The Politics of Menstrual Suppression in Brazil more

Anthropology News • February 2009 in focus Mexico City continued from page  mortality rates fell and fertility rates rose. After a heavy loss of life during the Mexican Revolution, efforts to re-grow the nation were overtly pronatal in accordance with the prevailing nationalistic ethos that located the greatness of Mexico in its large families and expansive population. By the 1960s, population growth came to be seen as a national liability and high fertility rates were targeted as its insidious cause. Beginning in the mid-1970s (when most of my informants were born), the government launched massive family planning programs promoting contraceptive use and extolling the virtues of small families. Such programs are now credited with the sharp decline of the fertility rate from 6.8 children per woman in 1970 to about 2.2 children per woman today. However, this rate—hovering just above replacement level—has not entirely quelled population-related anxieties. As Carmen, a public health official, told me: We are still in the process of the demographic transition ... The goal that Mexico had for 2006 was to get to a fecundity rate of 2.1. We did not get there. One-tenth is easily said, but one-tenth means several years ... And all of our indicators [of family planning] went down because we let our guard down and because we were a conservative government. So, we are re-doing it. And still we are not in a replacement situation. Mexico’s population continues to grow. We are many millions and each minute four children are born. So, I still cannot sing victory. The nation’s low—but allegedly not low enough—fertility rate continues to concern state officials because it is seen as both the main cause of population growth and a sign of stalled modernization (ie, an “incomplete” demographic transition). These views are based on a measurement that conveys information about quantified, cumulative reproductive behaviors. Yet, in practice, the fertility rate is usually disaggregated as public health interventions target the sexual practices of specific groups, like the indigenous and urban poor, who are said to be major contributors to population growth. Justifying ARTs through Modern familial ideals Though few of my informants directly cited the national fertility rate, many of them did feel acutely aware of the so-called population problem, especially as they squeezed onto packed subway trains or sat bumper-to-bumper in stalled traffic en route to the fertility clinic. Their daily experiences of a crowded public sphere, along with exposure to campaigns promoting contraceptive use, reminded them of the social conundrums rooted in the existence of too many bodies. Hence, some saw their own concentrated, costly, high-tech efforts to have children as socially out-of-place. Striving to justify their use of ARTs, they often portrayed it as a “modern” way not just to reproduce but marriages. Such marriages, in contrast to traditional marriages of the past, include features like mutual friendship, trust and both emotional and sexual intimacy between spouses. Hirsch argues that this global marital ideology is not simply mimicked or directly internalized by people in Mexico; rather, it is co-opted in culturally specific ways. Likewise, the people I knew seemed to localize and mobilize similar modernist romantic ideals c o M M e n TA Ry also to create a family and, more specifically, to create a modern Mexican family—one fortified by strong marital bonds and affective ties within the nuclear household. A woman, whose husband went to work in the US for one year so they could afford fertility treatment, explained to me why she was using ARTs: “For the love of my partner. And to have a child, to feel what it is to be a mother... So many reasons! But, mostly, for love.” Likewise, one man told me: “I feel that having children is the culmination of the [marital] relationship.” These individuals, like others, sought to justify their use of ARTs by invoking modern marital ideals. As Jennifer Hirsch describes, one way that Mexican youth today self-consciously inhabit modern gendered identities is through the formation of companionate in order to justify using ARTs in a context where fertility control is prioritized and population-related anxiety is palpable, yet where having children remains personally and socially valued. It was one of several ways that they negotiated the tension between sociopolitical pressures to control reproduction and their own labored efforts to conceive. Ultimately, their experiences illuminate how reproductive desires, population politics and modernist ideals converge around the local use of ARTs, molding this now global technology into distinctively Mexican forms. Lara Braff is a PhD candidate at the University of Chicago. She is currently writing her dissertation on the cultural meanings and social implications of ARTs in Mexico City. Her fieldwork there was supported by a Fulbright-Hays grant. The Politics of Menstrual Suppression in Brazil Emilia Sanabria ÉcolE dES HautES ÉtudES En SciEncES SocialES Pharmaceutical sex hormones have a complex history. Initially administered to treat menstrual irregularities, their contraceptive properties were first presented as a sideeffect. This side-effect was reconfigured into a primary effect with the development of the oral contraceptive pill in the 1960s. The standardization of the 21/7 pill regimen (21 active pills followed by a 7 day pause or 7 placebo pills) is generally accounted for by the ease of administration it presented—given that women could resume a new pack on the same day of the week each month—and by what was seen as a cultural preference for regular menstruation. Today, the “need” for regular menstrual periods is being put into question, largely under the impetus of the pharmaceutical industry. A menstrual suppression survey of 1,000 women, funded by Wyeth Pharmaceuticals, recently found that 67% would not miss their periods if they disappeared. According to a report put forward by the Association of Reproductive Health Professionals who commissioned the survey, 40% of women would choose to never menstruate and only 22% would opt to have a monthly period. The survey nevertheless reveals that only 17% of women feel that it is safe to take hormones, whilst 37% feel it is not safe—findings that are absent from the Executive Summary and Key Facts. The idea that regular menstruation is a new and potentially harmful phenomenon has received much attention since the 2003 FDA approval of Seasonale—an ordinary combined contraceptive pill repackaged to produce only four menstrual periods a year— and the English publication of Brazilian gynecologist Elsimar Coutinho’s controversial book Is Menstruation Obsolete? (1999). Arguments for menstrual suppression are founded on two interconnected claims concerning menstruation. The first differentiates the regular bleeding pattern experienced by contraceptive pill users from “natural” menstruation, suggesting that because hormonally regulated bleeding is already artificial it is also dispensable. The second claim denaturalizes regular menstruation, arguing that it is a “new biological state” as “in the past” (or in “tribal” contexts) women experienced less menstruation, reaching menarche later, having more children and breastfeeding them longer than “modern” women do. Modern life, it is suggested, has produced regular menstruation as a new norm. Menstrual suppression advocates recommend the use of uninterrupted hormonal contraceptives as a means of returning to “nature’s norm” of fewer periods throughout one’s reproductive life, often suggesting that the “increased hormone exposure” brought about by “incessant menstruation” is harmful to women’s health.  in focus February 2009 • Anthropology News Lifestyle options and Population control My research is based in Brazil, where long-acting hormonal methods such as three-monthly contraceptive injections, subdermal hormonal implants and hormone-releasing intra-uterine devices—all of which interfere with regular menstruation—are presently widespread. The availability of contraceptive pills as over-the-counter pharmaceuticals in Brazil has allowed Brazilian women to use the pill with or without regular interruption, enabling them, for example, to skip periods during Carnaval. Although presented in the US and Europe first and foremost as a lifestyle option, menstrual suppression grew out of the search for long-acting hormonal contraceptives that would overcome patient “misuse” in the developing world, providing efficient methods to deal with the “overpopulation problem” seen as characterizing these regions. There are key differences between the kinds of populations produced, in a biopolitical sense, through the marketing strategies and biomedical practices surrounding different menstrual suppressive methods. In Brazil different methods target lowincome segments of the population who rely on under-funded public health services, on the one hand, and those who can afford private health insurance (roughly 25% of the population), on the other. This is particularly visible in CEPARH, the clinic that Elsimar Coutinho runs in Salvador da Bahia (Northeast Brazil). This is an atypical institution in the Bahian medical landscape, simultaneously catering to Bahian elites and offering a charitable, free family planning service to “the poor,” though in clearly differentiated spaces. Upstairs, it functions as an exclusive state-ofthe-art gynecological center, where wealthy women are offered the newest contraceptive technol- according to different rationales, which resemble the twin disciplinary and regulatory goals that form the basis of Foucault’s initial enunciation of biopolitics. The distribution of sex hormones follows these two complementary logics. As contraceptives, sex hormones are central to interventions on the population; through the development of new forms of administration that produce consumer subjectivities, sex hormones are also involved in the individualizing modes of biopolitics, concerned with the performance of the body at the molecular and affective levels. The hormonal practices observed in Salvador reveal a form of what Ginsburg and Rapp call “stratified reproduction” (Conceiving the New World Order 1995), which is reflected and reiterated through the distribution of both different kinds of menstrual suppressive hormonal contraceptives and their distinct associated discourses of womanhood. Where low-income women’s reproduction is concerned, lack of family planning is widely seen as contributing to social marginality, violence and crime. Reducing the birth rates of poorer segments of the population is seen as synonymous with lifting the nation out of underdevelopment. In this neoMalthusian vision, poverty is seen to be the result of excessive fertility rather than its cause. In a context where 40.1% of women aged 15– 49 have undergone surgical sterilization, menstrual suppressive hormonal injections (such as Depo-Provera and Contracep) are pitched as efficient and reversible alternatives for low-income women. In the 1996 survey data, hormonal injections accounted for only 0.8% of contraceptive methods, but this has undoubtedly increased over time. In Salvador, Salvador estimated that the threemonthly injection accounted for 60–70% of contraceptive methods they distributed. In contrast, biomedical and popular discourses surrounding hormonal products marketed to private sector patients center not on demographic control, but rather on self-control. Private sector patients are invited to take up menstrual suppressive methods to enhance the self and regulate affective flows. Subdermal hormonal implants tend to be classified with injectable contraceptives as methods that target the global poor, most notably in light of the Norplant experience (see Mintzes et al, Norplant: Under Her Skin, 1993). In Brazil, however, the marketing and price of hormonal implants has produced women to balance their busy professional and personal lives. Sex hormones can thus be said to operate regulatory control at several distinct levels in Brazil. In their form as contraceptives they are adopted as modes of regulating the population, as standardized treatments are administered to control the body politic through the body of “the poor.” In the private health sector, the marketing of hormonal regimes and menstrual suppressive methods emphasizes the personalization of treatment, as patients are enjoined to take up these methods to regulate their bodily capacities and act upon the affective domain. Here drug profiles and social identities are mutually constitutive. The two biopolitical modalities revealed Queueing in the shade of CEPARH’s mobile family planning unit in a lowincome neighborhood (Salvador, Bahia). Photo courtesy Emilia Sanabria c o M M e n TA Ry ogies and can have tailor-made hormonal doses implanted subcutaneously to suppress menstrual bleeding or as a form of hormone replacement therapy administration. Downstairs CEPARH offers a free family planning service that has been denounced by the feminist and black movements as unethical or eugenically motivated. Between CEPARH’s different floors, sex hormones circulate where Depo-Provera is disproportionately popular in relation to the rest of the country, the number of Depo-Provera units distributed by the state of Bahia alone (excluding those bought directly over the counter) rose from 354 in 1994 to 45,675 in 2003. Although no comprehensive state-wide data is available for the period 2003–08, in 2008 health providers in three distinct family planning centers in these as private practice treatments, that is, as elite consumer products that are only made available to low-income women during clinical trials. Hormonal implants, like the uninterrupted use of the contraceptive pill or the menstrual suppressive intrauterine system Mirena, are marketed to private sector patients as drugs for the modern lifestyle, freeing women of menstruation. Advertisements emphasize remapping the possibilities of the body and a particular kind of sexual optimization that the freedom from menstruation and the control of hormonal flows is seen to afford. In Salvador, implants combining various hormones in “individualized” doses said to match each patient’s profile are available. Testosterone is often added to delineate musculature, give “disposition” and boost sexual desire, making the body both sexually and socially productive, and enabling by hormonal practices in Salvador evoke the shift that Rose describes in The Politics of Life Itself (2007), from collectivizing forms of biopolitics based on compliant patienthood and concerned with demographic control to a new epoch of “somatic individuality” and “selfoptimization.” What is striking is that in Brazil these two epochs coexist, although the marketing and distribution of hormonal methods articulates differentiated populations within the Brazilian national context. Emilia Sanabria is a postdoctoral researcher at the École des Hautes Études en Sciences Sociales (EHESS/CNRS) in Paris. She has a PhD in anthropology from the University of Cambridge, where she co-founded the Cambridge Interdisciplinary Reproduction Forum, and can be contacted at emilia.sanabria@ehess.fr.