Category Beyond the natural body

THE MIXED BLESSINGS OF SEX HORMONES

In this epilogue it is time to reflect on what sex hormones have brought us. Clearly, hormones have changed our world. The quest for sex hormones exemplifies the dreams of modernity. The promises of the new science of sex endocrinology mirror the modernist claim that “a progressive growth of scientific knowledge will uncover the natural order of things, making possible the construction of techologies through which control might be exercised over the course of the development of events” (Smart 1992:56). In this Enlightenment tradition, science and technology are considered as intrinsically progressive and beneficial. The role of science and technology in our society is perceived as improving the “human” condition.

The quest for sex hormones was firmly rooted in this belief of science as progress. Since its early years, the science of sex hormones promised to provide a technological fix for many problems, particularly “women’s problems.” Robert Frank’s The Female Sex Hormone very vividly illustrates this modernist tradition when the author promises his readers that female sex hormones are “bound to relieve many of the ills from which women suffer” (Frank 1929: Introduction). The intriguing question is: has Frank’s dream come true? My book would have a happy end, providing the answer is a straightforward yes. Unfortunately, but not unexpectedly, the answer is not that easy. The introduction of the hormonally constructed body concept has led to a situation in which “control can be exercised across the life course from menstruation through menopause” (Clarke 1990a). So far, we may be inclined to conclude that Robert Frank was right and very much ahead of his time. We may question, however, whether and to what extent sex hormones are an adequate solution for “women’s problems.” Undoubtly, many women will emphasize the benefits of hormone therapy. Yet it is the very idea of control and the awareness of (potential) health hazards that turned the dream of hormones as problem solvers into a reality of growing ambivalence and severe criticism. Two examples of the use of sex hormones, the pill and hormone replacement therapy, clearly illustrate the two faces of the hormonal revolution.

The story of the pill is a story about liberation and control. On the one hand the pill is “except for the word ‘no’ the most effective and convenient contraceptive ever devised,” a technology that contributed to the increasing liberation of women (Seaman and Seaman 1977:95). On the other hand it is a

story about Western science ignoring the local needs of specific users, particularly the communities on the Caribbean islands and other Third World countries. The “one size fits all”11 approach to making contraceptives such as the pill does not acknowledge diversities among women. I have argued that these universal tendencies are highly problematic because they cause serious health risks. Moreover, in the domain of population policy, the pill is not unproblematic because it serves as a tool in the pursuit of a technological fix for problems which ultimately are political, economic, cultural and moral in kind.

A similar story can be told for the use of sex hormones for the treatment of menopausal symptoms. Since the 1960s hormone replacement therapy for menopausal women has become very popular, particularly in the United States, where the sales of estrogen preparations have quad-rupled. Today these drugs are even one of the top five prescription drugs (Greer 1991:185). Again, the use of hormones has two faces. It promises a relief of many negative bodily experiences during aging. Many women consider hormone replacement therapy as an efficient therapy and as an acknowledgement of their problems by the medical profession. The other face is more gloomy. It shows the many controversies that have accompanied the introduction of hormone replacement therapy. There are the recurring debates about risks of cancer and other serious side-effects. There is the criticism on the reductionist view on menopause: hormonal explanations of menopause reduce the complexity of aging to a disease entity. (Greer 1991; Seaman and Seaman 1977).

In summary, sex hormones may best be portrayed as a mixed blessing. The implication of my remarks is not a cultural or technological pessimism but rather that we need to understand science and technology with all its tensions and ambiguities. My argument throughout this book has been that bodies and technologies are not unequivocally determined by nature. Medical technologies do not necessarily have to be the way they actually are. Who knows what might have happened to the hormonally constructed body concept if there had existed an andrological clinic, rather than a gynecological clinic? Imagine what might have happened in a world with different cultural and moral attitudes towards gender and responsibilities for family planning and childcare. It is not beyond imagination that we would have ended up with a male contraceptive pill, a medical treatment of male menopause and a classification system of multiple sexes. Alas, we will never know whether this really would have happened. We know, however, one thing for sure: science and technology can take many shapes. A critical deconstruction of the processes that shape science, technology and bodies might help us to envisage technologies that have a chance of survival.

Living in the material world

Beyond the Natural Body shows that the power to control sex and the body is embodied not only in scientific theory, but also in materialities. This is why I suggested that it is crucial for feminist studies of science to take into account this materiality of the scientific enterprise. The suggestion that science is primarily texts and theories seriously fails to take into account the strongest tools that scientists have at hand to transform and sexualize the world we live in: the creation of material products. A focus on the materiality of science shows how the construction of meanings and practices of sex and the body is not restricted to the domain of theories and semiotics.

In the first place, sex endocrinology produced new diagnostic techniques. The use of tests introduced for measuring hormones in animals did not remain restricted to the laboratory. Clinicians, particularly gynecologists, transferred the laboratory tests to the clinic as tools for the diagnosis of hormonal deficiences. Laboratory scientists introduced three types of tests: the sex hormone blood test (one to estimate male sex hormones, one to estimate female sex hormones), the pregnancy test and the vaginal smear test. Clinicians used the sex hormone blood test to measure the sex of homosexual men and to classify women into hormonal types. The female sex hormone blood test was also used for the diagnosis of menstrual disorders and pregnancy. The pregnancy test became widely used as the first laboratory test for the early diagnosis of pregnancy. The introduction of the vaginal smear test provided gynecologists and physicians with a powerful new diagnostic tool to investigate their female patients. They have used this test for the diagnosis of menstrual disorders, and more recently for the diagnosis of cancer. The introduction of this test profoundly shaped the medical treatment of the female body, extending medical intervention techniques from the uterus and the ovaries to the vagina.

In addition to the introduction of diagnostic techniques, sex endocrinology provided the medical profession with a new class of drugs that were developed to cure a newly constructed category of diseases: hormone deficiency diseases. Sex endocrinologists defined low levels of hormones as deficiencies. In this manner, they transformed the hormonal model of sex into a model of disorders and pathologies. The concept of hormonal deficiency disease implies that this category of diseases can be treated with the administration of hormones to make up for the lack of these substances. I described how this hormonal model of diseases became integrated into medical practice. The introduction of hormones as drugs had a major impact on medical practice, particularly on women, since it was the female body that became increasingly subjected to medical intervention. The specification of the hormone model of the female body as cyclic in nature further facilitated the process of classifying women’s diseases in terms of deficiencies that could be treated with hormones. The introduction of the pill, last but not least, revolutionalized sexual experiences by providing a means to separate sexuality from reproduction.

The introduction of the concept of sex hormones not only changed the medical treatment of the human body, but also redefined the existing social configurations structuring medical practice. The story about hormones thus becomes a story about power and medicine. The field of sex endocrinology generated a set of power relations that did not exist prior to its emergence. What changed in this period was the question of who was entitled to claim authoritative knowledge about the female body. The introduction of the hormonal model increased the medical authority of gynecologists over disorders traditionally belonging to other medical professions, such as psychiatry. The hormonal model thus enabled gynecologists to draw the female body more and more deeply into the gynecological clinic. Gynecologists, however, had to share their increased medical authority with another professional group: the laboratory scientists. With the introduction of the concept of sex hormones, scientists explicitly linked women’s diseases with laboratory practice. Laboratory scientists entered a field until then relatively untouched by laboratory science. Before the turn of the century, the study of women’s diseases, traditionally ascribed to dysfunction of the ovaries, was the exclusive field of gynecologists. In the decades to follow, research on the ovaries shifted from the clinic to the laboratory. Laboratory scientists succeeded in becoming experts on disorders in the ovaries and female reproduction. In this manner, laboratory scientists gained a new realm of influence, claiming authoritative knowledge over a subject previously allocated to gynecologists. The gynecologists thus lost their position as the sole experts on women’s diseases and reproduction.

This story of hormones is a story of multiple and mobile power relations, very similar to Foucault’s accounts of power (Foucault 1975; 1976). Here power is not a fixed, homogeneous thing, located in one specific place or institution, neither is it possessed by one specific actor. My account of the history of sex hormones shows the dynamic, capillary power of a science which linked cultural assumptions, concepts, ovaries, urine, diagnostic tests, lab equipment, marketing strategies, clinical trials, population policies and bodies, thus transforming the world we live in. Beyond the Natural Body shows the enormous transformative power of biomedicine: a world with hormones looks quite different from a world without them. Sex hormones shaped our understanding of sex and the body, they changed the medical treatment of our bodies, they constituted a new specialty in the biomedical sciences, they thoroughly changed the cultural and material authority of the laboratory and the clinic, and last but not least, sex hormones redefined the relationship of women to reproduction.

Cyclicity versus stability

The chemical model of sex was a rather radical model because it reduced the differences between the sexes to one hydroxyl group: men and women differ only in the relative amounts of their sex hormones. This does not mean that sex endocrinology did not emphasize differences between the female and the male body. In addition to the chemical model, sex endocrinology also provided a model in which sex differences came to be conceptualized in terms of the rhythm of hormone production. Biologists and gynecologists specified the quantitative theory of sex differences in terms of the notion that the male and the female body differ from each other with respect to their hormone regulation. Gynecologists used the hormonal blood test to specify the nature of hormone regulation in the female and the male body. Based on this test, the female body became characterized by its cyclic hormonal regulation and the male body by its stable hormonal regulation. In this biological context, sex differences thus became conceptualized in terms of cyclicity versus stability.

This association of femininity with cyclicity was not entirely new. In the second half of the nineteenth century, psychiatrists became interested in the “periodic madnesses” of their female patients and ascribed these to the cyclic nature of their menstruation. At the turn of the century, the German psychiatrist Krafft-Ebing questioned the “mental integrity” of menstruating women (Baart and Bransen 1986:8). This association of femininity with cyclicity was thus compatible with notions about femininity that already existed in culture and medical practice. What is new is that sex endocrinologists transformed this notion of cyclicity into a basic model for understanding the specific nature of the physical features of the female body. They linked cyclicity with a chemical substance, regulating the development of a wider variety of functions than just reproductive functions. This extension of the concept of cyclicity is exemplified in the handbook Female Sex Endocrinology (1949):

the complete physical and mental structure of a woman is, just as her reproductive functions, exposed to cyclic stimulation of sex hormones. This is not only manifest in the cyclic changes in the endometrium, but also in fluctuations in temperament, changes in breast size, heart beat, and so on.

(Binsberg 1949:1)

Sex endocrinologists thus redefined the meanings assigned to femininity, emphasizing cyclicity as the key concept for understanding the female body.10

In this case, we see how sex endocrinology incorporates cultural norms and —at the same time—actively reshapes these ideas. A similar pattern can be distinguished in the manner in which sex endocrinology conceptualized the female body in terms of its reproductive functions. In the hormone model, the female body became increasingly defined as a reproductive entity. The image of the female body as primarily a reproductive body has a long history manifest in many cultures. Foucault described how in the late eighteenth and early nineteenth centuries scientists incorporated this cultural notion into the medical sciences. In this period, medical scientists increasingly defined the female body as an object of sexuality and reproduction (Foucault 1984:104, 115, 119). Sex endocrinologists integrated the notion of the female body as a reproductive body into the hormonal model, but not without thoroughly changing it. They introduced highly technical tools to investigate the female reproductive functions to an extent that was not possible before. Sex endocrinologists shaped medical practice most profoundly, because they provided the medical profession with tools to intervene in features that had been considered inaccessible prior to the hormonal era. The introduction of diagnostic tests and drugs enabled the medical profession to intervene in the menstrual cycle and the menopause, thus bringing the “natural” features of reproduction and aging into the domain of medical intervention.

THE TRANSFORMATIVE POWER OF SEX. HORMONES

What intrigued me most in writing this archeology of sex hormones is the very complex and multileveled impact of the hormonally constructed body concept on our understanding and treatment of the body. The story of hormones exemplifies the transformative power of science and technology. Or to quote Giddens: “Knowledge does not simply render the body more transparent, but alters its nature, spinning it off in novel directions” (Giddens 1990:153). The interpretation of the body in terms of sex hormones contributed to its transformation, ranging from changes in the very words we use to express our bodily experiences to changes in medical practices and power relations.

The chemical model of sex and the body

The most revolutionary change generated by sex endocrinology is the introduction of a chemical model of sex and the body. I have described how sex endocrinologists introduced the concept of sex hormones as chemical messengers of masculinity and femininity. With the introduction of the concept of sex hormones, sex became attached to chemical substances. The hormonal model of the body is thus basically a chemical model. That scientists at the time were aware of this transformation is exemplified in The Male Sex Hormone, a book published in the early 1940s in which the American author describes the role of male hormones in sexual differentiation in terms of “Manhood is chemical” (Kruif undated: 2). The introduction of this chemical model had major consequences for the conceptualization of sex and the body.

First, the very act of attaching sex to chemical substances implies that sex is an entity that can exist apart from any fixed location in the body. If sex is a chemical agent transported by the blood, it can wander around through the whole body. This model meant a crucial change in the conceptualization of sex and the body, both with respect to cultural notions and conceptualizations of preceding disciplines. Prior to the emergence of sex endocrinology, scientists, particularly anatomists, used to locate the “essence” of sex in one specific organ. Femininity was located first in the uterus and later in the ovaries. All through the history of the biomedical sciences, masculinity was primarily located in the testes. Sex endocrinology now had a twofold impact. This new field of the biomedical sciences reinforced, and at the same tune challenged, the earlier conceptualization of sex. The introduction of sex hormones as chemical substances secreted by the gonads initially reinforced the cultural notion that the gonads were the seats of masculinity and femininity. Sex endocrinology focused, however, not on the gonads as such, but on their secretions: the chemical substances. In this manner, sex endocrinology transcended the anatomical model of sex and the body in which sex is located in one specific organ. The chemical model enabled scientists to distract attention away from the gonads as the organs where sex is located. Sex endocrinologists included the hypophysis in the hormonal model of the body, thus extending the “essence” of sex from the gonads to the brain. In the hormonal model, sex is no longer located in one specific organ, but develops in a complex feedback system between the gonads and the brain. This conceptualization of sex and the body meant a break with the cultural notion that masculinity and femininity are solely located in the gonads.8 It also meant a break with the anatomical model of sex and the body.

Second, the introduction of the chemical model led to a shift away from a primarily descriptive approach and toward an experimental approach. While anatomists focused on identifying which organ is the seat of femininity or masculinity, sex endocrinologists looked for the causal mechanisms that control sexual differentiation. Sex endocrinology is basically an experimental science. Locating the “essence” of sex in chemical substances implies that sex is an entity that can be identified and isolated from the organism. Locating sex in chemicals means that there can be too much or too little of these substances in the organism. Sex thus becomes an entity that can be measured, quantified and manipulated with laboratory techniques. Consequently, sex endocrinology became a science that actively intervenes in the lives of women and men, introducing diagnostic and intervention techniques that have profoundly shaped medical practice.

Finally, a chemical model of sex and the body makes it possible to abandon a rigorous dualistic notion of sex, a notion characteristic of cultural ideas of sex differences and of the anatomical model of sex. If one locates the “essence” of sex in specific sex organs such as the gonads, masculinity and femininity can be conceptualized in terms of mutually exclusive entities. In this model, male bodies are simply male, and female bodies simply female. Attaching sex to chemicals rather than organs means that sex becomes an entity with multidirectional capacities. Sex endocrinologists introduced a quantitative model of sex differences, in which all organisms can have feminine as well as masculine characteristics. The original assumption that each sex could be recognized by its own sex hormone was gradually replaced by a model in which male and female sex hormones are present in both sexes. Yet sex endocrinologists did not take the real challenge that their model provided, namely to abandon the dualistic notion that there exist only two sexes. From a standpoint of gender classifications, their revolutionary findings did not mean the end of the two-sexes model. Based on the same knowledge, it might have been possible to introduce a classification system of multiple sexes, just as has been suggested by Anne Fausto-Sterling (1993). In “Five Sexes: Why Male and Female are not Enough”, Fausto-Sterling suggested that “biologically speaking, there are many gradations running from female to male; and depending on how one calls the shots, one can argue that along that spectrum lie at least five sexes—and perhaps even more” (Fausto-Sterling 1993:21). The new science of sex endocrinology, however, decided to adhere to the traditional gender classification system.9

The tension between universality and locality

As I have indicated, the transformation of scientific body concepts into natural phenomena requires a second activity: the concealment of contexts. Beyond the Natural Body shows that the decontextualized status of scientific knowledge is the result of specific scientific activities. I have described how knowledge claims about sex hormones acquired the status of context – independent facts and artefacts because they became materialized in chemical compounds that could exist independently of the laboratory conditions that shaped them. The history of sex hormones exemplifies how scientists turn observations into materials in which contexts gradually disappear, materials which are subsequently claimed to enjoy an a priori natural existence.

Female sex hormones, for example, have taken on a variety of different forms, showing an increasing degree of context-independency:

1 observations of specific disorders in patients following surgical removal of the ovaries in a gynecological clinic in Vienna

2 preparations of gonads extracted and purified in Laqueur’s laboratory in Amsterdam

3 crystals in a bottle on laboratory shelves, carrying an Organon label with a chemical formula

4 pills in a plastic strip provided by health care professionals.

Laboratory experiments have played a major role in this decontextualization of knowledge claims. Scientists used experiments to transform the concept of sex hormones into standardized substances with precisely denned qualities that then became accepted as such by the international scientific community and the industrial world. Subsequently, clinical testing procedures have made these standardized substances available as specific drugs and eventually the pill. Local laboratory practices thus became decontextualized by developing instruments, techniques and standards robust enough to survive outside the laboratory.

However, scientists are not always successful in decontextualizing knowledge claims. There exists a basic tension between scientists’ striving for universal, decontextualized knowledge and the notion that science is shaped in its local contexts,2 a tension with severe practical consequences particularly with respect to the development of (contraceptive) technologies. The decontextualization strategy suggests that technologies can be made to work everywhere, but this is not always so. Scientific artefacts require a specific context in which they can work, one similar to the context from which they arise. If this context is not available, scientists have to create it. Or to use Latour’s metaphor of railroads again: scientists first have to construct railroads before the locomotives can move in the envisioned direction. The problem is that for contraceptive technologies such as the pill, the railroads are chiefly constructed in the western industrialized world. Most contraceptive technologies are made in industrialized countries and therefore bear the fingerprints of western producers, including locally and culturally specific ideas of how ideal contraceptives should look like. Every technology contains, so to say, a configured user.3 Consequently, technologies cannot simply be transported elsewhere.

The case of the contraceptive pill illustrates the complications that emerge if western technologies are introduced into developing countries. Although pill researchers claimed that the pill was a universal, context-independent contraceptive, it nevertheless contained a specific user: a woman, disciplined enough to take medication regularly, who is used to gynecological examinations and regular visits to the physician, and who does not have to hide contraception from her partner. It goes without saying that this portrait of the ideal pill user is highly culturally specific (with varieties even within one culture). This user is more likely to be found in western industrialized countries with well-developed health care systems. From this perspective it can be understood that the pill has not found a universal acceptance. Actually, the user-specificity of the envisioned universal contraceptive pill was already manifest during the clinical testing in Puerto Rico. The early trials witnessed a high percentage of drop-outs. I have described how disciplining women to the conditions of the tests was not always successful. Many women did not participate in the gynecological examinations or simply quit the program because they preferred other contraceptive methods, particularly sterilization. The Puerto Rican trials provided the pill researchers with information indicating that the pill did not meet with universal acceptance. These test conditions were, of course, a much heavier burden than the conditions of using the pill after it had been approved by the FDA. Two conditions remained, however, the same: frequent visits to a physician (the pill was available only on prescription) and regular gynecological examinations (women using the pill had to take regular gynecological examinations, including blood-pressure tests and vaginal smears to check for adverse health effects).4

The making of the pill into a successful contraceptive technology thus required a specific context, a context in which

1 there exists an easily accessible, well-developed health care infrastructure

2 people are accustomed to taking prescribed drugs (many developing countries mainly use “over the counter” drugs, which people can buy in shops)

3 women are used to regular medical controls

4 women and men are free to negotiate the use of contraceptives.

The pill could be made into a universal contraceptive only if its producers put great effort into mobilizing and disciplining people and institutions to meet the specific requirements of the new technology. Needless to say, many of the required transformations were beyond the power of the inventors of the pill. The sad conclusion therefore is that, although new contraceptive technologies such as the pill are often tested in Third World countries, the local needs of its potential users are rarely taken into account. During the tests the technologies are more or less successful because scientists make the contexts fit the demands of the testing, for example by enrolling trained medical staff and by selecting trial participants who may be made into ideal test subjects but who are not necessarily representative of the whole population. It is by creating such controlled settings that scientists are able to make the technology work. These controlled settings, however, no longer exist when the trials are over and the technologies are put on the market.

This situation often leads to health risks among the users of the new technologies. Since the 1980s, feminist health organizations seeking safe and reliable contraceptives have reported women’s complaints about serious side – effects while using contraceptives such as implants and injectables, particularly in developing countries (Anonymous 1985; Mintzes 1992: Ward 1986). Many of these adverse health effects seem to be related to insufficient medical follow-up. These contraceptive technologies all require a health care infrastructure that can provide medical controls for their administration and removal.5 In many Third World countries, such an infrastructure simply does not exist, particularly in rural areas. To avoid potential health risks, women’s health advocates campaign for the development of contraceptives that require less dependency and interaction with health care providers. They prefer the so-called user-controlled technologies and stress that users’ views should be taken into account in assessing acceptability (Bruce 1987; Pollock 1984).6 Scientists in the field of reproductive technology acknowledge the problems with the diffusion of new contraceptive technologies and introduced so – called “introductory trials” in the 1980s. These trials were conducted to assess the acceptability of new contraceptives in different social and cultural settings (Hardon and Claudio-Estrada 1991:12).7

These developments exemplify my point that scientific artefacts are not in themselves universal and context-independent. They have to be made into universal technologies by a whole variety of different activities. The introduction of contraceptive technologies shows that science is not always successful in its striving for universal, context-independent knowledge.

The quest for universal knowledge

Let us first look more closely at how scientists have tried to create contexts in which their knowledge claims about sex hormones could be transformed into natural facts. The history of sex endocrinology shows both successes and failures, which can best be understood in terms of the notion of networks of knowledge. In this perspective, knowledge “never extends beyond and outside practices. It is always precisely as local or universal as the network in which it exists. The boundaries of the network of practices define, so to say, the boundaries of the universality of medical knowledge” (Pasveer 1992: 174). The successes and failures in scientists’ striving for universal knowledge are thus related to the extent to which they are successful in creating networks. Bruno Latour’s metaphor of the railroads exemplifies this point:

When people say that knowledge is “universally true,” we must understand that it is like railroads, which are found everywhere in the world but only to a limited extent. To shift to claiming that locomotives can move beyond their narrow, and expensive rails is another matter. Yet magicians try to dazzle us with “universal laws” which they claim to be valid even in the gaps between the networks.

(Latour 1988:226)

In terms of this network perspective, the concept of sex hormones was a strong concept because of its pronounced connotations for sex and the body. Female sex hormones could be linked with “female diseases” and related medical institutions, and male sex hormones to “male diseases” and related medical professions. The concept of sex hormones simultaneously summarized and simplified the interests of specific groups. At this point, however, there existed vast differences between knowledge claims about female sex hormones and male sex hormones. The previous chapters have shown how the networks that evolved around statements about female sex hormones were much more extensive and substantial than the networks around male sex hormones.

First, there were major differences in the number of researchers who became involved in both types of research. Because methods as well as research materials for female sex hormones were well developed and easily available, more and more researchers became involved in research on female sex hormones. We saw how the number of publications on female sex hormones increased steadily in the 1920s and 1930s and soon outnumbered those on male sex hormones.

Second, there were striking differences in the number and variety of the groups outside the laboratory that became involved in research on female and male sex hormones. Knowledge claims about female sex hormones could be linked rather easily to relevant groups outside the laboratory. The making and the marketing of female sex hormones fitted nicely into already existing institutional structures formed earlier in the century. In the process of making female sex hormones into chemical substances, laboratory scientists were able to create networks with gynecologists and pharmaceutical companies prepared to provide them with the required research materials. In the transformation of sex hormones into drugs, we saw a further extension of these networks from the laboratory and the pharmaceutical industry to other medical professions, and to groups beyond the laboratory and the clinic. With respect to female sex hormones, Organon was quite successful in enrolling the relevant groups to promote new types of drugs to a wide variety of audiences, sponsors and consumers, including general practitioners, psychiatrists, neurologists, medical health institutions, women’s clinics, factory boards of directors and insurance companies. In the marketing of female sex hormones, the number of indications for which sex hormones were tested increased simultaneously with the involvement of more groups, in a process by which female sex hormones were made into drugs applicable for a wide variety of diseases in women.

What is important here is that some networks are easier to create than others. Negotiations to establish networks do take place in “a highly prestructured reality in which earlier choices delineate the space of further choices” (Berg 1992:2). In the case of female sex hormones, laboratory scientists and pharmaceutical companies did not have to start from scratch. They could rely on an already organized medical practice that could easily be transformed into an organized market for their products. The gynecological clinic functioned as a powerful institutional context that provided an available and established clientele with a broad range of diseases that could be treated with hormones.

Knowledge claims about male sex hormones were more difficult to link with relevant groups outside the laboratory. The production as well as the marketing of male sex hormones was rather constrained by the lack of an institutional context comparable with the gynecological clinic: men’s clinics specializing in the study of the male reproductive system did not exist in the 1920s. The production of male sex hormones was rather problematic because it was hard for laboratory scientists to gain access to the required raw materials. The marketing of male sex hormones remained confined to a smaller number of groups, thus lowering the number of indications that became included in the drug profile of male sex hormones. Although there existed a potential audience for the promotion of male sex hormones, this audience was not embedded in any organized market or resource network. These differences in institutional context had a major impact on the marketing of sex hormones. Because the promotion of female sex hormones could easily be linked to the interests of a well-established profession, female sex hormones developed into drugs that were prescribed for a far wider array of medical indications than male sex hormones.

In the case of sex endocrinology, successes and failures in creating networks were highly dependent on the fact that there existed a medical specialty for the reproductive functions of the female body, and not for the male body. It was this asymmetry in organizational structure that made the female body into the central focus of the hormonal enterprise. Sex endocrinologists depended on these organizational structures to provide them with the necessary tools and materials. These differences in institutionalization between the female and the male body are a very crucial factor in shaping the extent to which knowledge claims can be made into universal facts. The institutionalization of practices concerning the female body in a medical specialty transforms the female body into an easily accessible supplier of research materials, a convenient guinea-pig for tests and an organized audience for the products of science. These established practices facilitated a situation in which the hormonally constructed female body concept acquired its appearance as a universal, natural phenomenon.

MAKING THE BODY NATURAL

Since its introduction in the early decades of the twentieth century, the hormonally constructed body concept has gradually developed into a dominant mode of conceptualizing the body, even to such an extent that we are encouraged to assume that the hormonal body is a natural phenomenon. But what exactly is required to transform a scientific concept into a natural phenomenon? I suggest that an answer to this question can be found in one of the distinctive features of science and technology: its striving for universal, decontextualized knowledge. Scientific concepts attain the status of natural facts in a twofold process. First, scientists create the contexts in

which their knowledge claims are accepted as scientific facts and in which their technologies can work. Scientists adopt what I would call a “(re) contextualization strategy” in which their knowl-edge claims can gain momentum. Second, scientists then conceal the contexts from which scientific facts and artefacts arise, in a process which I will refer to as a “decontextualization strategy.”1 One of the reasons why science succeeds in convincing us that it reveals the truth about nature is that the social contexts in which knowledge claims are transformed into scientific facts and artefacts are made invisible. Science makes us believe that its knowledge claims are not dependent on any social context. During the development of science and technology the established links with the worlds outside the laboratory are naturalized. “There was, or so it seems, never any possibility that it could have been otherwise” (Akrich 1992:222).

The power of structures that already exist

Science, more than any other investigative and descriptive activity, creates and conceals the contexts from which it arises.

(Duden 1991c:20)

We need the power of modern critical theories of how meanings and bodies get made, not in order to deny meanings and bodies, but in order to build meanings and bodies that have a chance for life.

(Haraway 1989a:580)

My argument throughout this book has been to show that sex hormones are not just found in nature. My concern was with finding an alternative explanation for the idea that the emphasis on the female body in hormone research simply reflects a natural order of things. Beyond the Natural Body illustrates how scientific body concepts such as the hormonal body assume the appearance of natural phenomena by virtue of the activities of scientists. In this archeology of the hormonal body I tried to unravel both the construction and the impact of this new understanding of the body. It is time to summarize and evaluate the major conclusions that can be drawn from my examination of the history of sex hormones.

THE CONTINUOUS TESTING OF THE PILL

The way in which the oral progestins were finally approved as contraceptives is a rather intriguing story. Based on the Rio Piedras trial and a handful of small – scale clinical trials in the continental USA, the FDA approved Enovid in 1957, not as a birth control pill but only as a treatment for menstrual disorders. According to Garcia this was a political choice:

The first application was not as an oral contraceptive but as a gynecological agent to treat menstrual aberrations, and that was done with political calculation and it wasn’t done with any other thing in mind because the contraceptive properties of it were well-known at that point.

(Garcia in Anonymous 1978:60)

Many actors understood very well what the FDA approval actually meant. In McCormick’s words:

Of course this use of the oral contraceptive for menstrual disorders is leading inevitably to its use against pregnancy—and to me—this stepping stone of gradual approach to the pregnancy problem via the menstrual one is a very happy and fortunate course of procedure.39

In May 1960, the FDA eventually granted its approval for the marketing of Enovid explicitly for contraceptive purposes (Maisel 1965:142). Pincus and Rock’s representation strategy turned out to be successful. The FDA executives used both the results of the clinical trials and all the studies, “every page of them,” from the Puerto Rican and Haitian field trials.40 The Caribbean trials functioned as an important ingredient in convincing the FDA, the medical profession and health officials of the “universal” character of the new contraceptive: it was proven that it could be used by women of any color, class and educational background.

Following FDA approval, the new contraceptive could be put on the market. G. D.Searle and Company, very much aware of the novelty of the product and its potential to damage the company’s reputation, did not take any risks. Its executives developed a careful marketing and public relations campaign. Ahead of the launching date for the product, they approached the editors of the Saturday Evening Post and Reader’s Digest and negotiated three major articles, telling the story of “the new contraceptive that was being tested in Puerto Rico.” This strategy was chosen to test whether their new product might generate any protest. The expected angry letters to the editors, however, did not appear. Searle had obviously misjudged the situation. Times were changing during the years that the pill was being developed. Despite the fact that contraception was technically a forbidden subject in Massachusetts, the moral attitudes to contraception and sexuality in general were relaxing in the 1960s (McLaughlin 1982:137-138; Vaughan 1972:52­53). Actually, by late 1959, half a million American women were already taking Enovid, originally prescribed to them as a drug for menstrual disorders, as contraceptives. Both doctors and patients knew the pill’s contraceptive power well before it was marketed as such. The FDA, in its first approval of Enovid, had “mandated Searle that the drug would carry a warning to the doctors that women would not ovulate while taking the pills,” a mandate which worked like a “free ad.”41 A similar practice existed in European countries. In The Netherlands a combined estrogen-progesterone preparation was first marketed in 1962 for the treatment of menstrual irregularities, carrying a warning that women would not become pregnant while taking this medication. This strategy was chosen to anticipate possible protests from physicians, the media, the lay public, as well as the mainly Catholic production personnel of Organon, the firm that introduced the pill to the Dutch market (Haspels 1985:20). In Spain, this cautious attitude was even found up until the 1980s. “The Spanish Pharmacopoeia described estrogen-progesterone combinations as effective in regulating menstrual cycles, but as having the serious side effects of preventing pregnancy” (Veatch 1981). This practice exemplifies how the activity of a drug is not dictated by nature, but is the result of a socially conditioned selection process, in this case religious and moral attitudes toward birth control (Bodewitz et al. 1987).

Searle soon witnessed the profits from its “daring decision” to market Enovid as a contraceptive: the company’s shares doubled in value in the years following FDA approval (Seaman 1969:179). Other American drug companies, such as Syntex and Parke-Davis, did not take this risk. They felt that contraceptives were not a suitable business for an ethical firm (McLaughlin 1982:137). Parke-Davis in particular was afraid that the marketing of a contraceptive would ruin their market in the Roman Catholic areas (Anonymous 1978:36-37) The market, however, was more than ready to accept the new contraceptive.

The FDA’s approval of the first oral contraceptive had an immediate impact on the health care system in the US. In the spring of 1960, many health department directors and welfare officials began to plan the opening of new contraceptive clinics (Maisel 1965:216). The acceptance of Enovid as an officially approved drug did not mean, however, that testing had come to an end. Research and development of the new contraceptive remained a major issue on the research agendas of Pincus and Searle, and those of the many other scientists and companies that now joined the bandwagon.

Since the 1960s, field trials of Enovid and other related compounds have been continued and expanded. One of the problems to be solved, which would remain a major issue for further testing until well into the 1980s, was the proper dosage of the drug. The dosage used in the early clinical and field trials was merely guesswork, “a shot in the dark,” as one of Pincus’s colleagues described it (Vaughan 1972:48). Systematic studies of reductions of the dose, needed to make the contraceptive “physiologically safer, but also more economic” (Pincus et al. 1962:440) were not included in the early trials. This might have increased the risk of pregnancies, thus lowering the “success” rate of the medication, which was measured only in terms of non­pregnant cycles. After FDA approval was obtained, new trials were organized to give more serious consideration to the side-effects that continued to be reported by women and physicians, the most important of which was the risk of cancer (Ramirez de Arellanoa and Seipp 1983:123).

The development of a pill with reduced dosage levels was taken up when the new contraceptive came to be used regularly by a great many women, underlying the necessity of producing a pill that required less raw material and that would cause fewer side-effects. A second generation of oral contraceptives under the brand name of Ovulen, with one half and later one – quarter of the dose of Enovid, was tested and put on the market in 1963. This first made the pill available outside the USA: in Britain, Austria and South Africa. The third generation of the pill, available in the 1990s, contains a dosage that is only one-tenth of the progesterone and one-third of the estrogen levels of the first generation of oral contraceptives (Maisel 1965: 195, 201; Vaughan 1972:49). The use of hormones as contraceptives since the early 1960s can therefore be described as an “infinitely large unofficial field trial” including women all over the world (Maisel 1965:146).

CONCLUSIONS

This episode in the story of hormones illustrates how scientists reoriented the hormonal enterprise to a totally new purpose: the control of fertility. As I indicated, medical innovation can only be successful only if scientists succeed in selecting and creating the required contexts in which knowledge claims can be established. In this respect, the development of hormones into contraceptives faced serious constraints, which shaped the entire development trajectory, from the search for the required test locations to the enrollment of women in the trials, and from the approval of the FDA to the eventual marketing of the contraceptive pill. The pill was a novelty since it was a compound to be prescribed for healthy women. This meant that the organization of clinical trials could not easily follow the routines of other clinical testing. Trials for the testing of drugs to cure a specific disease could rely on patients who could be assessed in clinical settings. For the pill, such patients did not exist. The testing of the pill required “healthy patients” who did not suffer from any particular disease and consequently did not belong to the clientele of a specific clinic.

The search for the required test locations was highly constrained by the political and moral taboos on birth control. The major quest was therefore: where to find test subjects and a politically feasible test location. Due to these constraints, the history of testing the pill reads as a detective story in which the participants try to conceal their real intentions from anyone who might hinder their endeavor. In this respect, the first trial in which hormones were tested in humans speaks volumes: the contraceptive potential of the hormones was tested first among women who were being treated for infertility problems! Subsequent trials were organized in settings where only very specific groups of subjects could be assessed: a mental hospital, a medical school and a women’s prison. These trials were not very successful in enrolling women. Established medical institutions could obviously not provide the required infrastructure for the development of the contraceptive pill.

What all this implied was that pill researchers had to create the required contexts themselves. The quest for “healthy patients” could be solved only by removing the tests to a completely different location: the infrastructure of the family planning organizations, particularly the Family Planning Association in Puerto Rico. This displacement did not necessarily imply a preference for Puerto Rico. It is very likely that the required test location might as well have been found among family planning clinics in those states of the US continent that had no laws prohibiting birth control activities. Actually, one such trial was organized, in Los Angeles, at about the same time that the third trial in Puerto Rico took place.42 The choice of Puerto Rico must therefore be understood as a mixture of cultural imperialism and practical testing considerations. Since the contraceptive pill was called into existence mainly because it was considered a technological fix for the population problem in “underdeveloped countries,” its testing required a population that reflected this ideology: poor, illiterate women. Puerto Rico, with its poorly educated and impoverished population, provided such a testing ground.43

The hormone story thus evolved into a highly political story which clearly shows the crass manipulatory strategies of big politics which can ignore other communities. This is very different from the intimate involvement of the communities I described in the previous chapters, where there was a kind of see-saw of dominance that kept everyone very aware of whom they were dealing with.44

The displacement of the clinical tests from the medical institutions to the clinics of the family planning organizations had enormous consequences in terms of the women who eventually became the major test subjects for the contraceptive pill. The first large-scale trials, with all the risks involved, did not take place among the white majority of Americans or Europeans. It was Caribbean women who entered this history as the guinea-pigs of one of the most revolutionary drugs in the history of medicine. Obviously, women do not have the same position as “objects of scientific inquiry.” This means that we cannot continue to address women as a group if we focus on knowledge production about the body. This conclusion is in line with the postmodernist approach in women’s studies, which suggests that the feminist preoccupation with the category of woman tends to obscure and mystify the vast differences among women’s experiences and characteristics in different cultural settings. Black feminists specified this claim by suggesting that feminist studies should take into account the differences between women that are created by the social contexts of being black or white.45

Applying this theoretical notion of the construction of differences to the story of the pill shows a rather peculiar pattern. The choice to test progestins in Caribbean women could be made only because scientists did not assume a priori fundamental bodily differences between women. All women are equal in scientists’ theories on the role of progestins in reproductive functions, even to such an extent that scientists make women disappear from their reports altogether. We saw how, in publications about the pill, women who participated In the trials are replaced by menstrual cycles: woman is represented as “cycle.” This representation strategy enabled scientists not only to make the most of their results, but also emphasized the similarities between women. The use of such categories as “cycle” replaces the individual subject by the group, suggesting a continuity that did not exist in the trials. That suggestion simultaneously affirms continuity while obscuring discontinuity by framing new scientific categories for data measurement. A representation in terms of cycles implies an abstraction from the bodies of individual women to the universal category of a physical process.

The history of the pill thus reads as the intriguing story of how scientists tried to construct similarities between women. This construction of similarities was not just a matter of discourse. During the testing of hormones, similarities were literally created by the introduction of a specific regimen of medication. As I indicated, Pincus could have made a menstrual cycle of any desired length by changing the prescription of how to use the tablets. He chose to make a “normal” menstrual cycle that subsequently became materialized in the pill. This diminished the variety in menstrual patterns among women: all pill-users have a regular four-week cycle. The pill thus literally created similarities in women’s reproductive functions.

This emphasis on similarities was a prerequisite for the quest to develop a universal technology: a contraceptive that was meant to be used by women of any color, class or educational background. This dream of making the ideal contraceptive for any woman, regardless of her specific background, was not fulfilled. The main acceptance of the pill has been among middle – and upper- class women in the western industrialized world, with one major exception: China. Most women in Third World countries have adopted sterilization and intra-uterine devices as means of contraception (Seaman and Seaman 1977: 76). Despite the development of the pill, the problem of fertility control is not yet solved. Even in the 1990s, there still exists a large and unmet need for fertility control among women worldwide (Hardon and Claudio-Estrada 1991).