpla-nos. Tese vary widely in the services they cover, the clinics they give accessto, and so on, compounding the stratication between “private” and “pub-lic” health even further. At one extreme, state-funded services vary (someare indeed excellent), but are generally characterized by lack o resourcesand long queues. In a context o stretched resources and overwhelming de-mand, the question oatendimento (medical attention) is intrinsically tied up with discussions concerningcidadania (citizenship) in a context where the

right to health is still very much in the making (Biehl and Petryna 2013).Medical practices and pharmaceutical drugs are used to fulll societal ex-pectations o work, appropriate fertility, and beauty, and to signal new so-cial relations. Given that the range o possibilities extends unevenly from very little access to health care to high-tech, specialist-led medical inter-

vention, with little in between, both possibilities become charged with par-ticular values. I became interested in how people in Salvador adopt medicaltechnologies, in a context marked, on the one hand, by the problem o over-

medication and a predilection for surgical operations, and by an absenceo quality primary care on the other. Medicine is a highly signicant socialinstitution in the making o urban Brazilian identities in a context wherethe highly di ferentiated class structure is reected in access to health care(Barbosa et al. 2002; Biehl 2004, 2005; Corrêa 2001; Edmonds 2007, 2010;McCallum 2005a; Scheper-Hughes 1992). McCallum (2005a) suggests thathealth insurance itsel functions as a marker o class distinction.

Te protests that took place across Brazil in June 2013 exposed massive

popular unrest over the limits o public services such as health care. Teeconomic boom o the 1990s and 2000s, which gave Brazil a new standing


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as no longer the “country o the future”—as Brazilians commonly say—butan “emergent nation” and key player on the international scene (Pinheiro-Machado and Dent 2013), left many behind as deep inequalities persisted.Aquino (2014) argues that the protests exposed the fact that the is un-able to ensure quality services to all, noting that the 25 percent o Brazilians who have private health insurance benet from tax waivers, which e fec-tively nances with public money the access to private care for this privi-leged minority. At stake here are contrasting visions o public health in acontext where the health system’s shortcomings are often glossed over astechnical problems or problems o resources, when they are also—and attimes primarily—political (Aquino 2014). Many Brazilian feminist schol-ars o health note the current de-politicization o health issues in relationto the radicalness and comprehensiveness with which public health was re-thought in the post-military transition o the 1980s (Aquino 2014; Costa2009; Diniz 2012). Diniz (2012, 126) notes that the inclusion o the socialand political aspects o health in the Women’s Comprehensive Health CareProgram ( ), launched in 1983, “lost ground to the discourse o ac-cess to medical consumption.” Likewise, Aquino (2014) and Diniz (2012)note policy back-peddling over the achievements that were conquered under

, most notably from religious and conservative lobbies.

Te period 1945–1980 saw massive changes in urban Brazilian classstructures following rapid industrialization. Gender, work relations, andattitudes to leisure, the body, and health shifted dramatically as womenentered paid employment. In their history o urban class formation, Melloand Novais (1998) explain that industrialization enabled the ascensioninto the middle classes o a new class o unskilled workers such as salesassistants or low-paid office clerks. Given the legacy o slavery and the per-petuation o a “culture o servitude,” physical labor lies at the bottom o

the hierarchy o employment and is stigmatized among the middle classes.Work is evaluated according to the degree o (dis)pleasure it a fords, anddistinctions are made between work that is clean or dirty, light or heavy,routine or creative, subaltern or managerial, and the years o formal edu-cation required to enter into a profession. Upward stratication produceda new class o managers, the rise o a service industry (publicity agencies,market research companies, etc.), and with it a new professional elite who

joined the traditional elite (comprising doctors, lawyers, landowners, and

businessmen). Te “stressed out bodies and tormented minds” o this newclass o professionals were—as Mello and Novais (1998, 629) impart, not


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without irony—in turn attended to by a growing body o psychoanalysts,astrologists, cardiologists, plastic surgeons, entertainment promoters, gymowners, divorce lawyers, massage therapists, interior decorators, endocri-nologists, dermatologists, and others. Te success o these specialties inBrazil is accounted for by reference to a process o “moralization,” whichchallenges the authority o the church, upholding in its place ideals oaper- feiçoamento (self- improvement) through work, spiritual development, andhygiene. Tis link between work, hygiene, and class is central to contempo-rary Brazilian class relations. A brie overview o the historical formation othese ideas reveals how the hygienist movement produced the body as a siteo intervention. In the early twentieth century concerns with hygiene andpropriety came to occupy a central role in processes o social di ferentia-tion and class. Physical and moral education were seen as necessary to theproject o producing healthy bodies, contained, polite individuals, demar-cating theculto (cultivated) from theinculto (ignorant). Te Brazilian histo-rian Jurandir Freire Costa (2004) argued that this producedhigiene as “em-blematic o social di ferentiation,” a mark o class that distinguishessenhores (gentry) from their subalterns. Tis movement o hygienic control trans-formed the “colonial family” by supplanting religious and patriarchal codeso conduct with an innitely variable hygienic—and, increasingly, an esthe-

tic—one (see Edmonds 2013). Some o the women I interviewed achieved what one might refer to as “middle-class status” through work or marriage,

and their reproductive trajectories and bodily projects are marked by thisclass transition.

Te minute details o physical appearance are carefully monitored andSoteropolitanos are able to deduce a great deal about a person’s socialstatus by analyzing their appearance, the neatness, style, and quality otheir clothes and shoes, as well as their gait and demeanor. Access to em-

ployment is contingent onboa aparencia (good appearance), a criterion thatblends beauty, presentation, locution, and jeito (manner/bodily expression).Although the economic means o achieving boa aparencia are unevenly dis-tributed, beauty and bodily care are important means o social ascent, ren-dering bodies sites where social hierarchies are renegotiated. Teinterior (rural zones) remains an important category o alterity in Brazil and oftenserves as a narrative foil to explain the substantial changes that have takenplace in urban Brazilian society. Crucial to this process o di ferentiation is

the concept o modernity, as implicit in the idea that people from the in-terior areatrasados (behind), or still hold to backward or ignorant traditional


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beliefs. On one occasion, my partner, young daughter, and I returned to Sal- vador after a weekend break. We opted to travel by thebarco de nativos (liter-

ally, “the native’s boat”) rather than the speedboat most middle- class beach-goers use. At 5 a.m., an old tractor wove its way along the single village road,picking up passengers. Sleeping children were gently passed into the tightlypacked rows o passengers on the hard wooden bench, along with luggage,sacks o produce, and baskets enclosing chickens. At around 6 a.m. we ar-rived at a small river port and embarked upon a two-hour journey to Va-lença, a small town a few hours’ bus journey from Salvador. We boardedsilently and took advantage o the boat’s rocking motion to gain a little morerest. Ten suddenly, obeying a signal unbeknownst to us, the boat awoketo a kind o organized agitation. Hair nets were removed and locks deli-cately unraveled, children’s hair was vehemently combed into order, elabo-rate makeup was applied, layers o warm clothing to ward o the dawn cool were stripped o f, revealing carefully chosen color-coordinated outts, plas-tic imitationhavaianas were swapped for pristine trainers or high- heeledshoes conjured out o bags. As the boat strenuously tugged along the lastcurve into Valença’s port, we observed the astonishing transformation thathad taken place among our fellow passengers. While we had initially stoodout as a family when we boarded the tractor, we now felt underdressed and

disheveled as we entered town. Tis anecdote brought home to us the con-siderable importance given to appearance and the intense issues at stake inhow one presents as one moves from the interior to thecidade (city).

Race is rarely the explicit language people adopt to speak about the “so-cial di ferences” at work in relations to medical institutions and bodily trans-formation projects in Bahia. I carried out this research over the courseo Luiz Inácio Lula da Silva’s two presidential mandates, when large-scalesocial programs targeting poverty were radically reconguring class rela-

tions. In the course o my discussions concerning contraceptive options,the salient issues that arose concerned shifting demands on public services,often couched in terms o debates about citizenship and responsibilities andframed within an aspirational politics driven by a desire to consume elite ser-

vices and goods. In her discussion o race and class in Salvador, McCallum(2005b) takes issue with the emphasis on community-based ethnographyin Brazilian anthropology, pointing to the difficulties arising from studyingclass without founding the discussion on direct observation o cross-classinteractions

. While she is careful to note that in Salvador, the body itsel is notthe sole or determining basis upon which racial categorizations are made


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(these also include dress, behavior, locality, and so on), she concedes thatbodily di ferences become imbued with particular—racialized—meanings.But this body is neither nished nor closed and is always the site o produc-tion and transformation: “changing its form and meaning, whether throughspiritual or magical technological intervention, through diet and exercise,or by medical means” (111). McCallum concludes that although the racial-ization o bodies is xed through the repeated re-inscription in spaces andinteractions that naturalize class di ferences, these are contested, wittinglyand unwittingly, by changes in the repeated patterns o movements andsubjectivity formations, which (re)structures these social hierarchies

Documents

Plastic Bodies by Emilia Sanabria