ing the medicalization of reproduc- tion in Brazil, where I have been ed full implementation of the pro- gram. Although surgical sterilization and the pill account ...
Anthropology News • January 2005
IN FOCUS
Choosing Sterilizations in Brazil GINA HUNTER DE BESSA ILLINOIS STATE
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eminists have called attention to the potential physical, psychological and political risks new reproductive technologies pose to women. These concerns are well founded in light of uses of old reproductive technologies. The forced sterilization of minority, disabled and impoverished women exemplifies the human rights abuses entailed in eugenicists’ and population control proponents’ efforts to manage certain groups of people. Family planning programs have often focused too on demographic targets at the exclusion of women’s preferences and broader health needs. Role of Ethnography A decade ago, at the UN International Conference on Population and Development (ICPD) in Cairo, women’s health advocates succeeded in consolidating a shift in international policy, planning and discourse from a population framework to one conceptualized around reproductive health that employs an expanded understanding of reproduction, one emphasizing the social context of sexual and reproductive behaviors and the need for women’s empowerment. C O M M E N TA RY Given their attention to the social and historical construction of reproduction, anthropologists can further reproductive health and rights through detailed ethnographic examinations of the ways reproductive health needs are defined in local contexts. Anthropological fieldwork is especially well suited to investigate the social nature of reproductive activities and decisions often overlooked in demographic and health studies focusing on the individual. Anthropologists can also determine the local meanings of health and the cultural commensurability of Western notions like “reproductive rights” and “self determination.” These analyses provide the groundwork for understanding how modern biomedical technologies are
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embraced by or imposed on people in diverse local settings. In Pragmatic Women and Body Politics Margaret Lock and Patricia Kaufert provide a framework for conceptualizing and investigating the process of medicalization. Contrary to interpretations that see medicalization as primarily a top-down form of social control inflicted on passive victims, these writers argue that medicalization must be situated within specific historical and cultural contexts. It must be seen as constituted by lay people and professionals alike. The usefulness of this approach is evident, for example, in understanding the medicalization of reproduction in Brazil, where I have been
ed full implementation of the program. Although surgical sterilization and the pill account for most contraceptive use in Brazil, sterilization was effectively illegal until 1997 and thus was not covered by either public or private health insurance. The lack of adequate family planning in the public healthcare sector and the illegality of abortion encouraged women to rely on sterilization. At the same time legal restrictions to sterilization created a situation where poor women resorted to a number of extraordinary means to get access to
[T]he desire for surgical sterilization must be understood as the pragmatic expression of women’s agency in the face of patriarchal gender relations and economic constraints.
Birth Control in Brazil of the 70 percent who use any method
Sources: PNSMIPF and PNDS, Brazil
examining surgical sterilization among low-income, urban women. Sterilizations in Brazil Brazil has some of the highest rates of surgical sterilization and cesarean section in the world. Unlike some countries where sterilization is prevalent, in Brazil the trend is not the direct result of a government population policy or widespread family planning program. Private family planning agencies, however, began operating in Brazil in the 1960s and too frequently promoted long term contraceptive methods without adequate attention to women’s health. To correct this, a comprehensive women’s health program, which includes access to reversible contraceptive methods, was passed in the mid-1980s. Unfortunately, a lack of funding and political will prevent-
contraception with uncooperative partners and their dissatisfaction and distrust of reversible methods as their primary reasons for wanting to undergo surgical sterilization.
the procedure. Most commonly, doctors and women circumvented legal restrictions by arranging for tubal ligations in conjunction with other surgical procedures, usually an unnecessary cesarean section. The association of sterilization with cesarean childbirth held deleterious consequences for women’s health. A law was passed in 1997 to regulate sterilization and reduce the use of cesareans; yet poor implementation of the law and limited service availability mean that poor women still struggle to access the procedure. Although contraceptive services have expanded in recent years, Brazilian women continue to rely on sterilization. During my fieldwork in a poor neighborhood in the city of Belo Horizonte, women cited the difficulties of negotiating
Being primarily responsible for childrearing, women argued that they, rather than doctors or male partners, should be entitled to make contraceptive decisions. Although women’s choices are highly structured, the desire for surgical sterilization must be understood as the pragmatic expression of women’s agency in the face of patriarchal gender relations and economic constraints. While Brazilian women have embraced medicalized contraception and postpartum sterilization, they lament the excessive use of cesarean sections, which obstetricians perform for a variety of reasons, including their own convenience. Women’s interests and health would be better served by the provision of postpartum sterilization following a vaginal delivery. Ironically, the new law, meant to discourage cesarean section, prohibits postpartum sterilization and requires women who want to undergo sterilization to return to the hospital 42 days following giving birth, an arrangement these already overburdened women find difficult and impractical. Rights in Context The Brazilian case provides many lessons for those concerned with reproductive health and rights. Historically, women’s health advocates in Brazil have had to struggle to obtain adequate reproductive health care services. They have struggled against those international and domestic groups interested in aggressively promoting limited birth control methods and population conSee Choices in Brazil on page 18
Anthropology News • January 2005
Mass Sterilizations Continued from page 13 to potential education and professionalization. Although children are very much wanted and loved, the discourse of family planning has successfully become morally linked to modernity, rationality and the notion of striving for a better life. Uses of Reproduction This ideology meshes perfectly with a family planning program whose goal is (and has always been) to use population control to “fight poverty”: as one official told me, “if they have fewer children, the money will stretch farther.” In Ayacucho, one of the poorest regions of Peru with a fertility rate of 4.2 children per woman, making reproduction about economics is a successful tactic. Even so, I was told that the program faced “challenges”: mainly, the poor, “because of their culture,” avoid the hospital and lack education about family planning techniques. Ultimately, in order to reach their government-imposed quotas, health workers used tactics such as giving women food if they would undergo sterilization, or withholding it if they would not. When “culture” is employed in this fashion, as an excuse for imposing sterilization programs on the most vulnerable, anthropologists need to pay attention. Understanding how culture is implicated in reproductive policy requires thinking through the socioeconomic uses of reproduction. The policy of mass sterilization affected the poorest Peruvians, just as access to reproductive technologies continues to be available only to the upper echelons of that society. Peru’s lower classes (who, not coincidentally, are thought to be “more Indian” than those who control the country’s wealth and power) are oppressed on many levels; the death or disappearance of 70,000 of them during the years of violence (1980-2000) caused barely a murmur from the Lima elite. In this context, what does it mean for a national family planning policy to “fight poverty”? If reproduction of the wealthy is assisted and approved, even as reproduction of the poor and indigenous is criticized as ignorant and systematically prevented, then genocide and eugenics are not unreasonable labels for the situation Peru faced in the late 1990s. The policy of
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IN FOCUS
mass forced sterilizations, under the guise of fighting poverty, challenged the right of poor and indigenous women to reproduce, and could be interpreted as part of an unvoiced effort to remake Peruvian society as rational, economically solvent, and above all, non-indigenous. An anthropologically-informed policy might propose that Peruvian families already have a strategy by which both fertility and poverty can be effectively managed, by parceling out kids under particular conditions. This system allows those who are infertile and can’t afford access to new reproductive technologies to foster a related child. Because the Peruvian state has very few social programs available to help children, impoverished couples who reproduce “irrationally” have little to no government support for raising several children. In this context, child circulation thus becomes a potential response to population control policy: a large number of children can be temporarily or permanently redistributed to kin with fewer children, distributing both the burden of providing for them and the benefits of their company, and doing the social work of maintaining strong connections throughout the social network. C O M M E N TA RY Policies on family planning are not produced in a vacuum. The circulation of children, the temporary placement of children in orphanages while parents get back on their feet, the illegal and legal adoptions that have taken place in the last few decades—all these techniques are responding to a reality of poverty and ingrained racism that the government policy does not fully acknowledge. As the head of Ayacucho’s Family Planning program emphasized to me that day, the program is not really about reducing poverty—“it will take a lot more than just planning families to solve Peru’s poverty problems.” Recognizing child circulation as an alternative method of “family planning” might help to prevent mass forced sterilizations in the future, but it would require that the government extend its definition of family to acknowledge the strategic kin arrangements that Peruvians have used for centuries. A■N Jessa Leinaweaver is a doctoral candidate in the department of anthropology at the University of Michigan.
Choices in Brazil Continued from page 14 trol. The specter of these population control interests linger even after the total fertility rates in Brazil have declined rapidly over the past four decades, largely because Brazilian women have gone to remarkable lengths to limit their fertility. Earlier this year, Emília Fernandes, head of the special secretariat for women’s policies, suggested that family planning be a requirement for families receiving welfare. While all Brazilian women need adequate access to a full range of reproductive health services, attaching family planning to welfare targets certain women for reproductive control. Although feminists immediately rebuked the plan and Fernandes was forced to resign from her post, the episode reveals high-level government officials’ ignorance of demographic trends. Evidently, some within the Brazilian government continue to be influenced by neo-Malthusian ideas that simplistically link poverty to overpopulation and ignore the economic and political arrangements that fail to meet basic human needs. Ensuring reproductive health and rights requires a concerted effort in ideological, political, economic and cultural spheres. Historically and ethnographically grounded accounts can trace the ways these transit global and local contexts. Such analyses can show how medical institutions are them-
Technology in Japan Continued from page 15 couples who use assisted reproductive technologies, based on assumptions about age and the family. Private fertility agencies in the US make their own decisions about who to accept as potential parents, sometimes based on sexual orientation. Furthermore, the US, like Japan, is a wealthy nation that donates a significant amount of money annually to developing countries in order to help alleviate population problems and improve access to education about contra-
Women waiting for a family planning session at a health post in Brazil.
selves culturally mediated. By placing men and women at the center of our analyses, ethnography can demonstrate human capacity for agency in the face of powerful medical and political forces. In these multifaceted analyses of power and resistance, anthropological accounts can also be politically engaged. Anthropological analyses of the political economy of reproduction and its consequences for men and women’s lives can become the ground from which health and rights are envisioned and achieved. A■N Gina Hunter de Bessa is an assistant professor of anthropology at Illinois State University. Her research in Brazil focuses on lay perceptions of reproductive processes, contraceptive practices and the medicalization of reproduction.
ception, AIDS and other reproductive health issues. Yet, the US, like Japan, has a tendency to focus on trying to ameliorate disparities in access to reproductive health care and education overseas, without necessarily addressing these issues adequately at home. The case of Japan prompts us to look more closely at the way that such issues are addressed in the US, and to place a priority on addressing the assumptions embedded in our own policies before exporting them overseas. A■N Shana Fruehan is a doctoral candidate in the Committee on Human Development at the University of Chicago.
