Panoopat Poompruek, Pimpawun Boonmongkon and Thomas E. Guadamuz

At the Dok Mai Studio, a group of Thai kathoei, aspiring to live as women, meet regularly to inject hormones. Here, they provide each other with advice about various oral medications and injectables, and about managing negative side effects to achieve the desired results—breasts, glowing skin, femininity. They provide support too, as they seek to negotiate a life in Bangkok that is at the same time accepted and transgressive.

Sai’s Story

Among the other Dok Mai Studio crowd members, Sai was the last to embark upon her journey of medicine taking. Some of her friends had taken medicines when she was in her fourth year of high school, and she had tried it herself, but she did not continue because an older student warned her that if she took a lot, she would become confused, would not have a clue about her studies, and would not be able to pass university entrance exams. So, Sai first resisted the urge. The first kind she took was Diane, an oral contraceptive brand. An older friend told her it would make her beautiful and her skin would become white. She took one tablet per day, and it was effective—she got breasts:

My senior at school told me it’d make you pretty. Her skin was very white. So I bought and took Diane and my breasts grew. In the past, I was in a boys’ school. So, when my breasts grew a bit, oh, it was a rage. I became interesting to the boys. And so I bought more, taking a pill a day. I just took them in any order, didn’t follow the arrow on the pack or go against it. Just pressed them off the blister pack and took them.

Sai began to use medicine in earnest in her fifth year of high school. By this time, she was permitted to wear a rong song hairstyle (short in the back but longer on the top of the head) as she was now a senior in her school. The pills gave her headaches so badly she could not bear it anymore. A friend advised her to switch to another brand, Preme. Sai was in luck. She did not get side effects from this brand, and so she has used it ever since. But when she talked with some older kathoei students, ¹ they told her that if she wanted to become more beautiful, she should take a combination of different medicines, like they did. Preme alone, they thought, was insufficient for becoming beautiful. So, she added another kind, Premarin. Her expectation was that by taking this second drug, her breasts would grow bigger. When two kinds of pills were insufficient for the job, Sai decided to add hormone injections to the mix. A clinic near her school provided Progynon injections for a promotion price. She had them once a month. The injections did help her breasts to grow, but she felt weak and devoid of energy. She herself called these side effects ‘laziness symptoms.’ Because of them, she could not prepare for her entrance exams. So Sai stopped taking these injections for a while, and just took her pills.

When She Hit It Hard

When Sai finished her final year of high school, her life had become freer—she did not continue her studies. She started working in a large cosmetics company, and there she could already dress as a woman. During this time, there was a shortage of Premarin on the market, so she could not take it any longer. Instead, she found so-called Lao birth control pills (ya khum Lao). She took these each day with Preme, combined with weekly injections of Progynon. She was able to reduce the side effects by adjusting the timing of intake, so ensuring that none affected her too much when she took them:

I’d mostly heard about these ways from others, and now I tried them out by myself. Preme, for example, I took three pills a day. I might split that into one in the morning and two in the evening, together with one Lao birth control pill. In other words, at the time when I was hitting it hard, I took them mostly in the evening, and so they would not have too much effect—I’d fall asleep and not feel anything. Because with these drugs, when one takes a lot of them. … I also felt at one point that when I went out to work, did makeup for the clients, if I faced really bright sunlight, I felt dizzy, didn’t have much energy.

After working for a while, Sai increased her dosage again when she met her first boyfriend and felt it necessary to make her body as womanlike as possible: “To make me beautiful, to not make him feel embarrassed about having me as his girlfriend,” Sai explained. She now took hormone injections, Proluton, twice a week, every Monday and Thursday. But Sai experienced numerous side effects, and after three months, she had to reduce her dosage:

It lasted some three months. During these three months it was like this, non-stop. My body really changed. My emotions changed so much that I felt like I was someone with violent mood swings, like someone who exploded with anger for no reason. And I ate so much. I was at my fattest at the time. At the time, I was some 53 kilos. I normally can eat whatever and not get fat, but during that time I ate so much. Phi Meng, I could eat over ten plates of rice in a day. Fifty-three kilos was a lot. I looked radiant, was fat, and had good skin. I was getting a lot of injections, had a new boyfriend, and worked as well. I felt that problems were circling me—my emotions were so violent and I spoke so arrogantly that my closest friend told me that if I didn’t cut down on my hormones, they would not want to come near me, because I’d complain and explode with anger just like that. I also had no sexual desire. I felt like, er, I was a woman and just wanted to do things related to beauty. Like this. But no sexual desire. My sexual organ didn’t have any feeling—it was as good as dead.

Although Sai could not tolerate the side effects any longer, she did not stop taking hormones entirely, because she still wanted her body to appear feminine to her boyfriend. Instead, she cut down her hormone injections to once weekly or once every two weeks. She also reduced her doses of Preme and Premarin to one tablet of each per day. The Lao pills she stopped taking altogether. For four years, whenever she observed that her body looked less feminine, or her boyfriend mentioned it to her, she lost confidence and increased her dosage again, both oral and injected hormones, to her previous levels. When she had regained her self-confidence, she would slowly cut down her dosage.

Sai, Revisited

Sai’s self-medication had a lot to do with having a boyfriend. She wanted him to feel that she was as much like a woman as possible. But he told her: “Sai, you’ve got to accept that in any case, you’re not a woman.” He was also unfaithful many times, and Sai finally decided to end the relationship. She moved out of Bangkok to “flee her love.” Her new life constituted only work. Having lost her motivation, medicines no longer seemed necessary to her, and she stopped taking them. When she began to hang out with her friends in Bangkok again, however, she resumed taking hormones. This time, she did not take such heavy doses, but used the same brands as before—Preme and Premarin, one each per day. Sai surgically augmented her breasts and had to adjust her dosage once more, to fit with the changes in her body. She was now taking hormones to ensure she would not develop bulging muscles, and to take care of her skin. She took two pills of Progynova each day and half a tablet of Androcur every two days to control the production of male hormones, as she had not had sexual reassignment surgery.

Twins Nam Daeng and Som

Nam Daeng

I didn’t know about it before I visited Corner, [a bar for] kathoeis who sell their cunt on Patpong. They were really in the top league of beauty. They said to me: “Why don’t you take birth control pills? When I was kid, I wasn’t as pretty as you. Go ahead, take them, in secret. If your mum does not let you take them, then hide it.” They advised me that people usually took one pill a day. I wanted to be more beautiful, so I took a lot. Took a lot first and then slowly tapered it down, because this can increase your hormones. So I did take them secretly. When I first took them my spots disappeared. When I got spots again, I took them again. After a while, I had no muscles, and began to feel pretty. I began to get moody, my moustache wouldn’t grow, and I had no spots. My moods were more feminine—whatever I did, I was so emotional. I didn’t have much energy, but I was ever so moody. I didn’t have energy but I had a fighter’s heart.

Nam Daeng’s and Som’s medicine use began when they were 17 years old, but they did not start using hormones at the same time. Nam Daeng began first, because at the time she already felt confident enough to dress as a woman. Som, at the time, was still choosing between gay and kathoe i identities because she was not quite sure if she would pass as a woman. She tried taking small doses of hormones from time to time, then stopped, because she had decided to be gay. Nam Daeng started with the oral contraceptive Diane, but it gave her migraines and she switched to another brand, Preme. In her first month of taking Preme, she took three pills a day—one in the morning, one at midday, and one in the evening. Based on advice she had acquired from the kathoeis at Corner—her role models in medicine taking—she later tapered down her use to one or two pills a day. She believed that by beginning with a strong dose, the effects of the medicine would stay with her longer. When she noticed the effects wearing off, she went back to taking heavier doses, and so on.

Hitting It Hard

When Som began to feel that her experiments with dressing as a woman were successful—people were complimenting her on her beauty and men had begun to take an interest in her—she abandoned her gay persona and started to dress as a woman full-time. What was needed though, were hormones, just as they had been for her sister Nam Daeng. Som began taking hormones five years later than Nam Daeng, at the age of 22, which kathoeis consider a late start. Som felt that she had to hurry her feminization, and she did so by taking large doses of hormones. She began with six tablets of the oral contraceptive Preme per day—three times per day, two tablets each time. Now Som and Nam Daeng were both experimenting with medicines—they tried whichever kind their friends said were effective, including the Lao birth control pills, which are considered the strongest available. But both had to discontinue these, as, while they made their breasts grow, they had heavy side effects: Nam Daeng

The Lao birth control pills are bought from Burma, by the ten or by the dozen. Some come in from China, too. These are really weird, scary birth control pills. They say that women only take one a month, but kathoeis take one a day. I tried taking one a day. The first time I took them was with this kathoei on Silom (Road), who told me to take them because they’d be quite something, two tablets. I took them and became beautiful in an instant. After the first blister pack, oh, my breasts grew straight away. My breasts hurt. But I couldn’t take the second blister pack because I puked really hard. But just that one pack made my breasts stand out. If something touched my breasts, they hurt so much. Oh, no. Like, they were really something. I put on a shirt and when the shirt touched my breasts they hurt really bad. They became real humps I could push up with a bra. If I did that, I looked like a chani (derogatory term for women) who’s had kids, and the bra got soiled with, like, white, thick milk that came out of my breasts.

After the Laotian pills, the twins switched to injectable hormones twice a week. Then they added two tablets of Androcur per week to the mix to reduce their male hormones. They also took their previous dose of Preme. In combination, these medicines constituted what the twins considered their full option. But they also kept on trying new medicines, so eagerly that they became the ones to whom others would turn to if they wanted to know which medicines worked well. If the twins said a certain medicine worked, others would start taking it.

Nam Daeng and Som took many kinds of medicines and so had to take several tablets at a time, several times a day. This complicated their lives. Older kathoeis also told them: “Don’t take too much, you’ll ruin your kidneys.” So both quit all hormones except the injectables, which impressed them because they were fast acting and convenient; they did not have to carry around pills every day. However, these injections could still be considered hitting it hard because they had them once weekly (or four times per month): Som

We had so many injections. So many that Nam Daeng and I stopped taking pills altogether. At that time, we just got the injections. Like, if I got the injection today, next week I’d already start to feel something. But with pills, I think you can see results in two months’ time, like in the second month. And though you’ve seen me complain, they’re good. Better than pills.

Quitting Hormones

Having supercharged herself with hormones, both oral and injectable, for some two years, Som quit. She had tried to adapt the medication regimen many times, changing the dose or the timing, but to no avail. The side effects were numerous. She felt nauseated and vomited, but was willing to put up with these side effects for beauty’s sake. But she also felt very weak and devoid of energy, because her muscles had shrunk. Both she and Nam Daeng had to work hard to earn money, and lack of energy made this difficult. In addition, she became depressed, then suicidal. She was lucky to have her mother warn her: Som

When I was taking a lot of birth control pills or injections, I knew that I wasn’t in my normal shape. Like, some people said that I’d cross the street without realizing it. Like I’ve told you, I’m someone who likes to observe things. I knew that eight injections in two months was a lot for my body. There was a time I just sat still and wondered why I was feeling so terribly sad and empty … I began to realize that this was an effect of the drug. I warned myself about it. One day, I sat in front of a mirror, and suddenly, I was talking with the mirror, just sitting there, combing my hair, as if this was nothing out of the usual. But my mother asked me, ‘child, are you all right?’ My mother had seen me sitting there, talking to the mirror for a while, talking to myself, complaining about this and that—it’s hard to explain, like saying ‘I’m so fed up—why is my life so tedious?’ to the point I wanted to kill myself, that bad. And that wasn’t the only time or the first time … I realized that if I’d keep on taking a lot of birth control pills, or have my cunt done, and then kill myself, what would happen? I’d accumulated this for my entire life, just wanting to be beautiful. So, I chose to quit.

Som was not the only one to suffer from mood swings. It happened to everyone who used hormones—Nam Daeng, Sai, and their friends. Although they were not so badly affected, and hormones did not make them suicidal, it was not that much better, either: Som

I asked a friend: ‘What’s wrong with you, sitting there, playing with that lipstick?’ She said: ‘My big sister gave it to me. I see this lipstick and I miss my sister.’ So I asked her: ‘These past three months, have you still been taking two in the morning, two at noon, and two in the evening?’ She said yes, she had. So I said: ‘It’s high time for you to cut down to one a day.’ Phi Meng, [she said] ‘I got a haircut and didn’t like it. Shave my head, if I’m not beautiful, shave it all off.’ So when they didn’t shave her hair, she cried. [So I said,] ‘when you’ve finished shaving your head, go become a nun.’ [But in a little while] she [started to] like [her hairdo] and cried again. Really scary, these birth control pills.

Like Som, Nam Daeng quit taking hormones because she did not have enough energy to work. She also had mood problems, but she said she could control these symptoms. Som found quitting the hormones difficult because she was depressed, but she persisted. Her kathoei friends were stunned: she had been a pioneer of hormone use and had more knowledge about hormones than anyone else in the group. Many of her friends tried to persuade her to restart, asking her: “Why did you quit? You wanna be a gay or what?” She replied: “I don’t wanna die.”

Arianna Huhn 1

It was a warm afternoon in early June 2010, and I was among a group of women waiting for a meeting of the local chapter of Organização das Mulheres Moçambicanas (Organization of Mozambican Women) to commence. We sat outside of the group secretary’s home, legs outstretched and covered in the multi-functional and colorful capulana cloth ubiquitous in East Africa. I wore my standard all-terrain sandals. The other women’s feet were either bare or sporting flimsy, colorful flip-flops adorned with images like the Portuguese flag or Mickey Mouse. The shoes were cheap in price and in quality, but they were one of few affordable footware options for a population living far below the poverty line. The winds blew lightly, stirring up barely audible waves in the nearest bays of Lake Niassa.

The women chatted and joked quietly, the conversation eventually turning to my recent weight gain. “Arianna,” Maria began cautiously, “You have really grown fat.” I am a smallish-framed woman, and had gained enough weight over the previous six months to elevate my Body Mass Index (BMI) from around 19 to 20—not a dramatic difference, and certainly not qualifying me as ‘fat’ by biomedical standards, but still a noticeable change. ² Several other women turned to join the conversation, adding their own observations of my increased breast size, the girth and number of lines around my neck, and my emerging love handles. The women laughed boisterously, clapped their hands together, and slapped their thighs in response to the litany. They jockeyed for space near to me so as to point out the specific features being discussed.

It wasn’t that gaining weight was something in itself funny or negatively viewed—in fact, becoming larger in bodily dimension is usually evaluated quite positively in much of Africa (Fogelman 2009). The humor lay in the novelty of the conversation topic, and the perceived source of my enlargement. Fatima finally breached this topic openly, commenting between fits of laughter that, “Arianna’s husband must be feeding her very well.” While I agreed that the observations about my body were on target, I had to quibble with Fatima’s explanation—my husband primarily occupied himself for our year and a half in residence by writing emails and sleeping. I responded to Fatima by explaining that my research grant was our family’s only source of income, and because these funds were purchasing our food, it was logically I who was feeding my husband well, not the other way around.

The women burst into a fit of laughter at this literal and preposterous statement. Fatima, more sympathetic to my despondency, went about explaining that by ‘feeding’ she was euphemistically referring to sexual intercourse. Through further conversations that day and in the ensuing months, I came to understand that the transference of sexual fluids is locally reckoned to be an essential determinant of body size. In this case study I explain these principles of local ethnophysiology and consider their potential ramifications. ³

Diet and Body Size

To begin to understand sex as equivalent to food in contributing to bodily dimension, we must first consider local conceptions of nutrition. In brief, people in the Lake Niassa region see food as consumed primarily to ensure vitality (thanzi). They categorize foods by whether or not they provide strength and power for the body to do its daily tasks. Deceptively similar to biomedical understandings, ‘vitality’ is distinct from life-giving properties, such that food is consumed specifically for energy, rather than to ensure the continuation of life (which is dependent on spiritual forces). Vitality enables individuals to care for themselves and for others, which is a fundamental moral duty and a necessity for achieving social personhood, or status as a community member via interconnectivity and interdependence. The Portuguese word vitamina (vitamin) was ubiquitous in the discussions that I engaged in and overheard about food in relation to these effects. Acquaintances explained that foods with vitamina become blood, which provided the consumer with vigor and health to farm, cook, care for children, and so forth. Alternately, foods deficient in vitamina left or rendered the consumer’s body weak, tired, and unable to engage in productive work (Huhn 2013).

Where a person eats plenty of vitamina foods, his or her body becomes plump to its full capacity. For some this may be a BMI of 19, for others a BMI of 26. Eating more vitamina is a sure way to become fat ter, but not necessarily fat, and a person who is not regularly consuming vitamina will become thin ner, but not necessarily thin. Fat and thin, in local formulation, are relative states dependent on each individual’s body, circumstance, and predispositions, rather than objective categorizations based on a calculation of weight and height. This explains why I received smirks when I first arrived in Metangula and explained my research agenda as related to body size and diet. “It is fine that you have an interest in our traditions,” one of my research assistants eventually said to me. “But, what a person eats does not change his or her body.” Words from Verónica, a middle-aged obese woman, typified others’ comments: “Some people say that diet makes a person thin or fat. But this isn’t true.” She reasoned, as did many, that she ate the same thing each day as others in her family who were of drastically different bodily dimensions. Verónica pointed to her adult son, who had a healthy BMI of 21. “A person’s body size,” she explained, “just comes out that way.” No specific foods can aid a person to achieve absolute fatness or thinness, as it is only the relative states of becoming fat ter or thin ner that correlate with diet.

Further complicating matters, foods do not possess stable properties for provisioning vitamina. Social circumstances also impact vitamina: an individual suffering from depression, for example, will only taste bitterness when consuming food. The unpleasant experience impedes the transformation of foods into blood and vitality, resulting in smaller bodily dimensions rather than largeness. It was thus not unusual for me to hear a clinically thin person told enthusiastically that he or she was ‘fat’ when regaining strength after a recent bout of poor health or after experiencing a financial windfall. Similarly, ‘thin’ was a relative evaluation, and it was not oxymoronic to hear a person who was quite rotund declare his or her thinness if he or she was ill or in emotional distress. The ability of a situation to affect vitamina properties was driven home for me one afternoon when conversing with a man at a Metangula bar. Discussing his recent bicycle accident, Paolo suggested that unpleasant things diminish our energy and will to live, and so our sanguinity. “Blood,” he said, “is things that taste good.” He added, “If there are problems in the house, people in that home do not eat. They have no appetite. Nothing tastes good to them.” Helena joined the conversation and added that even sugar would taste bitter to someone who had problems. “The tongue only works when a person is without worries,” she said. An unhappy person, in other words, will veer toward their thinner form, regardless of diet.

In addition to diet and circumstance, people seemed to be working out the idea that an individual’s body could also artificially swell when suffering from bipi, or high blood pressure (B.P.), referencing a diagnosis that some larger individuals are given at the local hospital. Rather than being understood as a result of largeness, bipi seemed to be emerging in local formulation as an illness itself, with obesity a key side effect and symptom. The blood of a person suffering from bipi, informants explained, would be foamy, causing the appearance of largeness, despite lack of health. Several of the bigger-bodied women I knew justified their size with bipi, seemingly as a way to deflect their better-off status, which can be an invitation for family petitions for assistance, or accusations of sorcery.

Sexual Vitamina and Gender

In addition to diet, social circumstance, and bipi, another factor influencing body size in Metangula is sexual activity, and specifically the exchange of ubazi (sexual fluid). The sexual fluids of a man enter into a woman’s body through her vagina, and the sexual fluids of a woman enter into a man’s body through his urethra. ⁴ From there, the substance becomes part of the recipient’s bloodstream, making sexual ‘vitamina’ just as necessary as alimentary vitamina for the production of blood, and so vitality. Sexual vitamina is, however, distinct from and complementary to the dietary variety, rather than a substitute for it. As Lúcia said when I asked her why a sexually inactive person couldn’t just, say, eat a lot of tomatoes to ensure his or her strength, “Can a woman eat tomatoes with her vagina?” Nope. ⁵

The effects of sexual vitamina on the body, however, unlike alimentary vitamina, seem to be distinctly gendered. For a woman, acquaintances explained to me, the vitamina of a man is necessary to reach the larger dimensions of her body size potential. A woman cannot fatten (though she can be fat), or otherwise reach her predisposed girth extreme, which is a sign of health and social interconnectedness, without regular sexual intercourse. While estimates varied, ‘regular’ seemed to mean at least roughly once per month. If a woman does not have sex at this interval, I was told, she deviates toward her predisposed thinner form. At the Health Center and around Metangula, I encountered many women who said they felt weak and complained that they were becoming thin from being unmarried or otherwise lacking sexual encounters. Those who had been seen by a medical professional often reported that they were diagnosed as suffering from anemia. This signaled to both the medical technician and the women being treated that they were deficient in blood. For the women, this indicated that their blood was ‘moving alone’—without a male intimate partner. When I expressed skepticism, multiple women added that medical professionals they met with had asked if they ‘had a husband’ (culturally implying a regular sexual partner) as part of the diagnostic process, suggesting concordance with their own interpretations. And rather than being given medicine, several said, they were instructed to have sex to address their health problems. I could not find any member of the current medical staff who would confirm these rumors. Similar perceptions, however, were so strong in the provincial capital Lichinga that the Anglican diocese put together a brochure extolling the value of semen for sexual reproduction only, not female health (Rebecca Vander Meulen, pers. comm., 11 February 2011).

The import of men receiving female ubazi through sexual intercourse is not as clear. Acquaintances did not conceive of a woman’s sexual fluids as necessary for a man to fatten. In fact, lack of sexual activity makes a man softer and larger as his body fills with unreleased sperm and, like bipi, makes his blood foamy and his body artificially big. This happens, I was told, if a man does not have sex often—at least once every six months by some accounts, at least once every week by others. Acquaintances pointed to the round bellies of male government officials whose families had not traveled with them to Metangula as evidence that male abstinence leads to rotundity. When I observed that some of these men were also thin, I was reminded that everyone’s body has its own predispositions. Men having ‘too much’ sex (regular intercourse three or more times a day) are in equal danger of frailty, I was told. Again, however, this is unrelated to female ubazi. Rather, such men run out of their own ubazi, and new supplies have to be created from vitamina siphoned from their blood, negatively prejudicing vitality and so leading to bodily thinning.

Abstinence is one way that such men could regain their strength. Lourenço, an acquaintance in his 30s, for example, explained to me that he refrained from sex with his wife whenever he found that he was lacking the strength to collect bamboo or make bricks. Being poor, he said, he did not have the luxury to simply eat well to regain strength when sanguine vitamina was redirected for sexual activity. Another strategy for enhancing sexual fluid production without risking blood loss was to eat specific foods. Men commonly snacked on sugarcane in the marketplace, soaked rice was one of few foods I witnessed men preparing for themselves, and acquaintances often sent me home with raw cassava “for my husband.” Additional ubazi-enhancing (but not blood-building) foods include peanuts and coconut meat.

While women can also eat ubazi-enhancing foods to increase their sexual fluid output, they are less likely to do so for three reasons. First, any excessive ubazi just leaks out of a woman’s body; it cannot be stored internally as it can in a man’s body. Informants pointed to regular vaginal secretions as evidence. Second, both women and men suggested that a woman’s sexual appetite is not as voracious as that of a man’s. A woman can thus have sex once and be satisfied for long enough, before having sex again, for a new supply of ubazi to be created without haste or depleting her blood supplies. Finally, female ubazi is not an especially prized part of sexual experience in Metangula. As elsewhere in Africa, informants indicated a male preference for dry sex, and women took measures to both tighten their vaginas and reduce their sexual secretions through use of astringent substances inserted into the vaginal canal. Adult woman I knew candidly pointed to plants like kobwe beans and tomato vines maintained in their yards, from which they harvested leaves from for such purposes. The preference for vaginal dryness is also perhaps why the importance of female ubazi for male health is culturally unelaborated.

Conclusions

The correlation between diet and body size in Western biomedicine is complicated in Metangula, where the energy-provisioning properties of foods are malleable, evaluations of largeness in bodily dimension are based on individual predisposition rather than standardized scales, and sexual intercourse is conceived as a literally embodied experience integral to female health. While Metangula’s ethnophysiology may be unique to the locale, or to the region, the logic complements broader African philosophies that envision the merger of bodies through sexual union as creating a metaphysical bond between regular sexual partners, through which earthly life continues and wrongdoing can summon the wrath of spiritual forces (Heald 1995), and interpretations of larger bodily dimensions indicate both good health and community engagement. The necessity of another person’s presence in order to be personally complete further speaks to the central importance of interconnectivity in broad African conceptions of both personhood and wellbeing. This is not in the sense of selfless collectivism effacing individuality, but in persons being literally composed and created through their encounters with and dependencies on other human beings (Geissler and Prince 2010).

Considering such manifestations and integrations of local ideologies about personhood in relation to the body can be useful when implementing programming related to health, sex, and diet anywhere. In African settings, and perhaps elsewhere, local ideas about sexual fluids have important implications for the prevention and spread of sexually transmitted diseases (STDs). If receipt of sexual fluids within the body is necessary for female wellbeing, for example, women are likely to be reluctant to use a condom during sex, and condoms were not positively evaluated by my acquaintances in Metangula. While many condoms were sold in the market and health professionals gave away many more at the Health Center, the end use was often children filling the condoms with air and using them as balloons, or wrapping them in plastic bags and string to form homemade soccer balls. Few people regularly purchased condoms and used them for health or contraceptive purposes, and even local NGO–organized volunteers were at a loss to explain to onlookers at a STD-themed lecture I attended how a woman was supposed to get her vitamina if she used a condom. Similar public health campaigns may fall flat if condom use is the only pathway for health presented, as it is directly at odds with local perceptions of what leads to wellbeing. Similarly, programming focused on extolling the nutritional properties of foods and the importance of a balanced diet may present information that is not easily compatible with local notions of nutrition in relation to broader social circumstance, with conceivable impact on the effectiveness of programming related to both under-nutrition and over-nutrition.

Robert Pool

Vaginal microbicides were originally conceptualized by Northern researchers and advocates as a female-controlled means of HIV prevention—something that women, mainly in Southern countries, particularly in sub-Saharan Africa, could use to protect themselves in situations in which male partners were reluctant to use condoms and in which they were unable to negotiate condom use. The assumption was that women would be able to use these products secretly, without informing partners. This assumption was supported in early hypothetical acceptability studies, in which women were asked whether they would inform their partners if they were to use a microbicide. The empowerment of women was central to the development of vaginal microbicides, thus bringing together feminist ideals and biomedical research. However, when products started to be tested in trials in Africa, women’s response was not always what researchers and advocates had anticipated. In what follows, I describe how individual women in South Africa redefined empowerment to fit their particular situation in the context of a microbicide clinical trial.

The trial, called MDP 301, was a randomized, double-blind, placebo controlled trial that aimed to determine the efficacy and safety of PRO-2000 gel in preventing vaginally acquired HIV infection. It was conducted at three sites in South Africa and one each in Zambia, Uganda, and Tanzania. The enrollment of 9,385 women was completed in August 2008, and follow-up was completed in August 2009. PRO-2000 turned out to be safe but not to prevent HIV transmission.

The trial had an integrated social science component, which focused on a random sample of almost 8 percent of trial participants. The aims of this component were to assess the accuracy of the data on sexual behavior, adherence, and condom use, to investigate acceptability of the product, and to assess participants’ comprehension of the trial and the informed consent procedures. Women were also asked whether they had informed their partner about the trial and the gel, and they were asked about partner involvement in gel use. Where possible male partners were also interviewed. Below, I draw on data from the South African sites. ¹

Before enrollment women received detailed information about the trial and the product. As part of the informed consent procedure, they were taught about HIV and risk behavior, and repeatedly they were told that the efficacy of the product was unknown and that it was therefore essential for them to use a condom to protect themselves whenever they had sex. Women were tested on this knowledge before they were enrolled, and their comprehension was continually monitored throughout the trial. They also received detailed information on the various clinical procedures and they were taught, using anatomical models, how to insert the gel using the pre-filled applicator.

Women who participated in the trial attended the trial clinic every month, where these messages were repeated and where they underwent clinical tests and examinations and received any necessary treatment. At the clinic they could also ask questions related to the trial and their health. As a result, they not only learnt about the trial and the gel, but were also educated on their own anatomy and on sexual and reproductive health more generally. The trial also formed a context in which women could gather and communicate about ‘women’s issues’ and discuss partners and relationships. They encouraged friends and neighbors to join, and met other women during clinic visits. As a result, a feeling of community and ownership developed among participants, who often spoke of ‘their’ trial.

The Appropriation of Empowerment

Contrary to the notion that microbicides would be used secretly, almost all women in the trial informed their partners about the gel. The most important reason was that they felt that men had a right to know, given that they were also being exposed to the gel.

I think it is not right keep it a secret from your partner, because if you come across a problem, if the gel affects him, he won’t know what affected him, whereas you knew but you kept it a secret. I think it’s the right thing to tell your partner about the gel.

How, women asked, would they explain to their partners if the gel turned out to have side effects, and especially a negative effect on their (the men’s) health? Even women who did not inform their partners still thought that it was right that they knew.

I think it is the right thing to do, but I made a decision not to inform him about using the gel [because] men ask too many questions. He would have asked me: why are you using the gel, and are you sure that it is going to protect you, and so forth. So I was avoiding questions like that when I decided not to tell him.

A second reason was that men would probably notice the gel anyway: they would feel a difference in lubrication during sex, or discover the boxes of applicators, or catch their partner inserting it before sex. Women said that men thought of themselves as being in charge and would be angry if ‘their’ women ignored their authority. Both men and women said that if a man noticed that his partner was inserting something in her vagina before sex, he would be likely to suspect that she was using muti (magical substances) to bewitch him.

As a result, almost all women did inform their partners about the gel. Most women (75 percent) told their partners about the trial when they first heard about it, and before they enrolled. Almost all the others told their partners soon after enrollment. A few men discovered the gel early on while the women were still procrastinating about informing them, and a few others discovered it later, after their partners had decided not to inform them.

This ‘informing’ was sometimes a gradual and diffuse process. For example, one woman said she had ‘told’ her partner straight after enrollment. But she had already been discussing the trial with him for a long time in relation to a cousin who was already enrolled, and she had told him she wanted to go to the same clinic and get tested. So she had been grooming him for a while before she actually told him that she had enrolled. It was common for women to first tell their partners that they were going to the clinic to find out about a study that was taking place, or to get themselves tested, and then coming home with the information sheets and the gel and explaining further. Confronted with a fait accompli, men found it difficult to refuse.

Women with ‘difficult’ partners were often patient and creative in the way they ended up getting their partners to accept gel use.

Interviewer

Did your partner know that you were using the gel?

Woman

He did not like it. I told him after I enrolled in the study and he refused to allow me to use it. I left it like that and I said to him: it’s fine … [but] I used the gel without telling him and we had sex all the time.

Interviewer

Did he feel that you were using it?

Woman

No, he did not feel it. And after two months using it in secret I talked to him again about it. But I did not tell him I was using it in secret. Then he said that if I used the gel he would not have sex with me. I asked him why. He said that he did not know if sex was going to be the same or not. Then I asked him how he felt about our sex and he said that it was okay. I then told him I had been using the gel, and he said that I could continue to use it.

Interviewer

How did he feel when you told him that you used the gel secretly?

Woman

He was angry and we had a little argument. But he realized there was no difference when I used the gel.

Sometimes women made use of the formal gender power relationship of male dominance and female obedience to neutralize suspicion. For example, one man refused to allow his partner to continue using the gel, but she ignored him and continued to use it anyway, and he never suspected anything. She could do this because it was inconceivable to him that she would disobey him.

Because he knows that when he says he does not like something I am doing, I don’t argue with him: I stop straight away. He is always proud that I respect him by obeying his instructions. He does not know that I am continuing using the gel.

Other men forbade their partner to use the gel but, when the women continued nonetheless, appeared to be aware of this but pretended not to notice, possibly in order to avoid confrontation and open questioning of their ‘authority,’ thus avoiding potential loss of face. Some men confirmed this, and in some of the focus groups, men explicitly made a distinction between actually having power in the relationship and only appearing to the outside world to have power. So while being dominant in the relationship was important for them, it was more important that other men saw them as dominant. As one man put it:

There are some men that meet and talk. It’s just that I’m going to be proud. I cannot meet with my friends and tell them how my girlfriend and I really live at home. I make out as if I do not take orders from a woman. They don’t know that when I get home I dance to her tune.

Finally, as the quotes from two women below show, the use of the gel in the context of the trial gave women the pretext and the confidence to address the issue of condom use, which is generally considered to be unacceptable in regular relationships. Indeed, this was one of the main reasons for the development of vaginal microbicides in the first place.

I had to sit him down, show him the gel, and tell him: each time we have sex I will use one gel and you have to use a condom. I explained that if I use the gel for one round of sex, then we have to use another gel for the next round. And he also has to use another condom.

(Woman A)

I told him that I was participating in a study that involved using gel. I told him I had to use the gel and he had to use a condom. And that when the study finished, it didn’t mean that he could stop using condoms, oh no!

(Woman B)

Conclusion

The empowerment of women envisioned with the development of vaginal microbicides entailed women using such products secretly. No one took into account the possibility that women would consider it wrong to use such products secretly, or that it might be impractical to do so in regular relationships. What was also not taken into account is the importance of the precise nature of the relationship between the woman and her partner. So whereas some men immediately were open and communicative in their relationship, accepted the gel easily, and integrated the gel into their foreplay, others were uncommunicative about the relationship and sex (except to say when they wanted it), and were suspicious of the gel.

Advocates and researchers also underestimated the power that women had, because they had tended to be too focused on the public surface of power relations and ignored the underlying dynamics of relationships in practice, and as a result they assumed that secrecy was the solution. So for example, when women discussed power and authority in relationships, they rarely said that men were the decision makers, but that they liked to think that they were, suggesting that they—the women—had more power than they appeared to have on the surface, but that they had to exercise it in more subtle and indirect ways.

Arguably, the sort of empowerment discussed here, of course, is not ‘really’ empowerment because it operates within the existing hierarchical structures and relationships without changing them. But the same applies to secret use. The difference is that the former is emically directed, by the women themselves, and grounded in their everyday practice, whereas the latter is etically directed, by the research and advocacy community, without taking the diverse practices on the ground into account.

This ‘power from below’ was stimulated and supported by the trial and clinic setting. This was reinforced through contact with other women with whom they could exchange experiences relating to the use of the gel and the response of partners. This knowledge, and the feeling of being part of the trial community, empowered women participants to take on partners and persuade them to accept gel use, and if they were unable to convince reluctant partners, it gave them the confidence to defy them and use the gel secretly anyway. It also gave them the tools and the confidence to go home and initiate a broader discussion about HIV prevention and condom use.

Sebastian Mohr

It is just before nine when I arrive at Andersen Sperm Bank on a cold Monday morning in February. Lise and Signe, the two technicians whom I have gotten to know since I first started my fieldwork a year and a half ago, are already busy in the laboratory. So is Martin, the leading lab technician in charge of coordinating daily activities. After I greet all three of them, Lise and Signe tell me that I have missed one of the best weeks at Andersen Sperm Bank. A number of young soldiers had been here the week before, Lise says and adds while smiling: “It was wonderful to have all those young guys in here.” “Why were there so many soldiers?” I inquire. Signe explains, that, apparently, the Danish Army had developed new underwear for combat situations, but this underwear also exposed men’s testicles to more heat than is deemed healthy for sperm development: “They wanted to know whether there were side effects and how they would go about leaving a deposit before taking off to combat,” Signe explains. I was aware that some soldiers deposit their semen before being deployed, but that concerns about underwear would drive groups of soldiers into a sperm bank to seek advice was surprising. I mention that I had thought that the Danish Army would have specialists for these instances. Lise and Signe agree. “But too bad you missed all those well-trained guys,” Lise jokes.

Lise and Signe joke a lot as part of their work. Humor is one way in which they frame their daily encounters with sperm donors and their work with semen samples at the lab. Yet, the fieldnote is remarkable because of the subtle ways sexuality and gender are invoked through the use of humor when Lise and Signe describe their encounters with men who donate their semen. Without directly referring to either sexual desire or practices, or concrete interactions with sperm donors, they were nevertheless able to create a meaningful context that invoked sexuality and masculinity. They also created a situation in which my own possible desires as an anthropologist were addressed. Lise’s comment, that it is too bad that I had missed all the well-trained guys, marks us both as individuals who desire these kinds of encounters and bodies, while simultaneously also making the young soldiers—representing a particular kind of masculinity—into desirable men with desirable bodies. Thus, Lise and Signe remade the sperm bank as a ‘sexualized’ and gendered space. But there is also a more obvious observation to draw from the fieldnote: young men are concerned about their fertility and make use of possibilities to conserve their potential to procreate. Their bodies are exposed to certain technological innovations and interventions that directly influence whether they will be able to father children or not. Biomedical knowledge about male bodies and semen, its assessments, and technological intervention in male bodies are thus changing the ways that men think about themselves and their bodies. Attending to instances at Danish sperm banks in which gender and sexuality were invoked, as well as interviews with sperm donors about their experiences of donating semen, I want to explore how and when gender and sexuality are made meaningful in the context of sperm donation in Denmark, and how biomedicine and biotechnology make their ways into Danish men’s gendered self-conceptions. I draw on fieldwork at three sperm banks—Andersen, Jensen, and Miller—and interviews with 26 sperm donors. Whereas the Andersen and Jensen sperm banks are located in Denmark, Miller Sperm Bank is a subsidiary location of Jensen Sperm Bank in the USA.

* * * *

Alfred and I had agreed to meet in my office for the formal interview. He had contacted me via my research project’s homepage. Jensen Sperm Bank, where Alfred was a donor, had sent out an email to all its current sperm donors explaining my research project. The email also contained a link to the research project’s homepage for those interested in participating. In his mid-20s, Alfred spent much of his professional and spare time on activities connected to physical exercise. His body was built accordingly. When I met him, he had been donating semen for about a year and would usually visit Jensen Sperm Bank twice a week. Alfred had no children of his own, self-identified as heterosexual, and was not in a relationship at the time. He had participated in my research project out of curiosity, he explained, but also because he thought that he had an obligation to critically reflect on what he had committed himself to. It became clear early in the interview that having to masturbate at the sperm bank was of central concern for him. We were talking about the organizational and legal frameworks of sperm donation in Denmark when I asked him if he had been aware of how sperm donation was organized before becoming a donor: Alfred

As I said, I was curious and my roommate at the time was a sperm donor before I started. I was curious to hear how that was, and I was maybe also a little bit outraged about, maybe not outraged, but also curious about, do you just stand next to each other, do you just close a curtain, do you go into a room, because I thought that that would be a very strange situation. I mean, this is not, usually you think of your sperm, that is something that you only have with yourself or with your girlfriend, something intimate, and just leaving it at some random place, that is, well that was a strange thought somehow. If you don’t think that is strange, then you’re probably missing some kind of empathy, if you’re really completely indifferent about that. So, yes, of course one asks about how that works. And my mind was put at ease that once you’re done, then you don’t have to hand it over to someone that is just waiting for it, but you just set it [on the counter] and leave.

Anticipating a transgression of personal space, Alfred was concerned about encountering other men masturbating, and he felt ashamed about having to approach people working at the sperm bank with his semen sample in his hand. His feeling of shame and embarrassment stems from having to negotiate his sexual desires in the semi-public environment of a sperm bank, for him a transgressive act (Donnan and Magowan 2009) which marked the boundaries of his concepts of (appropriate) male heterosexual conduct. Donating semen in a sperm bank breaches normative frameworks that enforce compliant behavior in relation to gender and sexuality (Mohr 2010; 2014a).

* * * *

These kinds of transgressive acts are also at play when semen samples are handled at the sperm bank laboratory. As already noted, sperm bank staff use humor to handle these kinds of transgressions, and thus playfully negotiate the ambiguous context of handling donor semen. Lise and Signe, the two lab technicians at Andersen Sperm Bank, both had experiences working with bodily fluids and substances (animal semen, human feces, urine) before joining Andersen Sperm Bank. This kind of educational and experiential background was very common among the lab technicians I met during my fieldwork. However, working with human semen provided for a context marked by potential transgressions of normative claims to gender and sexuality, something that is not at stake in other contexts and that relates to semen’s symbolic meaning as a sexual substance in Danish culture.

Whereas semen at the sperm bank laboratory is made into a procreative compound, a substance that has been called techno-semen (Moore and Schmidt 1999) in order to enter a global reproductive supply chain, semen is usually encountered as part of sexual practices and therewith embedded in symbolisms of lust, desire, and disgust, a point that also becomes clear in Alfred’s quote above. Handling semen’s ambiguity thus becomes the focal point of work in the sperm bank laboratory, something that I call containment: material-semiotic practices which involve semen, its various containers (specimen cups, test tubes, vials, and straws), as well as computers, centrifuges, and cryopreservation tanks in order to make donor semen into a governable reproductive substance by managing its lust and disgust potential (Mohr 2014a). The containment of semen ensures that work at the laboratory is successful. In situations in which the containment of semen is not successful, on the other hand, semen is re-embedded into its symbolic meaning as a lustful and/or disgusting substance.

During participant observation, I paid special attention to instances in which lab technicians were talking about getting semen on their hands and equipment or about encountering blood or pubic hair in semen samples. These encounters provoked disgust since they reminded technicians that semen samples actually came from real men, something that they normally did not think about when processing semen samples. For Julia, a lab technician at Miller Sperm Bank, a subsidiary location of Jensen Sperm Bank in the USA, it was the smell of semen that was nauseating:

It is Thursday morning in early December, and Julia and I are in the lab. It is not busy today, so Julia has time to talk about working in the lab. I ask her if there are special challenges when working with semen: “The smell is just horrible. I can’t get used to it,” says Julia. Having noticed a particular smell at sperm bank labs myself, I want to know how she would describe that smell: “It is a musky smell, almost like dark mustard but just a little bit sharper,” Julia replies. When opening specimen cups, she would deliberately hold samples away from her body in order to avoid encountering the smell: “But I also don’t like it when the sample is clumpy,” Julia adds. She then tells me that there once had been a donor whose samples would always be clotted and she had found it hard to work with them. “Another thing that is gross is when you have a hard time getting a sample into the pipette, and then it just drips on your hands and stuff, disgusting.” Julia then reflects on how her work at the laboratory is perceived by outsiders: “For a really long time, my boyfriend would not say anything about my work to his colleagues. And when he did, they made fun of him as if this were some kind of sex work or something.” I am astonished by this story. Julia then says while smiling: “But I look at this from the bright side. I keep saying to him [her boyfriend] that I am his dirty little secret,” and we both break out in laughter.

Work at sperm bank laboratories is centered around encounters with semen. Aimed at containing semen as a reproductive substance, these encounters involve technological equipment and biomedical substances like dilution and freezing solutions that help to remake semen into technosemen, an exchangeable substance used for third-party reproduction. Nevertheless, despite all this containment work, semen’s symbolic meaning as a lustful and/or disgusting substance breaks its way into the context of lab work at all times. As Julia’s experience shows, semen’s physical characteristics such as smell and consistency can provoke disgust and serve as a reminder of semen’s symbolic meaning as a sexual substance in an otherwise hyper-technologized environment. Julia’s story points to how gender and sexuality operate in the context of work with semen samples. Semen is perceived as the result of gendered sexual practices. It is made meaningful as a substance emitted by male bodies due to sexual excitement, and working with donor semen is, as a result, understood as a transgressive act that breaches established scripts for gender and sexuality, “some kind of sex work,” as Julia put it. Staff at sperm bank labs are aware of how gender and sexuality converge in semen, and they thus handle this particularity of their work accordingly through humor—in Julia’s case framing her own work as “a dirty little secret.”

* * * *

This convergence of gender and sexuality in semen is a cultural phenomenon particular to contemporary Danish and Western European contexts. As Gilbert Herdt (1987) demonstrated in the case of the Sambia in Papua New Guinea, the repeated insemination of boys with semen from older men is understood as securing the successful transition from boy to manhood and not necessarily as a homosexual or even pedophile act, as would be the case in Denmark or most other contexts. Yet as will become clear, beyond this particular convergence of gender and sexuality in semen, the context of sperm donation in Denmark also makes for a coming together of biomedical practices and men’s gendered self-conceptions (Mohr 2014b). As men were narrating their experiences of being a sperm donor to me, it struck me how their understandings of masculinity were tied to the biomedical practices involved in sperm donation.

I met William, in his mid-20s and a sperm donor for about a year, at his apartment for the formal interview. Like Alfred, William had replied to the email sent to donors by Jensen Sperm Bank. Training to become an engineer, he had heard about being a sperm donor from some of his classmates. William was proud of his semen quality. For him it was a sign that he was a healthy man with valuable genetic traits, even though the assessment of semen quality says nothing about genetic health. When I asked him in which way he felt proud about having good semen quality, he said: William

Well, just that feeling, you know, that you are healthy and well, just as when you are at the doctor’s and he says to you: you are a healthy young man. Then you feel like: ahhh, this is beautiful, wouldn’t you agree, to know that you don’t have any illnesses. The worst thing is to be sick, and it was just wonderful to know that one has good genes.

For William, having good semen quality made him into a “healthy young man,” whereby he understood good semen quality to be the result of his healthy male body. Being a sperm donor enabled William to see and experience himself as that young healthy man that he refers to in his quote, and this specific self-experience is only possible because of the biomedical assessments of semen which are part of sperm donation in Denmark. But besides connecting knowledge about his semen to his embodied gendered self-conception, being a sperm donor also had implications for William’s experience of sexuality and especially for his sexual relations with his girlfriend: William

I want to stop at some point [with donating semen] because the biggest price you pay is, and as a guy I can tell you this, you are really restricted by the fact that you have to go down there and have to ejaculate [at have udløsning] and that they are supposed to go 48 hours before. I don’t live together with my girlfriend, but that doesn’t mean that you don’t miss this freedom, you know, you can’t fall asleep at night or whatever, and then this becomes the biggest sacrifice. Sometimes, I also think about this when I am together with my girlfriend. It is just really hard to avoid those kinds of thoughts, you know, thinking about the money and then wondering if it is worth it. But as soon as I get these thoughts, I try to suppress them. Sometimes though I can’t help it; you can’t always stop yourself from keeping an eye on this. But in a strange way, somehow I think all of this has also been good for our sex life. I mean, we have been together for almost 4 years and somehow, just as if, when I have to wait a little longer, in that way that has been good for us. But it is nevertheless a small sacrifice. Sometimes, I have money on my mind, you’re thinking: ups, there you go, 300 crowns.

Abstaining from sexual activity in order to be a sperm donor is a sacrifice William is willing to make. Yet in his narrative, thinking of this as a sacrifice seems to be a result of valuing his semen through the amount of money that he receives for his semen samples. The organizational logic of sperm donation in Denmark—orgasmic control, monetary compensation—thus impacts how he experiences his sexuality and how he thinks about his intimate loving relationships. Donating semen changes the ways that men experience themselves. It makes for enactments and embodiments of masculinity particular to the context of contemporary reproductive biomedicine in which the control of masturbation and the assessment of semen regulate what it means to be a man.