Abstract: Body mapping is a visual (drawing) tool, technique and methodological process that has been used by practitioners and researchers in a variety of contexts across the world, including in sexual and reproductive health interventions and research. One of the benefits of body mapping is that it can be used with semi-literate and illiterate populations. In this article, we describe the limitations of traditional body mapping methods and the use of clay as a body mapping medium—a three-dimensional body mapping approach as compared to traditional two-dimensional approaches—within a methodology we call the clay embodiment research method (CERM). This methodology intertwines elements of ethnography, clay body mapping and group work. Its three interdependent components are a form of participant observation, a series of seven themed participatory clay body mapping workshops; and a group interview using photography of the clay works. We discuss the participants' experience in a study of reproductive health knowledge among trafficked women in Nepal in which we used CERM, noting the benefits they said they got from the process, such as developing and sharing knowledge, enjoying learning, allaying fears, promoting self-development, building confidence, enabling problem solving and educating others.

Key words: clay; three-dimensions; body mapping; embodiment; visual methods; participatory research; qualitative research

Undertaking research that explores the lived experiences of marginalized, poorly educated sub-populations in cultural contexts when the topics of inquiry are sensitive and communication can be difficult and challenging. The quality of data obtained from such research, and thus the reliability of its analysis and use, depends on the extent to which such challenges are resolved. In this article, we set out some of the methodological challenges we faced in exploring the reproductive health knowledge of young women who had been trafficked into the sex industry in Nepal. We discuss the conceptual approaches relevant to the research and the limitations of methodologies previously developed for our circumstances, particularly body mapping techniques. We set out the methodology we eventually applied—which we refer to as the clay embodiment research method—focusing on the use of clay as a body mapping medium. We then describe the experiences of our research participants in engaging with this approach. [1]

In our research, we set out to qualitatively describe the knowledge of a particular group of young Nepalese women on their reproductive health, and how their knowledge was gained (ONG, 2018; ONG, MELLOR & CHETTRI, 2019). These women were from rural regions of Nepal, impoverished backgrounds, had no or limited formal school education, and were survivors of trafficking into the sex industry in Nepal. They are marginalized in their own communities, in a society whose "norms are heavily patriarchal" (HAMAL GURUNG, 2014, p.175), where trafficking is "part of a larger social acceptance of violence against women and girls" (CRAWFORD, 2017, p.114) and, due to its long history of delivering girls into the hands of brokers, has become culturally acceptable (POUDEL & CARRYER, 2000). [2]

Both we and our lead NGO partner organization in Nepal, Asha NEPAL, wanted the voices of the women to be heard through the research; however, there were several important issues we had to address, principally amongst these was cultural sensitivity in relation to taboo subjects—such as reproductive health and sex trafficking (ONG, 2018). We had to factor in the Nepalese collective culture, and to consider the women's age range, illiteracy and vulnerability to reproductive body trauma, and the power differential between them and us. We were also concerned about our intrusion into their lives while ourselves facing funding-related time constraints. In addition, we wanted applied research outcomes. [3]

In this article we discuss the issues we faced with developing an appropriate methodology for the cultural context of Nepal and our vulnerable cohort of research participants (Section 2). We then illuminate the rationale for using a three-dimensional body mapping approach as opposed to traditional two- dimensional body mapping techniques (Section 3). We provide the background for discovering that clay was appropriate for use as a medium in body mapping in Nepal and other factors that influenced its application (Section 4). Then we describe the use of clay in body mapping with women with low literacy levels in Nepal and its use in the clay embodiment research method (CERM) (Section 5). Finally, we share the participants' experiences of the CERM and its personal value for them (Section 6). Lastly, we reiterate the key points of our article in a brief conclusion (Section 7). [4]

We were initially interested in ethnographic research methods. However, we recognized PINK's (2009) observation that in contemporary research contexts issues such as we have described can lead to limitations imposed on the working lives of ethnographers and research participants, and, in applied research, the amount of time researchers can dedicate to projects. PINK argues that this has led to ethnographers developing innovative methods "to provide routes into understanding other people's lives, experiences, values, social worlds and more that go beyond the classic observational approach" (pp.4-5). LIAMPUTTONG (2007) also points out that researchers often adapt research methods to meet the needs of the research participants. Notably, she contends that a single approach of interviewing may not work, thus requiring the researcher to adopt more flexible and collaborative approaches. [5]

While we recognized that we could not use traditional ethnography because it involves long time periods in the field, we could use an ethnographic technique—participant observation—borrowing from JORGENSEN (1989), to "gain entrée" (p.40) to the field. Participant observation can involve taking an active or passive role depending on the research context (De LAINE, 1997; DeWALT & DeWALT, 2011; JORGENSEN, 1989). We favored an active approach. According to JORGENSEN (1989), "it is highly desirable for the participant observer to perform multiple roles during the course of the project, and gain at least a comfortable degree of rapport, even intimacy, with the people, situations and settings of research" (p.21). This sat well with our aim of gaining insights into the socio-cultural worlds of the women and girls, their embodied (body) experiences, their modes of learning and group dynamics. [6]

Although we were initially interested in the photo voice techniques of WANG and BURRIS (1997), we were drawn to photoethnography for use in the context of a group interview because it was more appropriate for our study. According to SHUSTER (2009), "while the fields of visual anthropology and sociology are fairly established traditions within the disciplines, photoethnography is in its nascent form" (p.10). SHUSTER even argues that photoethnography has, as yet, no real definition. This appealed to us as we were able to adapt it for our study. [7]

The inspiration for our approach was, in part, driven by the results of workshops Tricia ONG, the lead author of this article, co-facilitated as part of an art therapy and women's reproductive health training program in Banepa, Nepal, for trafficked women and girls and health professionals helping to reintegrate trafficked women back into the community. In one of the workshops, she used A4-sized photographs of her family from Australia—her daughter as a young child and herself in the delivery suite of an Australian hospital shortly before the birth of her son—to facilitate discussions around pregnancy, childbirth, and other reproductive health issues. The Nepalese women were fascinated by the photographs and were intensely curious about her family life in Australia. More importantly, the photographs ignited invaluable conversations about reproductive health issues which are sensitive in Nepali culture. A key discovery was the extent to which the Nepalese women lack knowledge of their reproductive bodies. [8]

Our search for suitable approaches for the cultural context led us to consider participatory action research (PAR) methods and participatory learning and action (PLA) methods. These offered the potential to accomplish many of the objectives we hoped to achieve in our research. CORNWALL and JEWKES (1995) particularly suggest that "participatory methodologies are often characterized as being reflexive, flexible and iterative, in contrast with rigid linear designs of most conventional science" (p.1668). They offer the potential to work collaboratively with local people who are knowledgeable about their own issues and to work together with them to find solutions to pragmatic problems (CORNWALL & JEWKES, 1995). CORNWALL and JEWKES also encourage the use of visual tools because they can be used with literate and illiterate populations. Although PAR/PLA techniques and strategies vary, they note that many of them are underpinned by a series of common principles such as Paulo FREIRE's (2018 [1968]) work in education. Thus there is potential for learning as an outcome of the process. More recently, PAR methods have also been underpinned by feminist research and critical theory (CORNWALL & JEWKES, 1995). [9]

From the range of methods we considered we then focused on body mapping. Two methods have been popularized in reproductive health and sexuality research contexts: Carol MacCORMACK's (1985) drawing technique and Jane SOLOMON's (2007) body mapping process which involves tracing around a human body and embellishing it in a series of workshops. A key benefit of body mapping is that it does not rely on verbal descriptions, making it useful for research with semi-literate and illiterate populations (CHENHALL, DAVISON, FITZ, PEARSE & SENIOR, 2013; KESBY & GWANZURA-OTTEMÖLLER, 2007) and as recently reported by DEW, SMITH, COLLINGS and DILLON SAVAGE (2018), non-verbal populations. CORNWALL (2002), who has used body mapping in reproductive health research with illiterate women in rural Zimbabwe argues that "rural, non-literate women are not 'ignorant': they theorize and make sense of their experiences within frames of reference that are different from the biological model" (p.228). SHAHADUZZAMAN and CHOWDHURY (1998) who have used it to gain insight into women's perceptions of reproduction in Bangladesh also argue that it is often difficult to find out how illiterate people perceive their bodies from verbal descriptions because "visual literacy is independent of alphabetic literacy" (p.72). [10]

Body mapping can also help to reduce bias that can arise from using western biomedical terminology when asking direct questions about the female reproductive body (CORNWALL 2002; KENNY, HOBAN, PORS & WILLIAMS, 2019; WALLACE et al., 2018). In reporting their study exploring the reproductive health knowledge of adolescent mothers from indigenous populations in Cambodia, KENNY et al. (2019) stated that "body mapping was identified as the best qualitative data collection method to use in this context because it reduced language and cultural barriers and was a means of engaging young participants in conversations about SRH [sexual and reproductive health] issues" (n.p.). BRETT MacLEAN (2009), NÖSTLINGER, LOOS and VERHOEST (2015) and ORCHARD, SMITH, MICHELOW, SALTERS and HOGG (2014) have also reported that research participants from western contexts have made important self-realizations through body mapping. [11]

Another important benefit of body mapping is that the process can be educative and often, without intent, therapeutic (JAGER, TEWSON, LUDLOW & BOYDELL, 2016). However, this largely depends on the nature of the groups and the context and the relationships between group members (ibid.). STURLEY (2000) who used body mapping with women and men exploring vasectomy experiences in rural Nepal, has noted that sometimes group research participants will copy each other's work and give each other misinformation about reproductive health issues, but, in general, participatory processes have inspired learning. As in all groups, sometimes dominant members can also impede processes and deter the input of quieter members thereby impeding learning (ibid.). Although this group process could also, potentially, silence voices within a group, no body mapping authors (to date) appear to have illuminated such issues. In general, however, participatory group body mapping processes appear to be favored for use in sexual and reproductive health contexts for their ability to stimulate dynamic discussions. [12]

However, body mapping is not consistently an effective method in populations such as the one from which our study participants are drawn. Traditional body mapping methods, such as MacCORMACK's (1985) technique have not been particularly successful in individual or group contexts in Africa, Nepal and other parts of South and South East Asia where drawing is not a commonly practiced artform. In her research exploring men's vasectomy experiences in rural Nepal, STURLEY (2000) reported experiencing difficulties with body mapping: "the villagers were illiterate, and thus their lines were not necessarily where they wanted them to be; drawing is not practised [sic] as an art here. There was a reluctance to draw on top of anyone else's line" (p.86). On reflection, STURLEY believes that providing an outline of the entire body would have worked better than "free drawing" of body parts. [13]

In their study exploring issues related to Human Immunodeficiency Virus/Sexually Transmitted Diseases (HIV/STD) in a remote community of Nepal, BUTCHER and KIEVELITZ (1997) observed that single and married women were resistant to engage in body mapping. Similarly, CORNWALL (2002) encountered this with women in rural Zimbabwe as did GAZI and CHOWDHURY (2003) with women in rural Bangladesh. All authors argue that the resistance related to being asked to draw reproductive body parts. SHAHADUZZAMAN and CHOWDHURY (1998) have also discussed resistance to body mapping and, in their experience, it related to a lack of confidence to draw as many participants had never drawn before or, more specifically, they may have never drawn "anything like this before" (p.70). BENNETT (2017) tried to use body mapping with a belian [traditional Indonesian midwife] when exploring infertility issues in Indonesia, and also experienced resistance. She realized that "I had expected the belian to engage in a practice that was for them culturally unfamiliar and required competencies that were outside of their comfort zone" (p.114). She also observed that "body mapping only made sense for belian when it was literally performed on and through the body" (p.115). Other researchers have also commented that the process of drawing has been quite embarrassing for their participants (GAZI & CHOWDHURY, 2003; STURLEY, 2000) or participants felt their drawings were not good enough. To counter resistance to drawing, BUTCHER and KIEVELITZ (1997) and CORNWALL (2002) gave their research participants sticks to draw in the earth before asking them to draw on paper. The use of groups has also been discussed as a positive way to overcome resistance because group processes are enjoyable and often stimulate dynamic discussions (SHAHADUZZAMAN & CHOWDHURY, 1998). [14]

Nirmala PRAJAPATI¹⁾, former national coordinator of Youth-PEER Nepal (Y-Peer Nepal) who has used body mapping in the context of reproductive health education, reported that Nepali adolescents find it difficult to talk about, and draw, internal and external (reproductive) body parts because of limited body knowledge. Alison MORGAN²⁾, a medical doctor who has used simple body mapping techniques with women in a reproductive health context in Nepal also reported limitations particularly where there is little accurate knowledge of the body. Likewise, KESBY and GWANZURA-OTTEMÖLLER (2007) noted that when children in their study in Zimbabwe were asked to draw reproductive body parts, their drawings lacked useful detail, and KENNY et al. (2019) have commented that adolescent mothers from indigenous populations in Cambodia had difficulty drawing and locating uteruses on their body maps. [15]

We suggest that the difficulties related to inaccuracies and inadequate knowledge reported with body mapping may arise from the two-dimensional nature of the method when used in illiterate populations, largely because they think about such issues in three dimensions. We have observed firsthand the struggle of Nepali women similar in circumstances to our study participants in comprehending two-dimensional representations of anatomy and body functioning but noted their ease in describing the body with three-dimensional aids such as self-made clay sculptures. The point is not anatomical accuracy (on which body mapping methods tend to rely) but rather that the descriptions and discussions evoked by three-dimensional models provide better insight into the underlying thinking about reproductive health. [16]

Furthermore, we suggest that, given the past reproductive body trauma likely to have been experienced by our study participants, the risk of participants' distress arising from the application of, for example, SOLOMON's (2007) body mapping approach was unacceptably high. We saw that it was feasible, nevertheless, to capture the advantages of body mapping—notably, its use in illiterate populations and alignment of its group participation with a collectivist culture—through the use of facilitating discussions around self-created three-dimensional representations of the body. The three-dimensional body mapping medium we used in our work with young illiterate trafficked Nepalese women was clay. Clay is a well-used material in traditional Nepalese life and, as described below, turned out to be an ideal choice. [17]

Taking time to observe women and girls working in villages and fields of rural Nepal one cannot help but be struck by how much they feel a connection with the earth. They spend much of their time connected to and doing chores associated with the mato [earth] (ONG, 2018). Clay, for example, is a prominent material in relation to cooking (i.e., stoves are made from it) (see Figure 1) and it is used in religious rituals. Nepal also has several Hindu caste occupations of potters.

In her research exploring the social and symbolic roles of high caste Nepali women to define their position in patrilineal Hindu society with a Brahmin-Chettri³⁾ community in Narikot in Mid-Western Nepal, BENNETT (2002) observed that four weeks before the Rali Rali Festival⁴⁾, unmarried girls make clay images of Shiva (god) and Parbati (wife of Shiva) who are then "married" to one another on the opening day of the festival. In a full marriage ceremony, the girls act as one or other side of Shiva or Parbati's family. On the following day, in a funereal process, they wash the images down the river. [19]

CAMERON (1998) in her ethnographic research of gender and caste relations with people in the farming village in Bhalara in the Bajhang District in Far-Western Nepal with "untouchable communities" argued that clay is important in the lives of the Bādi⁵⁾: "the Bādi are potters, who make vessels out of local red clay. Their most popular items are water storage vessels (gāgri) and tobacco pipes called sulpa" (p.30). CAMERON also illuminated that these pottery items were—at the time of her (pre-2000) research—being replaced by plastic, bronze and brass containers from India and also other parts of Nepal. The Newari ethnic group also has an occupational caste of potters (i.e., Prajapati) such as those from Thimi, situated inside the Kathmandu Valley, whose tradition is at "a crossroads between extinction and innovation" (FOLEY, 2013, p.2). [20]

MASLAK (2003) who undertook research with the Tharu (Hindu) community, one of Nepal's indigenous communities in the Terai, a lowland region in southern Nepal, examined the cultural conditions and circumstances that factor into educational decision-making for girls. She argued that clay formed the basis of an altar and families used "clay sculptures to represent the duota [spirit]" (p.156). In other words, the sculptures embody the spirits and gods. However, MASLAK observed that women in this region do not participate in the process of crafting the duotas from clay; it is the role of the men. [21]

Although there is a paucity of literature on the use of clay in research, clay and art therapists have given valuable insights into the value of clay as a medium in three dimensional representations. According to MALCHIODI (2007), "clay is made from earth and water" (p.94). Due to its malleability, it enables the exploration of texture and provides a means to create in three-dimensions. Clay engages the four senses of "sight, touch, sound and smell" (p.103). Clay therapists ELBRECHT (2012) and SHERWOOD (2004) argue that it engages with the body and can invite the recall of memories. Hence, they say clay can also be very useful for body-related work. SEFTEL (2006) has discussed its use in art therapy practice with women healing from pregnancy loss. Ellen SPEERT⁶⁾ ran a workshop using paint, clay, tissue, paper and other media with this group of women observed that "the three-dimensional materials allowed the powerful expression of their rage, grief, and emptiness. The women often spoke of the need to have a tangible and lasting part of their lost child" (SEFTEL, 2006, p.103). Clearly, this example showcases the intensity of emotion that can be raised when clay and other materials are used in relation to expressing the loss of a pregnancy. [22]

Interestingly, SHERWOOD (2004) cautions therapists not to use clay with pregnant women. While she has provided no rationale for this directive, one can reasonably assume that it may heighten emotion. ELBRECHT (2012) and SHERWOOD (2004) also warn that care must be taken when clay is used in therapy because it can elicit trauma and/or it is used without professional expertise. According to SHERWOOD,

"work in my clinical practice with clay demonstrates that the attraction of clay lies in its capacity to capture experience as it emerges in the immediacy of the moment from the client's body, and in the surprising and often powerfully evocative forms it arouses in the client's consciousness" (p.3). [23]

Evidently, clay is quick to elicit emotion. Nevertheless, SHERWOOD suggests that working "thematically" or in a guided way can enable clients to remain focused on their immediate issues. In other words, working organically may elicit body and other trauma. [24]

Having used clay in workshops with trafficked women in Nepal, Tricia ONG notes that the amount of clay one works with and how well one knows a client/research group are also key considerations in using clay in therapy and/or research contexts. Clay therapists such as ELBRECHT (2012) use "clay fields" (i.e., large boxes filled with wet sticky clay) that allow clients to immerse themselves in larger amounts of clay which would involve a deeper sensory immersion and, potentially, trigger (very quickly) unconscious trauma. However, in Nepal, early experiences indicated that giving our research participants small (hand-size) balls of clay to enable them to "contain" their immersion in the clay promised to be successful (see Figure 2).

In 2011, Tricia ONG co-facilitated a half-day clay therapy workshop in Banepa, Nepal as part of the art therapy and women's reproductive health training program offered to trafficked women and girls and health professionals working with them. A vivid impression she had was that, within a safe space, the clay work was calming for the women, whilst enabling them to visualize experiences that they could not, seemingly, express in words. From a psychoanalytic perspective, the clay provided a distancing or "transitional object" (WINNICOTT, 2005 [1971], p.xvi) for the women to focus on, whilst inviting conversations about intimate personal experiences. Furthermore, the three-dimensional sculptures created by the women were very revealing; beautiful self-images were "embodied" in the clay. [26]

These observations, and that of that rural women learning by doing and seeing, contributed to the idea that clay was the right three-dimensional medium in our research method. This was, in effect, tested when Tricia subsequently collaborated with Asha NEPAL in conducting what were initial clay mapping workshops with small groups of sexually abused young women (not being the research participants) and a staff counselor. The women were given limited directives to engage in the clay and all spontaneously made three-dimensional clay works which were reflections on experiences and memories of lives in their village homes, and much more. With no prompting, the girls then shared personal stories related to their individual sculptures, divulging issues such as separation from mothers, and the trauma of working in an abusive domestic labor context. Afterwards the staff counselor told Tricia that the young women had never shared stories like these before and that she learned things about the young girls that they had never divulged in counseling sessions with her in the six-months she had been working there. As an "outsider" to the girls' worlds, Tricia also realized that she might have created a safe space for the girls to talk about these personal experiences even though she was a stranger to the culture. [27]

Tricia ONG and Sabrina CHETTRI⁷⁾, a native Nepali who was employed on the project as a research assistant and co-facilitated the workshops, subsequently conducted another clay mapping workshop for three young women on menstruation as a formalized "pilot" of clay body mapping (ONG et al., 2019). This workshop was organized by a volunteer from the Bhaktapur Youth Information Forum⁸⁾ whose work includes providing reproductive health education. Three women volunteers who were semi-literate and illiterate were given instructions to simply create whatever they knew about menstruation in clay. Initially, they could not think of a way to represent menstruation, especially aspects that occur within the body. However, in the end some of them created representations of uteruses, menstrual pads and menstrual blood (Figure 3). The creative task was followed by questions we asked that drew from a flexible interview questionnaire we had created for the research. The women struggled to, or could not, explain where the "bleeding" comes from in relation to menstruation. The thread of the surprisingly open discussion led to revelations about menstruation traditions and practices in the culture, some negatively perceived—the seclusion of women at menstruation, prevention from touching utensils in the kitchen, etc.—and some now regarded as celebratory rituals for entering womanhood. The women also did a little bit of clay work around pregnancy. As none of them had given birth, a little clay work on pregnancy showcased it as an outer body experience. In other words, they had difficulty conceptualizing the process of being pregnant internally or visualizing what a baby might look like inside the uterus.

Small as they were, these workshops demonstrated the comfort of working with clay for Nepalese women and girls, and their natural ability to work in three-dimensions. They helped us work through how to create attentiveness, engagement and a sense of safety in the workshops. Taken together, the workshops showed how effective the clay medium can be in evoking detailed and wide-ranging information of otherwise culturally sensitive issues from illiterate women. Tricia and Sabrina also picked up lessons in the organizational practicalities involved in working with ethnic and culturally diverse participants, seating positions, messiness of working with clay, real time interpretation, recording and photography. Importantly, the workshops also served as a warning as to how quickly emotion could be elicited through clay—with little prompting and sometimes unexpectedly—with this group of young women. This reinforced the notion that working thematically (as a series of workshops) could be very important to avoid eliciting reproductive body trauma with trafficked women. [29]

Our experiences with, and lessons learned from, these small workshops shaped the methodology we developed for our reproductive health knowledge study of young women who have been trafficked into the sex industry in Nepal (ONG, 2018; ONG et al., 2019). The methodology draws on ethnography, (adapted) PAR methods and Tricia ONG's background in creative arts therapy. The size of groups was determined by our experiences of clay workshops in Nepal and consolidated by CRAWFORD, MENGER and KAUFMAN's (2014) experience of limiting focus groups to four in a menstruation study in Nepal due to the sensitivity of the reproductive health study alone. In Nepal, societal discourse around reproductive health issues is a taboo topic (MENGER, KAUFMAN, HARMAN, TSANG & SHRESTHA, 2014). In addition, the discussion of sexual subjects is particularly difficult for Nepalese women (ibid.). As AHEARN (2001) says, this is because sex has been, and largely continues to be, the domain of men. Following consideration of the study's objectives, research value and the social context in which it was to be applied, the study was granted ethics approval in both Australia and Nepal (ONG, 2018; ONG et al., 2019). [30]

We call our approach the "clay embodiment research method" (CERM). Its key distinguishing feature (vis-a-vis traditional body mapping) is the use of self-sculptured clay representations of the body as the initial stimulus for exploring the women's knowledge and its genesis in a safe space, with the resulting shared stories and experiences themselves serving to prompt group discussion about the wider context in which they occur. [31]

In its application, the CERM has three interdependent components: 1. critical ethnographic participant observation; 2. a series of themed participatory clay embodiment/three-dimensional body mapping workshops; and 3. a group interview using photoethnography. In our study we conducted seven workshops (Component 2) with the following themes:

The whole of the CERM, articulated as a culturally sensitive method, provided a means by which we were able to: identify how young Nepalese women who have been trafficked into the sex industry perceive and experience their reproductive bodies; document their hopes and fears about reproduction; ascertain how these influence their reproductive decision-making; and develop recommendations for reproductive health education and reproductive health support for young trafficked women to relevant agencies in Nepal (ONG, 2018; ONG et al., 2019). [33]

While it is the intertwining of clay body mapping with ethnography and group work that generated robust data, we believe that the key to the success of our study was that the use of clay matched our participants' main modes of learning and facilitated rich, in depth discussions and the sharing of stories and experiences. As used in the CERM, clay body mapping can be considered to be an indirect method as it does not involve a direct engagement with the body. However, paradoxically, it can also be viewed as an extension of the body and as such a direct method because clay therapists such as ELBRECHT (2012) and SHERWOOD (2004) have argued that clay can induce body-related memories. [34]

The various findings of the reproductive health study itself are reported elsewhere (ONG et al., 2019). Here, we focus on the use of the CERM approach and how it was experienced by the participants in the study. We demonstrate the value of three-dimensional body mapping with clay for the research participants themselves (that is, the trafficked Nepalese women), and how, from their point of view it helped them to build reproductive health knowledge and improve their psychological wellbeing. [35]

Six women (aged 14 to 22 years) participated in our study.¹⁰⁾ For reasons of practicality, they were divided into two groups: four unmarried trafficked women and two married trafficked women (ibid.). The clay workshops were run sequentially. At the end of each, we informed the women about upcoming workshops so they could prepare for emotionally and we could change the order if we felt a workshop like Workshop 6: "Male Reproductive Body" would be too sensitive. This also gave them an option to opt out if they wanted to. One woman withdrew from the workshops, but this was for personal reasons (ibid.). [36]

The workshops were co-facilitated by Tricia and Sabrina. In each clay workshop, women were given hand size balls of clay and Sabrina encouraged the women to create anything they knew about the reproductive body in clay (relevant to the theme of the workshop), and Tricia used a flexible interview guide to ask them questions and prompt as needed. Sometimes dialogues were paused by Tricia to get Sabrina to translate the Nepali conversations (as she only understood basic Nepali) to ensure she understood the context of the conversations. [37]

The clay work facilitated such dynamic discussions that most questions were answered before they could be asked. Some women were initially resistant to engage with the clay, so co-facilitators engaged in it at a superficial level to encourage participation. This later became unnecessary as the process became fun. In the early workshops, embarrassment was an issue for some women as they created reproductive body parts unexpectedly (i.e., penises) (ONG, 2018). Naming reproductive body parts such as vaginas and penises was also an issue of embarrassment, but the women used Nepali colloquialisms to overcome this. Group cohesion and trust between the co-facilitators and the other women, and the use of humor, was also a factor in getting over the embarrassment of talking about sensitive reproductive health issues. [38]

At the end of each workshop, clay works were photographed by the women or Tricia or Sabrina (ONG et al., 2019). All the women's conversations were in Nepali and transcribed to Roman Nepali by Sabrina and then translated by her into English with help from Tricia because of challenges in the field (ibid.). All workshops were audio-recorded. [39]

The six young women who participated in our study came to it with diverse levels and accuracy of information about the reproductive body and reproductive health issues. Niuresha (17 years old), for example, picked up western biomedical theory from a variety of locations such as school and hospitals, while Aisha (20) had experiential knowledge from sexual intercourse, being pregnant, and giving birth. Even Rosina (14) who constantly said she "knew nothing," surprised us with her incredible insights on pregnancy and sex. Their prior understanding emerged in the course of the workshops and at the post-workshop "Group Interview using Photoethnography" (the third component of the CERM). It was also evident that the acquisition of information through informal learning, where peers, for example, had shared knowledge with each other, does lead to the accrual of inaccurate knowledge. Aisha (20), for example, copied Indira's depiction of a uterus in clay saying that she had never learned about this inner female body part before the workshops (Figure 4 and Figure 5). In a subsequent workshop she created another in the approximate size of a uterus, to which she then exclaimed "I learned it from Indira" (Figure 6). Yet Indira's representation of a uterus was "anatomically inaccurate."

Figure 6: Aisha's depiction of a uterus in the final workshop (ONG et al., 2019, p.40; reprinted with permission from Sexual and Reproductive Health Matters) [40]

All the women said their knowledge of the reproductive body and reproductive health grew markedly in the course of the workshops. Sulob's (18) comment captures the gist of their observations:

"I have learned a lot. I have learned at what age should a child be informed about things and I also learned about how our inner body looks like through imagination or through friends (in the workshops). Also, about the bodily changes that we go through, about period pains, and also about how a girl would be and all the stuff that's related to being a woman. I have also learned about how a baby comes out, so after how many days is the appropriate day to conceive through discussion." [41]

Across the workshops, Niuresha (17) indicated she had a significant amount of reproductive body knowledge and she told us she had learned her information from school, hospital clinics, and through other experiential means. In Workshop 5: "Pregnancy," when the group, consisting of Niuresha (17), Rosina (14), Soniya (18) and Sulob (18), were discussing Soniya's (18) clay work of a pregnant mother and baby "in-utero," Niuresha (17) shared detailed knowledge about how a woman's water breaks during pregnancy, including how "9-10 layers" need to break before the baby comes out (see Figure 7). (It is worth noting that she had discussed how she had observed a cow giving birth in Workshop 5: "Pregnancy," so she knew a little about the breaking of water—or amniotic fluid—at a birth). We asked her how she came to know about the "layers of the uterus," which we think she learned from a hospital clinic and she then indicated that she believes it is important to know things about the body (even though she does not say why) and that she particularly likes learning, especially about the detail of things. This discussion is captured in the following extract:

Niuresha: "I like knowing things, from where it starts, where it ends and where it goes."

Figure 7: Soniya's representation of a pregnant mother and a baby "in utero" [42]

In Workshop 6: "Male Reproductive Body" and Workshop 7: "Outer and Inner Female Reproductive Body," Niuresha (17) raised the topic of virginity because she wanted to know more about the "pain" associated with losing virginity because she had heard about this issue in her village of origin. In the "Group Interview using Photoethnography," she then described how the group discussion in the clay body mapping workshops had allayed her fears over the loss of virginity. In the following extract, she explained this:

"I had a lot of questions and I got a lot of answers to my questions. Most of our elders used to say that it would be really difficult for you to have a sexual relationship with a boy for the first time and I used to get scared about the thing so after the workshops, I learned virginity break is painful for some and not painful for a few, and also that a virginity tissue can be broken through exercise and stuffs like that." [43]

In Workshop 7: "Outer and Inner Female Reproductive Body," Aisha (20) explained that she had learned a lot about the reproductive body by engaging in the clay body mapping workshops. In particular, she said she felt she had helped herself for the longer term and her friends had noticed this, which also indicated that she had become a role model for them:

Sabrina: "I am asking about now [immediate moment]. Do you think about it [the workshops] after going back home, like things like this?"

Aisha: "People ask me what I do in CAP Nepal, and I tell them that I do these kind of things and they see that I have learned a lot, and will probably do better than they would do [in life]." [44]

Later in the same workshop, she also explained that she had learned about the reproductive body (from Indira) and that it gave her happiness to be able to share her "hardships." By hardships, she was particularly referring to an experience of reproductive loss in which she had recounted to us her experience of miscarrying twin boys in violent circumstances in a dance bar. In addition, she explained how being engaged in the clay body mapping workshops had been a productive use of her time:

Aisha: "I've learned about how the baby would sit, all kinds of hardship I faced that I could show in the clay, and I'm happy that I could make it, and have learned a few things too that I did not know"

Aisha: "How big a uterus would be, I learned it from Indira. It is better to come here and learn something than lingering at home with friends. I have also learned that these kinds of organizations help and are established to look after the girls above 14 who are raped or sexually abused, and I also learned a lot from you both, and to be playing with you both, I have learned a lot and I am really happy, and I can also make stuffs like that, and for that I am really happy." [45]

Across the workshops, Rosina (14), the youngest participant of the study, constantly said "I don't know" when asked anything about the reproductive body. However, as we validated her knowledge, such as pointing out in the pregnancy workshop that she was the only woman to note that some women have "black spots" (freckles) on their faces in pregnancy, her confidence grew. In addition, she began to contribute more to the group. In fact, by the end of the workshops, we observed that she had also shared some intimate information about sexual intercourse before any of the other trafficked women in the group volunteered it. In the "Group Interview using Photoethnography," she explained exactly what she had learned in the clay body mapping workshops, and how it had made her feel:

"Throughout these workshops, I have learned about the inner body, about how a male reproductive body would look like, what all the things are in it, how we would get pregnant, about menstruation, and I've also learned a lot from the three of them [Niuresha, Soniya and Sulob]. That's why I feel really happy." [46]

In Workshop 5: "Pregnancy," Niuresha (18), Rosina (14), Soniya (18) and Sulob (18) were sharing the knowledge they had gained about pregnancy, which was experiential and also from western biomedical theory. Then, Soniya started to create a "baby-in-utero" out of clay and it was evident from the discussion that none of them could conceptualize a uterus and "how the baby sits" within it (see Figure 7). However, in the discussion that then ensued—led by Soniya—there was an opportunity to engage the young women in a conversation that enabled them to work out a number of issues related to pregnancy and birthing using her clay model of the baby and uterus. These issues included 1, where the umbilical cord is attached to the baby/mother; 2, how the baby breathes/gets nutrition; 3, how the water breaks even though they did not create the water sac/water; 4, how the vagina is positioned in relation to the uterus, and so forth. [47]

This discussion caused great excitement, as some of the young women such as Niuresha who knew that "after the water breaks, we see 9-10 layers (uterus). Those layers slowly open so the doctor puts his hand inside to see how many layers open" began to really understand what this "western biomedical theory" meant in relation to a "real uterus." Some of this problem solving is captured in the following group dialogue:

Sabrina: "One is connected to the baby, one is connected to the mother's body, why is it connected?"

Sabrina: "Even if it's connected to the sac full of water, what's the use of it getting connected to the mother's body?"

Niuresha: "So that it sticks to the mother, that's why it's connected, to stay alive"

Sabrina: "Is it because it needs to get attached to it or because it needs something else?"

Niuresha: "The baby sits inside the water so it needs something so that it can breathe"

Niuresha: "If the mother is breathing from her lungs, the baby should also be breathing from somewhere"

Niuresha: "First we get pregnant, then by 2-3 months everything is developing from nose to eyes to mouth to everything"

Sabrina: "We are asking you question after question, but how do we grow big? How do you get big, how do you grow?"

In Workshop 7: "Outer and Inner Female Reproductive Body," after Niuresha (18), Rosina (14), Soniya (18) and Sulob (18) had spoken about the reasons for "throwing babies"(meaning abandoning or aborting babies) in Nepalese society, Sabrina pointed out that the young women had learned a lot from sharing their personal stories. This observation led to a conversation about the young women contemplating educating their own children (girls and boys) in the future and the reasons why it is important to share reproductive health information. In the following extract, the young women discuss this issue:

Sabrina: "They have learned a lot from this, so would you be telling your daughters about this in the future? Niuresha, would you tell about it? About menstruation, about the body parts we have? About the inner and outer body parts we have? About pregnancy? About everything we have done here?"

Sulob: "Yes, I would tell. I would teach her from the very beginning. It would be more of a friendship than a mother-daughter relationship, nothing would be hidden"

Rosina: "I would share stuff, I have learned a lot from here and I would be learning a lot in the near future. I would tell her. I would want to save my daughter from evil"

Sabrina: "Like what Rosina said, like what Sulob, would you also be friends with your daughter?" [To Soniya]

Sabrina: "Not about everything, but about these things. Would you tell people? Soniya said she would be sharing it with people she could share it with. Would you be sharing?"

Sabrina: "You would be sharing it with your daughter, but if you had sons, would you be sharing it with your sons too? Would you share the differences between a male and female body with your sons too?"

Soniya: "Anything that I can share, like the difference between the male and the female reproductive parts, like you cannot share it when he grows old as it would be embarrassing for him, so I would be sharing it with him from when he is really young"

Sulob: "I will be sharing about body changes with them too, with a boy child or a girl child"

Niuresha: "There's a whole lot of difference between a boy body part and a girl body part. I would be informing the boy body part to my son so it would be easier for him in the future [with his wife]." [49]

Notably, Rosina says she wants to "save my daughter from evil." From this comment and others made throughout the workshops, we surmised that she, as a daughter/young girl, had already experienced a lot of trauma in her life beyond trafficking. For example, she had spoken about her mother being abused by her stepfather and we were also aware that he had trafficked her, so we think she had a feeling of wanting to educate a daughter to protect her from the experiences she had been through. [50]

In another example of wishing to educate others, in the "Group Interview using Photoethnography," while discussing the women's individual learning in the workshops, Soniya raised an issue that the group had not talked about regarding knowledge acquisition on contraception. She then articulated that she had particularly learned about it; how to prevent having children, how to (hopefully) discuss these issues with her future husband and how she, like Niuresha, would want to educate persons and daughters about reproductive health in the future. Soniya particularly said she would want to educate her children from a young age:

Soniya: "I have thought about it. And they have not talked about contraception and family planning methods ... If we don't want to have a baby, we can keep Norplant and injections and stuffs like that, and if my husband wants to have a baby and if I don't, I've learned how to explain things to him and discuss about it together"

Sabrina: "That was the bit where everyone discussed about it and all four of you said you would be explaining it to him"

Soniya: "And about it, I would also be educating my kids from the tender age of their childhood"

In addition, in Workshop 2: "Outer Female Reproductive Body," Indira (22) created a male figure in clay in which she created the most accurate representation of an erect penis of any of the women without being asked to do so. Interestingly, Aisha (20) had also done this spontaneously in Workshop 1: "I am a Woman/Girl"—to her embarrassment. In the next workshop (undertaken the same day), Indira who had not destroyed the clay sculpture of the male figure from the prior workshop added breasts to it to explain an issue related to breastfeeding (see Figure 8). Looking at Aisha and Indira, Tricia then said to them that Sabrina was learning from them. Both indicated that they felt happy sharing their knowledge not just about the male reproductive body, but about breastfeeding because they had personally experienced it (both had given birth and had babies). [52]

This discussion was particularly aided by the fact that Indira was breastfeeding her son in the workshop, which enabled the group to ask questions about the process of breastfeeding as it was occurring. In addition, Indira said that by sharing this knowledge it will easier for her—accepting Sabrina as a peer or woman from Nepalese culture—if she knows some of these things for later in her life (indicating too that they expect that she will become a wife and mother in the future as this is a societal expectation). Notably, on recounting this to us, "joy/pride" was expressed through the body language and facial expressions of Aisha and Indira:

Sabrina: "With the male there [Pointing to Indira's clay work], I never knew it was upward, like when it’s erect it straight or ..."

In any sensitive research and in complex cross-cultural environments, finding the right research methodology is a challenge. In our study, we decided to deviate from the norm and adapt methods that were suitable for the cultural context and our vulnerable research participants. This led us to design the CERM which incorporated elements of ethnography, specifically active participant observation, the PAR technique of body mapping, and photoethnography. Body mapping is a visual method (i.e., drawing technique and or technique that involves tracing around a human body) that has been used in reproductive health research and has had particularly benefits for use with illiterate populations. However, some body mapping methods are not suitable for some populations where drawing is not familiar and others have the potential to elicit trauma in vulnerable populations if they involve a direct engagement with the body. In this article we described the use of clay as an alternative body mapping medium, and its suitability in our exploration of the reproductive health knowledge of trafficked women in Nepal who were vulnerable to reproductive body trauma. We used clay because it was discovered to be a culturally appropriate material for Nepalese women, and they worked naturally in three-dimensions because of the familiarity of clay. Suffice to say, this—and the way clay therapists use it—informed the way we used it in our study. [54]

Clay body mapping, when included in the broader CERM approach, was found to be fast and carried potential dangers, but it also had benefits for the semi-literate and illiterate trafficked women who participated in the process because they learned through visual means. Their experiences indicated that it helped them to develop and share their reproductive health knowledge. Some expressed enjoyment at "knowing" or learning about reproductive health issues and the clay process helped them with this. Others’ fears about reproductive health issues were allayed through discussions facilitated in the clay workshops. One of our participants also commented on the value of engaging in the clay workshops to promote her self-development and that this had enabled her to become a role model for others. Several of the women expressed an increase in confidence because we were able to acknowledge their personal reproductive health knowledge in discussions over the clay. One of the particularly important outcomes was the capacity to use clay for problem-solving in relation to reproductive health issues. For example, the women could create a foetus in uterus over which to have a discussion. Then if an element was incorrect, they could re-shape it—because the clay was malleable—until it was right. The value in this was also the process of being able to contribute to the development of a group clay sculpture and prompt each other on how they thought the birthing process occurred because they could "visualize" it. While this process showed gaps in their knowledge, it also affirmed to us that clay could be used for purposes other than research—reproductive health education—because the clay can be shaped to make reasonably accurate representations of the reproductive body in three-dimensions. The final experience is the realization from some of the women that they could help to educate others, i.e., in this research, the research assistant. Overall, all enjoyed the process because it was fun. Humor also provided a great catapult for learning in our sensitive reproductive health context. [55]

Yet, since clay body mapping is new, we recognize that research needs to be undertaken to explore its potential, particularly if it is to be used with other vulnerable populations in reproductive health research (ONG, 2018; ONG et al., 2019). GASTALDO, RIVAS-QUARNETI and MAGALHÃES (2018) have recently noted, as a methodology, body mapping is visual, narrative in form and participatory and it is inconsistently named and used differently by different health researchers. They say that "the utilization of body maps in health research internationally has been highly attuned to political contexts, physical conditions and people's subjectivities" (§2). Therefore, they argue that it requires critical examination especially in regard to decolonizing practices. NAIDU (2018) has also recently reported that body mapping has the potential to "to erode agency and power" (p.111); she also says it needs examination. As DEW, McENTYRE and VAUGHAN (2019) observed, if it is adapted to the needs of participant groups, such Aboriginal populations in Australia where art is a part of the culture, it can be "culturally acceptable and collectively enjoyable" (§22). In addition, it can be empowering. As JAGER et al. (2016) have noted there is still potential for body mapping to be developed as "an interdisciplinary research method across diverse cultures to address critical issues in health and is amenable to sharing information between researchers and with the public" (§50). Furthermore, ABOELELA et al. (2007) have argued that it is these characteristics which define it as necessary for global health research. We would concur. [56]

We thank Asha NEPAL and the Centre for Awareness and Promotion (CAP) Nepal for their support in enabling us to undertake this culturally sensitive research study in Nepal. We also thank Nirmala PRAJAPATI, Saru SHILPAKAR and Kamal KAFLE for their adolescent sexual and reproductive health expertise as their cultural knowledge was extremely important to the outcomes of this study. Lastly, we thank the young women from the Bhaktapur Youth Information Forum for giving us their valuable time to help with the clay body mapping pilot.

3) The Brahmin-Chettri are Nepal's dominant ethnic group who practice Hinduism and are responsible for the development of Nepal's Hindu patriarchal society. <back>

4) We have not been able to find out the meaning of this festival even though it probably has a more common name. <back>

5) The Bādi are considered an untouchable caste because of their traditional occupations. Their untouchability increased when many were forced to turn to sex work out of economic necessity due to downturns in their industries in the 1950's. <back>

6) SPEERT is an art therapist who developed a short-term workshop for women who had experienced pregnancy loss in California (SEFTEL, 2006). <back>

7) Sabrina was a new social work graduate with expertise in reproductive health education. She is female, bilingual and close to the ages of the women and girls so they were able to relate well to her as a peer and friend after initial rejection (ONG, 2018). <back>

8) Bhaktapur Youth Information Forum is a Nepali not-for-profit organization working with young people and women in the sexual and reproduction health sector. They particularly use a peer education approach. <back>

9) This theme was added after the pilot of the CERM was undertaken to enable the women to get to know the clay and also to begin to think about their reproductive bodies. <back>

10) For full demographic information, see ONG et al, (2019). Pseudonyms are used to anonymize the women <back>

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Tricia ONG, PhD, has recently held the role of an associate lecturer, theater-based education programs, in the School of Health and Social Development at Deakin University, which uses one-actor performances and a panel discussion to address the public health issues of violence against women and trans and gender diversity. She also teaches into a broad range of units in the master of public health, master of health promotion, and master of health and human services, and similar undergraduate units. She has a PhD in public health, a master of creative arts therapy, a graduate certificate in business management (project management) and other global women's health certifications. Results from her PhD were published in Sexual and Reproductive Health Matters. Independently, she is collaborating with UK and Nepal researchers and partners to facilitate clay body mapping workshops on the Dignity Without Danger menstruation project in Nepal.

Casual Academic
School of Health and Social Development
Deakin University, Burwood Highway, Burwood, VIC
3125, Australia

David MELLOR, PhD is a retired clinical psychologist and academic who has undertaken and published on the outcomes of many cross-cultural research projects. His primary research focus has been on health issues related to children and adolescents. He graduated from the University of Melbourne with a bachelor of science (honors) degree and later a PhD. In between, he completed a master's degree in clinical psychology at the University of Western Australia, a diploma of education at Murdoch University, and a diploma in social sciences at Stockholm University. He also supervised Tricia ONG's PhD. He taught undergraduate psychology courses and was chair of the psychology programs at Deakin University, and also associate dean (international) for the Faculty of Health before retiring in 2018. He now holds the appointment of emeritus professor.

Emeritus Professor
Faculty of Health, School of Psychology
Deakin University, Burwood Highway, Burwood, VIC
3125, Australia

Sabrina CHETTRI has a bachelor of social work degree and is currently working as a protection and psychosocial support worker project officer at Caritas Nepal. She was the interpreter and research assistant for Tricia ONG and co-facilitator of the clay body mapping workshops. She also contributed significantly to the development of the CERM in Nepal.

Program Officer (Protection and Psychosocial Support)
Caritas Nepal
Bhani Mandala, Lalitpur, Nepal

Ong, Tricia; Mellor, David & Chettri, Sabrina (2020). Clay as a Medium in Three-Dimensional Body Mapping [56 paragraphs]. Forum Qualitative Sozialforschung / Forum: Qualitative Social Research, 21(2), Art. 9, http://dx.doi.org/10.17169/fqs-21.2.3380.

Forum Qualitative Sozialforschung / Forum: Qualitative Social Research (FQS)

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