Abstract
Body mapping methods are used in sexual and reproductive health studies to encourage candid discussion of sex and sexuality, pleasure and pain, sickness and health, and to understand individuals’ perceptions of their bodies. VOICE-D, a qualitative follow-up study to the VOICE trial, developed and used a body map tool in the context of individual in-depth interviews with women in South Africa, Uganda, and Zimbabwe. The tool showed the outline of a nude female figure from the front and back perspective. We asked women to identify, label, and discuss genitalia and other body parts associated with sexual behaviors, pain, and pleasure. Respondents could indicate body parts without having to verbalize potentially embarrassing anatomical terms, enabling interviewers to clarify ambiguous terminology that may have otherwise been open to misinterpretation. Body maps provided women with a non-intimidating way of discussing and disclosing their sexual practices, and minimized miscommunication of anatomical and behavioral terminology.
Introduction
Sociocultural taboos related to the discussion of sex are prevalent across Africa (Burgoyne and Drummond 2008). Despite the sociocultural diversity of the continent, there is a general reluctance to discuss sensitive issues related to sexual health because of feelings of embarrassment and shame and fear of judgment (Amadiume 2006; Tamale 2005). A study in South Africa (SA) indicated that discussions about sex are proscribed, masked by use of polite and euphemistic language and gestures (Ndinda et al. 2011). Evidence from Zimbabwe suggests that it is culturally unacceptable for Shona women to talk openly about sexual issues (Machingura 2012). Study findings also suggest that taboos in Uganda mean that open discussion of matters related to sex and sexuality are rare (Amuyumunzu-Myamongo et al. 2005; Nabulime and McEwan 2011). Furthermore, it has been argued that in the broader African context, it is culturally inappropriate to discuss issues related to excretory and sexual organs (Chabata and Mavhu 2005; Mabaso 2009; Storch 2011). Researchers conducting qualitative studies exploring sexual behaviors in these contexts may therefore be faced with numerous methodological challenges when attempting to discuss these issues with research participants (Denes 2013; Duby 2015). Innovative research tools and approaches could enhance collection of accurate, precise, and complete data related to sexuality and sexual behaviors.
Interactive and participatory qualitative research methods such as body mapping have been used in health-related research (Cornwall 1992; Gastaldo et al. 2012; Jaswal and Harpham 1997). Body mapping is a visual method enabling the illustration of people’s perception of their bodies, the function of different body parts, and concepts of health and illness (Brett-MacLean 2009; Harries et al. 2019). The body mapping technique typically refers to participants drawing representations of their body (either as an individual or in a group), labeling body parts, and adding other research-specific information, which may include emotions, labels, colors, and symbols (Brett-MacLean 2009; Cornwall 1992; Gastaldo et al. 2012). Body maps and the body mapping process can be used as both a research product and a research process and can be utilized in focus group discussions and individual in-depth interviews (IDIs) (Duby 2015; Gastaldo et al. 2012).
Body mapping activities are designed to help participants feel comfortable and non-threatened, and to speak openly about sensitive topics such as sexual behavior (Duby 2015). Body map-type tools can be used as visual aids to assist researchers in understanding the way in which participants interpret research questions and terminology (Duby et al. 2016). Body mapping has been used in qualitative studies exploring issues such as women’s insights on reproduction and their understanding of contraception (Cornwall 1992), personal HIV experiences (Solomon 2007) and the emotional, physical, and social impact of being HIV positive (Willis et al. 2018).
VOICE-D (van der Straten et al. 2015) a two-stage exploratory study conducted with former VOICE HIV prevention trial (Marrazzo et al. 2015) participants, used body mapping, together with IDIs, to encourage open discussion about sexual behavior. A specific aim of VOICE-D was to explore behavioral factors amongst VOICE participants that may have contributed to the inefficacy of oral and vaginal tenofovir-based pre-exposure prophylaxis (PrEP) observed in VOICE (Marrazzo et al. 2015; Mâsse et al. 2009; McGowan and Taylor 2010). During VOICE, investigators were aware that penile–anal intercourse (PAI) may have been misreported due to misinterpretation of terminology in questionnaires and other biases. In VOICE-D, we provided participants with a body map template specifically designed to understand participants’ anatomical knowledge and definition of PAI. This article describes the use of a body map template as a tool to initiate and facilitate dialog on sexual behavior, clarify anatomical understanding, and verify knowledge and definition of PAI among women participating in stage one of VOICE-D.
Method
Ethical Considerations
The study protocol was approved by Institutional Review Boards at the participating study sites, and at the Human Research Ethics Committees at partner institutes in the United States. Written informed consent was obtained from participants prior to any data collection.
Study Population
VOICE-D study design and procedures are described in detail elsewhere (Duby et al. 2016; van der Straten et al. 2015). Eighty-eight former VOICE participants (40 women from SA, 22 from Uganda, and 26 from Zimbabwe) participated in stage one of VOICE-D (van der Straten et al. 2015).
Development of the Body Map Tool
The body map template (Figure 1), a diagram printed in black and white on A4 paper, showing the front and back outline of a nude female figure, was used by interviewers during IDIs to initiate and support dialog on sexual behavior, specifically PAI (Duby et al. 2016). A decision was made not to use a medical-type sagittal view diagram due to the low literacy levels of some participants. The body map tool underwent a process of field testing and refinement, in which research staff at the three study sites gave input on the clarity, comprehensibility, and appropriateness of the template.
Figure 1.
Body map template (Duby et al. 2016).
Data Collection
The IDIs and body mapping activity were conducted by trained female interviewers and were based on a semi-structured interview guide. A single IDI was conducted with participants in their preferred languages: English, Zulu, Shona, or Luganda. A short demographics questionnaire was administered to participants prior to the IDI. In the second part of each IDI, interviewers explained the body map activity to participants and provided participants with a pre-drawn body map template, distinctly showing the vagina and anus (Duby et al. 2016). They used the body map to assess participants’ understanding of PAI terminology and to clarify misunderstandings or misinterpretations surrounding PAI. During VOICE, questions related to PAI were asked via the participant administered Audio Computer Assisted Self-Interview (ACASI) method. In VOICE-D, interviewers used the body map to assess understanding of the PAI question (pertaining to frequency of PAI in the past three months) asked via ACASI during VOICE. Furthermore, women were asked to identify and discuss genitalia and other body parts associated with sex, pain, and pleasure. Women’s responses, in the form of key words or short sentences, were noted by the interviewer on the template. Women’s reactions to the body map template were captured on interview debrief reports.
Data Analysis
Audio recordings of IDIs were transcribed into the local languages, then translated into English, quality checked, and validated by study staff. Qualitative data were coded and thematically analyzed using the NVivo 10 software package (QSR International), by a team of four analysts; ≥80% inter-coder reliability was established and verified on ~ 10% of the transcripts throughout the coding process. Annotated body maps were analyzed together with corresponding transcript data.
Results
Study Sample Characteristics
Characteristics of the study sample are presented in Table 1. The mean age of the women was: 26.7 in SA, 29.5 in Zimbabwe, and 31 in Uganda. Overall, 42% of the participants completed secondary school or more. Majority of the participants at the three study sites had a primary sex partner or were married. In SA, however, none were legally married and only 13% were living with their primary sex partner. Participants in Uganda reported the highest number of partners in the past three months. This was expected given the number of participants who reported engaging in sex work. Almost all women reported having vaginal sex in the past three months. Participants were not asked about PAI as part of the VOICE-D demographics questionnaire given that their understanding of PAI was to be explored during IDIs.
Table 1.
Stage One Study Sample Characteristics.
| Characteristics | South Africa (N = 40) | Zimbabwe (N = 26) | Uganda (N = 22) | Overall (N = 88) |
|---|---|---|---|---|
|
| ||||
| Mean age (median) | 26.7 (25) | 29.5 (30) | 31 (31) | 28.6 (27) |
| Completed secondary school or more | 20 (50%) | 14 (54%) | 3 (14%) | 37 (42%) |
| Currently married | — | 22 (85%) | 13 (59%) | 35 (40%) |
| Has current primary sex partner or married | 38 (95%) | 24 (92%) | 22 (100%) | 84 (95%) |
| Same partner as during VOICEa | 27 (71%) | 22 (92%) | 19 (86%) | 68 (81%) |
| Currently living with primary sex partnera | 5 (13%) | 22 (92%) | 10 (45%) | 37 (44%) |
| Partner provides financial supporta | 32 (84%) | 22 (92%) | 20 (91%) | 74 (88%) |
| Vaginal sex in past 3 months with primary sex partnera | 37 (97%) | 24 (100%) | 22 (100%) | 83 (98%) |
| Mean number of other partners in the past 3 months (median)a | 0.1 (0) | 0 (0) | 16 (1) | 4.1 (0.4) |
| Mean total partners in lifetime (median) | 3.3 (2) | 2.1 (1) | 31.2 (5) | 9.9 (2) |
With primary sex partner or married.
In-depth Interviews and Body Map Activity
Eighty-eight IDIs involving body map activities were conducted at study sites from December 2012 to March 2013. Reactions to the body mapping activity were diverse: A majority of the women were amused, while others were shy or embarrassed when initially shown the body map. All participants, except one, engaged in the body mapping activity; a majority performed the task without difficulty. However, some women needed guidance on use of the template or encouragement due to initial discomfort to discuss sensitive issues such as sexual behaviors, more especially PAI. Only a small number of women were reluctant to discuss their sexual behavior (refusing to discuss PAI due to discomfort about the topic; labeling only biological functions of the body; and avoiding looking at the map). A few initially thought that the diagrams represented male and female figures. The back view of the diagram was also difficult for some women to understand. There was some confusion about which orifices were the vagina and anus, hence they initially mislabeled the vagina as the anus.
Body maps were used by most women to discuss pleasure; only half used the tool to identify areas associated with pain. A majority were able to label sexual functions of body parts. Anatomical terms and their understanding (e.g., anus) were clarified, including the meaning of local terms used for sexual acts such as “sex from behind” and terms for PAI (Duby et al. 2016). A total of 10/88 participants reported that they were confused about the anatomical location (vagina or anus) that the VOICE PAI question was referring to. Furthermore, 14/88 participants admitted that they had either not understood the VOICE PAI question or thought that the question referred to penile–vaginal intercourse from behind (Duby et al. 2016).
Annotated Body Map Templates
Anatomical Understanding
Most women labeled the different parts of the anatomy correctly (Figure 2A–2C) and explained different types of sexual penetration. Women pointed directly to anatomical locations on the body map when probed by the interviewer to explain what they understood about the role of the vagina and anus in sexual activity:
Figure 2.
Annotated body maps: (A) Zimbabwe: Front view: Breasts bring pleasure; vagina as a pleasure point; vagina can also be a pain point during sex if aggressive. Back view: Correctly identified anus; correctly identified the vagina from behind. (B) SA: Front view: Eyes to seduce and make eye contact during sex; lips to kiss to prepare you for sex; breast to breastfeed and to suck by males during sex so that the woman gets turned on; to hold your partner to feel safe and secure to prepare for sex (foreplay); vaginal hole for males to put their private parts in; navel is sensitive, males like to suck it but I don’t like it to be sucked; vaginal hole to pass urine; “bean” clitoris for foreplay. Back view: Anus for anal sex; vagina for male to enter with his penis because woman is bending here. (C) Uganda: Front view: Breast; vagina. (Back view): Anus (no pleasure); hips; vagina (pleasure through sex with man).
Respondent (R): This is a front private part; when facing like this, it is when sexual activity will commence from the back [referring to the second body mapping template image and describing having vaginal sex from behind].
Interviewer (I): And this upper part?
R: Anus. The part which passes waste into the toilet.
I: What else?
R: Sometimes for sexual activity.
I: Some use it for sex?
R: Indeed.
I: And this one …
R: They practice sex using this back part.
I: How?
R: A male would insert his penis into the female’s back part.
(Zulu speaker, SA)
Interviewers referred to the tool and probed further to clarify anatomical understanding, especially with participants who were not very responsive during this particular discussion:
R: I see a woman’s vagina and back part in the pictures.
I: That is this, is it for a woman?
R: Mmm [Yes]
I: … what other different parts of a woman can you see?
R: This is the place where feaces pass …
I: What about this one …?
R: [Silence] … I have not understood this one.
I: You did not understand it; you said that this is the back part where feaces pass.
R: Mmm [No] [silence]
I: What about here, what do you see?
R: Here? … Isn’t this the vagina?
I: It is the vagina?
R: Mmm [yes].
(Lugandan speaker, Uganda)
Sexual Behavior
The template helped stimulate discussion about sexual practices such as PAI, including explanations for how PAI might be initiated:
I: So if a man and a woman are having anal sex, where does the man put his penis?
R: He will put it in the back part because the woman’s vagina will be slightly below the back part. The back part is slightly above.… The woman’s vagina is slightly below.…So it means if he is having sex at the back, he will also put it there.
I: In the anus?
R: That is where he will put his penis if he wants to have sex at the back.
I: So you now understand?
R: (laughing) I do.
(Shona speaker, Zimbabwe)
The body map prompted women to freely share their knowledge of different types of sexual behaviors by associating specific sexual behaviors with the bent-over back view of the female figure on the template:
This one, you can see that she has her back turned and is ready for sex at the back. (Zulu speaker, SA)
Differences between sexual acts, such as vaginal sex from behind versus PAI were clarified:
(Laughing) I don’t know the name but its common, where the woman will be in a bent position and the man will put his penis in your vagina from the back.… Not the back part. (Shona speaker, Zimbabwe)
Given the sensitive nature of the topic, at times women appeared uncomfortable and embarrassed about discussing sex. Interviewers referred directly to anatomical locations on the body map to prompt women to speak openly about sex:
I: Isn’t there any other role that sex plays here (pointing to body map)?
R: Here? I don’t know how to explain it.
I: We are listening. Feel free to talk about anything you see.
R: [Laughing]. This is the bum (izinqa) (pointing to body map). It is painful when a man puts his penis in there, but you get used to it and end up enjoying it.
(Zulu speaker, SA)
Some participants expressed discomfort during the body mapping activity and were reluctant to verbalize anatomical terms. They pointed directly to the ano–genital regions on the body map without saying the words out loud. Women also used indirect, ambiguous, and euphemistic language to refer to genitalia, such as “private parts” or “front/back” part, “thing” or “pee-pee”:
I think this is the third hole … you only use it for going to the toilet.… I think it’s still the same hole.… What can I call it really? I really don’t know.… It has many names … this one as for urinating and that one for sex. There are actually three holes. Do you see that one? … That one is for defecating.… This is for urinating and that, that, that is where a man inserts his thing.… He inserts his … private part … his “peepee” (ipipi). What do you want me to say? What do you want me to call it? (Zulu speaker, SA)
Women used the body map to discuss areas associated with sexual pleasure points (Figure 2 A–2C), highlighting not just genitalia, but explaining how eyes, lips, breasts, navel, or hips are involved:
Your whole body parts will play a role in sexuality … (Zulu speaker, SA) Women also used the map to accompany discussion and identify parts of the body associated with painful sex (Figure 2A). These were mostly limited to genitalia.
If you have sex from the back [anal sex] (mukasangana nekumashure) sometimes you can have some pain.
(Shona speaker, Zimbabwe)
Clarification of Understanding of PAI
Women pointed directly to the anatomical location on the body map template, and described their understanding of PAI:
This is the genitalia (isitho sangasese), in front here. … This one here.-That is where a man inserts his penis. … He inserts it here, in the hole (indicating on template). … These are buttocks and that hole at the back is for defecating. … This is the body part in front where sex takes place and this one is from the back … it goes into this hole here.… He puts it into this hole. (Zulu speaker, SA)
Similarly, another participant stated:
I: Having sex from the back!! (Emabega ewafulumya)
R: Yes.
I: Where does he pass from if you look at this picture critically?
R: Here [in the anus].
I: When they have sex from there?
R: Yes.
I: That’s how you understood it?
R: Yes.
(Lugandan speaker, Uganda)
Taboos surrounding PAI were evident in the discomfort and reluctance of some participants in discussing anal sex behavior; the body map enabled interviewers to prompt discussion around this topic:
I: In your own understanding which part is used when having sex from the back? Can you please point to me the part here [referring to the body map template]?
R: (silence) Umm you can’t have sex using the back part [anus] (kumashure kunobuda netsvina).
I: We can’t use that part for sex?
R: Uhm (no).
I: Okay but you were asked about this (during VOICE)?
R: Yes, they would ask us if we used that part or not during sex.
I: So you think it’s not?
R: Haaa no!
I: There is no one who uses this part for sex?
R: The back part [anus] (nekumashure kwetsvina)? No one use that part for sex.
(Shona speaker, Zimbabwe)
Reluctance to Participate in Body Map Activity
For the majority of participants, the diagram and questions about sex presented during the body mapping activity encouraged open discussion. However, a few participants who participated in the activity were uncomfortable with the body map and were reluctant to discuss sexual behaviors. Only one participant asked to skip the activity altogether, referencing her distaste for and unwillingness to discuss anal sex:
No, I shall not speak about body illustrations; I do not practice sex at the back part (ucansi iwangemuva) … Shoo! [giggles]. You said one may skip the question she is not pleased with? Indeed, that is how it was explained.…-When not pleased with that, one may skip it.… I do not want to venture into this one. (Zulu speaker, SA)
Discussion
The body map template used during IDIs in VOICE-D was feasible to implement and generally acceptable to women in this setting. Although some women were initially amused, shy, or embarrassed when shown the body map; all except one, participated in this activity. Most women readily labeled maps; however, some needed assistance with using the template, or reassurance as they were initially reluctant or uncomfortable to discuss sexual behavior, in particular PAI, as well as discussion of sexual pleasure and pain. By utilizing body maps, interviewers were able to establish women’s knowledge of anatomical locations of body parts related to sex, and clarify misunderstanding of ambiguous and imprecise sexual behavior terms (Duby et al. 2016). Use of body maps enabled understanding about women’s sexual preferences, attitudes, and sexual behaviors.
To the best of our knowledge, this is the first study to describe the use of a standardized, pre-drawn body map as a catalyst to discuss sexual behavior, and, more specifically, to verify knowledge and definitions of PAI among women participating in an HIV prevention trial. Other qualitative studies exploring PAI in women did not report using supplementary tools to aid the discussion or clarify understanding of PAI. In a previous study, part of rectal microbicide acceptability research, ethnically and racially diverse English-speaking women attending a community clinic in Boston were asked at the beginning of the interview what term they used to describe PAI, in an attempt to clarify the participant’s understanding of PAI and to assess the participant’s use of terms to describe PAI (Maynard et al. 2009). Apart from interview guides, no additional tools were used to clarify terminology relating to or discuss PAI. In a qualitative study conducted within a subsample of women, from urban areas in SA and rural areas in Uganda and Zambia, participating in a Phase III microbicide trial, very few women reported PAI. Penile–anal intercourse was discussed using only open-ended questions (Montgomery 2008).
Our findings in VOICE-D indicated that the body mapping activity facilitated and aided discussion on confidential and sensitive topics, especially on issues around PAI (Duby et al. 2016). Given the lack of unambiguous, precise, and culturally acceptable terms for anus and PAI in the Luganda, Shona, and Zulu languages, and the use of ambiguous, indirect terms such as “the back part,” or “part where feces comes from” to refer to the anus (Duby et al. 2016), the body map was useful in enabling interviewers determine what women had understood by the PAI question they had been asked by ACASI during VOICE. A previous publication showed that several VOICE-D participants admitted to misinterpreting the VOICE PAI question, only after understanding of PAI was clarified using the body map (Duby et al. 2016). The body map deflected eye contact, and women could point to body parts without having to verbalize potentially embarrassing anatomical terms. Women were able to label various parts of the body, including sexual and reproductive parts. The body mapping activity also functioned as a visual stimulus for participants, while the interviewer introduced a series of relevant prompts to encourage open discussion around sexual behavior and sources of pleasure and pain.
Although none of the interviewers had previous experience working with body maps, all of them were comfortable with this activity after receiving appropriate training on use of the body map tool. Interviewers reported that the tool was especially helpful in the discussion of PAI, allowing them to probe further about participants’ understandings, attitudes, and experiences relating to PAI. VOICE-D interviewers were sensitized about discussing PAI in a non-judgmental manner, as they themselves may have felt discomfort to discuss the topic due to personal beliefs, cultural norms, and taboos regarding PAI. Interviewers who are not properly sensitized to the discussion topic or not adequately trained in administration of the body map tool may not be able to gain the confidence of the participant to engage in the activity, and thus have a frank and open discussion about the topics being discussed. Participants should be adequately informed about the body activity at the beginning of the interview, so that they are aware of the process and understand what a body map is and the reasons for its use. It was important for interviewers to constantly assess the level of comfort or discomfort when utilizing this tool during the interviews. Interviewers had to use their personal judgment to make certain that participants were comfortable with the body map exercise, while at the same time ensuring that they collected accurate data to correctly assess their actual sexual behavior and risks.
A few limitations should be noted. Our assessment of the usefulness of this tool was based on interview data and informal feedback from interviewers. Women were not asked directly if the body map exercise prompted them to openly discuss their sexual behavior. Participants’ views on this particular type of body map activity should be explored further in future studies using this approach. Although the body map template was field tested among study staff prior to use with participants, there still appeared to be some lack of comprehension and misinterpretation of the diagrams by participants. Ideally, this tool should have been field tested for use in this context among a sample of women who were as similar as possible to the target population.
Despite these limitations, the body map template used in combination with IDIs in this study, was a feasible, effective, and low-cost tool to enhance and facilitate sensitive discussions around sexual behavior, specifically PAI. When used appropriately, body mapping can be a useful research tool. It can aid communication, improve clarity, and reduce misunderstanding and misinterpretation by verifying any ambiguous anatomical and sexual behavior terminology, and in so doing provide researchers with deeper insight into sensitive sexual topics.
Acknowledgments
We gratefully acknowledge the women who participated in this study. We also thank the VOICE-D study teams at each research site.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: VOICE-D was funded by the U.S. National Institutes of Health (NIH). The Microbicide Trials Network is funded by the National Institute of Allergy and Infectious Diseases (UM1AI068633, UM1AI068615, UM1AI106707), with co-funding from the Eunice Kennedy Shriver National Institute of Child Health and Human Development and the National Institute of Mental Health, all components of NIH. The content is solely the responsibility of the authors and does not necessarily represent the official views of NIH.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
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