Review Vaginal practices as women’s agency in Sub-Saharan Africa: A synthesis of meaning and motivation through meta-ethnography Adriane Martin Hilber a, b, * , Elise Kenter a , Shelagh Redmond a , Sonja Merten b , Brigitte Bagnol c, d , Nicola Low a , Ruth Garside e a University of Bern, Institute of Social and Preventive Medicine, Finkenhubelweg 11, CH-3012 Bern, Switzerland b Swiss Tropical and Public Health Institute, Switzerland c Department of Anthropology, The Witwatersrand University, Johannesburg, South Africa d Department of Environmental and Population Health, Cummings School of Veterinary Medicine at Tufts University, USA e PenTAG, Peninsula Medical School, University of Exeter, UK article info Article history: Available online 28 January 2012 Keywords: Sub-Saharan Africa Gender Sexuality HIV/AIDS Vaginal practices Meta-ethnography Review Women abstract This paper reports on a systematic review of qualitative research about vaginal practices in Sub-Saharan Africa, which used meta-ethnographic methods to understand their origins, their meanings for the women who use them, and how they have evolved in time and place. We included published documents which were based on qualitative methods of data collection and analysis and contained information on vaginal practices. After screening,16 texts were included which dated from 1951 to 2008. We found that practices evolve and adapt to present circumstances and that they remain an important source of power for women to negotiate challenges that they face. Recent evidence suggests that some practices may increase a woman’s susceptibility to HIV and other sexually transmitted infections. The success of new female-controlled prevention technologies, such as microbicides, might be determined by whether they can and will be used by women in the course of their daily life. Ó 2012 Elsevier Ltd. All rights reserved. Introduction Women around the world engage in a variety of vaginal prac- tices to manage their health, hygiene and sexuality (Hull et al., 2011). Practices include ingestion or application of herbs, douch- ing, use of physical drying techniques, and even sorcery (Braunstein & van de Wijgert, 2005). They are rooted in the different meanings and practices of female sexualities around the world. In America and Europe, where female sexuality has been associated with pathology over a long period (Lancaster & Di Leonardo, 1997) interests in vaginal practices were often associated with either female chastity and cleanliness (douching) or immorality (contra- ception, abortion, or treatment of sexually transmitted infections) (Gordon, 1974). In other parts of the world, including India, Turkey, and China, an important body of literature has addressed sexual and health-related practices over centuries, embedded in local cultural meaning (Datta-Chaudhuri, 2003; Kukulu, 2006; Raven et al., 2007). In parts of the world where written sources are scarce, however, early accounts stem mainly from colonial records, which have exoticised vaginal practices as erotic practices of the ‘other’ and been used as an argument to demonstrate the inferiority of the colonised (Piot, 1999). This has also been the case in other parts of Africa (Blacking, 1967; Dias, 1998; Junod, 1898). Interests in vaginal practices have resurfaced with the rise of the HIV pandemic in the 1990s, with a focus on the investigation of potential harms, which is not devoid of a notion of ‘othering’. Studies about sexuality and sexual behaviour in Africa tended to frame the issue as a further example of a culturalistic view of African sexuality (Caldwell, Caldwell, & Quiggin, 1989) where ”freedom of female sexuality” [185e234], including the use of exotic vaginal practices, contributed to the rampant spread of HIV (Brown, Brown, & Ayowa, 1993; Gresenguet, Kreiss, Chapko, Hillier, & Weiss, 1997; Sandala et al., 1995). As more information became available (Martin Hilber, Hull et al., 2010) it became clear that practices were more complex than previously thought; they were not exclusively sexual. Social studies in specific African soci- eties reported that several suspected ‘harmful traditional practices’ such as female genital mutilation (FGM) and ‘dry sex’ were important sources of power that women use to secure their social and economic position (Arnfred, 2006; Scorgie et al., 2008). Significant questions about preferences and their potential to influence life saving prevention technologies such as barrier methods (van der Straten et al., 2010) and microbicides (Martin * Corresponding author. Tel.: þ41 31 631 4861. E-mail address: amartinhilber@ispm.unibe.ch (A. Martin Hilber). Contents lists available at SciVerse ScienceDirect Social Science & Medicine journal homepage: www.elsevier.com/locate/socscimed 0277-9536/$ e see front matter Ó 2012 Elsevier Ltd. All rights reserved. doi:10.1016/j.socscimed.2011.11.032 Social Science & Medicine 74 (2012) 1311e1323