Plastic Bodies: Sex Hormones and Menstrual Suppression in Brazil. Emilia Sanabria, Durham: Duke University Press, 2016, 252 pp.
In a place where bodies are routinely modified via medical interventions and prominent physicians declare “war on menstruation,” what are hormonal contraceptives and what sociobiological tasks do they perform? These are the questions Emilia Sanabria’s Plastic Bodies aims to answer. Her fine ethnography offers an analytically sophisticated account of the multiple trajectories of menstrual blood and sex hormones in Bahia, Brazil, where disaggregated components of hormonal contraceptives are put to uses well beyond pregnancy prevention. These substances participate, she contends, in a particularly Bahian ontology in which bodies are plastic—fundamentally alterable and open to interventions. “[I]n the Bahian medical landscape … women come to understand themselves as chemically transformed and transformable beings” (p. 189). Well written and thought provoking, this book productively examines the tensions between fluidity and boundedness, bodies and substance, nature and culture.
Plastic Bodies is based on ethnographic research in Salvador, the coastal state capital of Bahia, Brazil. Home to the largest black population outside the African continent, Salvador is religiously diverse and highly socially stratified. Brazil’s two-tiered public and private health care system reflects and reproduces this stratification. Sanabria notes that “[b]iomedicine in Brazil is marked by unregulated overmedication and a predilection for surgical procedures, on the one hand, and by the absence of many basic services on the other” (p. 129). Within this uneven healthscape, and with the rise of pharmaceutical markets in Brazil, hormonal contraception has transformed into a tool for menstrual suppression and self-enhancement.
The starring substances of her ethnography, menstrual blood and sex hormones, led the author on a winding journey through public and private hospitals, pharmacies, primary health care clinics, community gatherings in low-income neighborhoods, a blood donation center, a pharmaceutical laboratory, a family planning clinic, and weekly meetings of a local travesti group. Her interlocutors are just as diverse: doctors, nurses, social workers, pharmaceutical representatives, and, of course, women (and some men) whose bodies constitute the substrate on, in, and through which blood and hormones flow.
The first part of the book explores women’s use of hormonal contraception to suppress menstruation, drawing on participant observation in clinical spaces and more than 60 in-depth interviews with a demographically diverse cohort of women. Most of these women tend to experience menstruation as upsetting the body’s normal equilibrium. Sanabria highlights their ambivalence regarding menstruation, a physiological reality viewed as at once normal and exceptional. Women in Bahia make ready use of hormonal contraception to rebalance their physical and emotional states, “regaining control over their bodies” (p. 72). It is in the ways menstrual blood is managed that the inside and the outside of the body are constituted and demarcated. Here Sanabria captures the particular ways in which women tune into the constant fluctuations of their bodies and bodily substances, drawing on local conceptions of the reproductive organs and their sociobiological constitution. The bounding of bodies and their substances, Sanabria suggests, is never quite finished.
In contemporary Brazil, the notion that modern women should be able to choose whether or not to menstruate turns on arguments that make liberal use of both pseudo-evolutionary and pseudo-feminist rhetoric. In the past, the story goes, women did not menstruate, or did so only rarely, heavily burdened as their childbearing bodies were. Today, women become pregnant less and thus menstruate more. Menstruation, therefore, is an unnecessary anomaly with inconvenient side effects. Sanabria’s analysis deftly weaves together international scientific debates, local medical representations of menstruation, historical and contemporary menstrual management practices in Bahia, and women’s narratives of their own experimentation with hormonal menstrual suppression. The dominant opinion, as she demonstrates, is that thanks to modern pharmaceutical advances, women have the choice—even the right—not to bleed.
In the second half of the book, Sanabria focuses on sex hormones, demonstrating that these substances do not simply intervene in, but, in fact, help produce bodies, genders, and socialities in Bahia. She highlights the tensions between the apparent plasticity of the bodies in which these substances act, on the one hand, and the relative rigidity of social norms and realities that condition the ways in which they circulate, on the other. Although male and female sex hormones “can now circulate outside bodies, specific norms and prescription regimes continue to reinscribe their uses within a dualistic model of sex” (p. 105). In Bahia, testosterone prescriptions for women have become a mainstream medical practice, with doctors actively debating and applying treatment regimes designed to rev up sex drive, tone skin and muscle, and enhance quality of life. Outside clinical spaces, transsexuals, and travestis must procure “female hormones” via the informal market, with little access to information about their indicated applications and potential side effects. While the substances themselves may be ontologically fluid, they remain bounded by ideas about their socially appropriate use.
The circulation of sex hormones also reinscribes socioeconomic differences, particularly in how hormones are offered in public versus private health care services. Hormonal contraceptives are packaged and prescribed to women of different social classes in ways that reproduce the longstanding inequalities that characterize contemporary Brazilian social relations. Sanabria’s findings indicate, furthermore, that biomedical use of sex hormones is “embroiled in aspirational class processes, where access to medical care of the kind associated with private medicine, to surgeries, and to imported pharmaceuticals is a means of literally embodying a form of class ascension” (p. 131). While Sanabria mentions that race was not a category that her interlocutors used to understand themselves and their social milieu (p. 34), the history of racism and racialized inequality in Brazil would seem to call for an analysis of the role of skin color and racial identity in the reproduction of the inequities she documents in the health care system. Still, her analysis of class and distinction poignantly problematizes the notions of self-governance and horizontality embedded in contemporary theories of biosociality.
Honing in on sex hormones as substances, Sanabria takes us through the process of disaggregating and repackaging hormones into the myriad forms in which they are ingested, injected, or implanted. Along the way, she reflects on form and materiality, suggesting that the manipulation of pharmaceuticals like sex hormones opens up renewed possibilities for conceiving of object ontologies. What appears solid and given is revealed to be the unstable convergence of varied substances and efficacies. Sanabria suggests that a more productive path for anthropological inquiry into the social lives of pharmaceuticals—one that “attend[s] to the materiality of drugs beyond their pharmaceutical composition” (p. 188)—would examine the multiple and ephemeral forms these drugs take and the social-material efficacies they produce.
Although it does not affect the overall contribution of this outstanding ethnography, it should be pointed out that Sanabria’s fieldwork is heavily concentrated in Salvador and its metropolitan area. The realities of the city differ considerably from those of the vast expanses of rural interior in most of the rest of Bahia, not least in terms of the availability of pharmaceuticals and medical services. One wonders how Sanabria’s analysis of menstruation narratives or pharmaceutical trajectories might have differed had she attuned more to such divergences. No single ethnographer, of course, can hope to cover a state as vast and diverse as Bahia, but it is worth noting these socio–geographic specificities.
Clearly written and engaging, Plastic Bodies will make an excellent addition to both graduate and undergraduate reading lists, in particular in courses on the anthropology of the body, reproduction, and science and technology studies. It will also be of interest to those who teach courses on Brazil and the Brazilian Northeast region.