THE USE OF VAGINAL DOUCHE products has been linked to adverse reproductive health consequences such as pelvic inflammatory disease (PID),1,2 reduced fertility,3,4 ectopic pregnancy,5,6 low birth weight,7 preterm delivery,8,9 cervical cancer,6,10 and other gynecologic health problems. Douching has likewise been associated with increased risk for bacterial vaginosis11–13 and sexually transmitted diseases (STDs),14,15 including HIV infection.15 Furthermore, such negative reproductive health outcomes have been shown to be exacerbated with increased frequency of douching.14,17–19
Despite the fact that medical professionals have deemed the practice nonbeneficial and unnecessary,5,18,20 women continue to douche as a routine part of what they perceive as maintaining feminine hygiene. National rates have been as high as 37% among all women (1988),21 yet of late, prevalence has been on the decline (27% in 1995).21 Of concern, however, is that the behavior continues to persist among minority women at a high rate (55% of blacks, 33% of Hispanics).21
Most often reported reasons for douching are centered on maintaining a “hygienic” vaginal environment. These reasons include: to feel fresh and clean,15,22–25 to clean after menses,15,24,26 to clean before or after sex,15,24,26 to reduce vaginal odor,15,24,26 to control vaginal discharge,24,26,27 and to alleviate itching.27 Other cited reasons include to please a partner,24 to prevent vaginal infections27 and pregnancy.15,23,26–28 Although the reasons vary, some reflect misinformation about the function of douching. These reported reasons are important, however, because they seem to be fairly consistent motivators for women to douche and contribute to the complexity of this feminine hygiene practice.
Although these reasons may aid in illustrating the profile of douchers, and possibly be an additional means of linking the relationship between douching and adverse health events, few researchers have determined if reasons for douching have an impact on douching frequency or STD outcomes. Thus, the goal of the current study was threefold: 1) to determine the prevalence of douching among a population of black women at high risk for STDs; 2) to examine associations between douching status and commonly identified predisposing factors (e.g., income, education, marital status, and so on); and 3) to consider differences in STD outcomes based on reported reasons for douching.
Materials and Methods
Cross-sectional data were collected from female patients attending an urban, publicly funded STD clinic in the southern region of the United States. Patients were eligible to participate if they: 1) presented at the clinic for an evaluation visit, 2) were between the ages of 17 and 45 years old, and 3) provided written informed consent. For the current analyses, only data from black patients were analyzed as a result of the small percentage of women from other racial/ethnic groups (less than 15%) hampering the ability to make any meaningful comparisons. The Institutional Review Boards at the University of Alabama at Birmingham and the Jefferson County Department of Public Health approved the research design and study protocol.
Audio computer-assisted self-interviewing (ACASI) technology was used to collect all survey responses. Measures used for this study included demographic characteristics, douching behaviors, sexual risk behaviors, self-reported STD history, and STD infection at the evaluation visit.
Douching status was categorized into three groups: 1) current douchers—participants who reported douching at least once in the 2 months before the survey; 2) former douchers—those who reported douching at some point in the past but had not douched in the previous 2 months; and (3) never douchers—those who reported that they had never douched. Other douching-related variables included age of douching initiation, frequency of douching (once a month vs. more than once a month), type of products used, and reasons for douching. Sexual risk behaviors measured included age of sexual initiation, number of lifetime sexual partners, condom use at last sexual encounter, self-reported STD history, and an objective measure of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) infection assessed by transcription-mediated amplification (TMA) (Aptima Combo 2; Gen-Probe Inc., San Diego, CA) performed on swab specimens.
All data were analyzed using the Statistical Package for the Social Sciences for Windows (SPSS), version 10.0.5 (1999). Descriptive and inferential statistics were conducted to characterize the study sample in addition to contingency table analyses for categorical variables to make statistical comparisons. Bivariate logistic regression models were used to calculate adjusted odds ratios (AOR) and 95% confidence intervals (CIs), with statistical significance determined at P <0.05.
Of the 962 eligible black female clinic patients approached, 891 (92.6%) agreed to participate. Nearly half (46.1%; n = 411) of the sample had douched in the preceding 2 months and were categorized as current douchers, 309 (34.7%) were former douchers, and 171 (19.2%) had never douched. The average age of participants was 24.7 years (standard deviation [SD] ±5.7 years; range = 17–45 years). Half of the sample was unemployed (49.8%), nearly 60% (57.9%) used a state-funded health care plan, 27.2% had less than a high school diploma or general education diploma (GED), and the majority (90.9%) was not married (P <0.05). When separated by douching status, significant differences were found for education (P = 0.015) and marital status (P = 0.021) with less education and being married indicative of current douchers (Table 1).
Sexual Risk Characteristics
In terms of sexual risk, over two thirds of the sample (67.3%) initiated sex at age 15 or older, over half (51.0%) had more than seven lifetime sexual partners, and nearly three fourths (71.7%) did not use a condom during their last sexual encounter. Over two thirds (68.7%) self-reported having had an STD in the past, and at the time of the evaluation visit, 15.4% were infected with chlamydia and 7.5% tested positive for gonorrhea. When comparing current and never douchers, current douchers reported having more lifetime sexual partners (46.7% vs. 64.3%; P <0.001) and a self-reported history of an STD (70.7% vs. 55.6%; P <0.001) (Table 2). Further analyses were conducted to compare the distribution of current infection (n = 185) between nondouchers (both never and former douchers) and current douchers. The results indicated that 56.6% of infections were among current douchers (total n = 104; 71 with CT; 33 with GC) as compared with 43.4% of nondouchers (total n = 81; 56 with CT; 25 with GC) (P = 0.004).
Current douching-related practices are shown in Table 3. More than half (58.2%) of the women who currently douched reported initiating the practice at age 17 or older; however, women who douched more than once a month reported initiating the behavior at a younger age (P <0.01). When asked about specific times when they douched, women responded that they douched most often after menses (65.4%) followed by douching when they had the need to feel fresh (42.2%) and douching after sex (26.6%). However, women who stated that they douched more frequently (more than once a month) did so more often after having sex (47.3% vs. 19.2%; P <0.001), when they experienced itching (16.1% vs. 2.0%; P <0.001), and when they wanted to feel fresh (56.3% vs. 37.3%; P <0.001) as compared with women who douche only once a month.
Reasons for Douching, Douche Frequency, and Sexually Transmitted Disease Infection
The relationship between reasons for douching and douching frequency as predictors of STD infection are shown in Table 4. Women who douched during menses (AOR = 4.78; 95% CI = 1.13–20.13) and to alleviate itching (AOR = 3.66; 95% CI = 1.00–13.41) were more likely to test positive for chlamydia, whereas women who douched after sex were less likely to be infected with GC (AOR = 0.19; 95% CI = 0.04–0.96). No statistically significant associations were found between douching frequency and STD infection.
Similar to findings from the 1995 National Survey of Family Growth,21 we found that nearly half (46%) of this sample of black females reported current douching. These results suggest that, although national prevalence rates for douching have been declining since 1988, many black women in the south are continuing to engage in the practice. Consequently, more intensive interventions to increase awareness about the negative health effects related to douching with a plan for primary and secondary prevention of douching are needed.
Previous studies have linked douching with such sexual risk behaviors as early age of sexual initiation, an increased number of lifetime sexual partners, increased frequency of sexual activity, and lack of condom use.2,23,29–32 Moreover, numerous studies have noted the relationship between douching behavior and STDs,15,33 particularly C. trachomatis infection.14,17,19,34,35 The current study found similar relationships between women who exhibited high-risk sexual profiles and current douching status. These behaviors were particularly noticeable when comparing current douchers to women who had never douched. There was a significant difference between current douchers and never douchers in terms of the number of lifetime sexual partners and self-reported STD history. Other measures such as early age of sexual initiation and lack of condom use during last sexual encounter showed a trend for riskier behavior among current douchers but were not statistically significant. Further analyses comparing current douchers with a group of both former and never douchers revealed a statistically significant association with current chlamydia or gonorrheal infection.
Contrary to other studies indicating that women begin to douche at early ages,23 we found that approximately one half of the women reported initiating douching at age 17 or older. The fact that our sample involved an older cohort of females could explain this discrepancy. Nonetheless, our data confirm that women are initiating the behavior during adolescence, thus justifying younger audiences for douching prevention messages. Similar to previous studies,15,22–26 we found that most often cited reasons for douching were to cleanse after menses, to feel fresh, and to cleanse after sexual intercourse. Additionally, increased douche frequency was associated with douching initiation at an earlier age (age <17) and douching to feel fresh. The current results signify that the reasons for douching tend to be based on a strong perceived need for vaginal cleanliness. Furthermore, these reasons have remained consistent over the years, suggesting an opportunity to intervene with young adolescent women before these reasons result in habitual douching behavior.
Various studies have been conducted supporting the relationship between douching and STD infection; however, several of them have specifically noted that frequency of douching is the source of this association.14,17–19 With the current sample, no statistically significant associations were found between douching frequency and STD infection (either current or past). One possible explanation for this finding may be that the majority of current douchers reported that they douched once a month (74.7%), resulting in a lack of variability in participants’ responses. However, when examining the relationship between reasons for douching and STD outcomes, we did find that douching during menses and to alleviate an itch were significantly associated with chlamydia infection. Blythe et al18 found a similar association between douching for symptoms and chlamydia. These findings demonstrate the layer of complexity that exists when examining the association of douching behavior and adverse reproductive health outcomes independent of sexual risk behaviors. These results also suggest further exploration of the social contextual issues surrounding the decision to douche (i.e., influence of family, friends, partners, and so on) to provide a clearer picture of the relationship between douching and STDs.
This study is not without limitations. First, the results of this study cannot be generalized to all women, to all black women, or to black women not seeking STD care. We focused on a high-risk, young adult, unmarried STD clinic population when, in fact, douching is a behavior that is practiced by a much more heterogeneous group of women.26 Second, the study relied on self-report data for several key variables. Although medical record abstraction for current STD infection was a secondary objective measure of STD risk, the accuracy of data on other variables such as feminine hygiene practices and other sexual risk behaviors may have been adversely affected by self-report, although the use of ACASI may have helped to minimize these problems. Audio computer-based interviewing techniques have been shown to elicit more accurate responses when assessing sensitive topics such as sexual issues.37–39 Third, similar to other studies of douching behavior, the cross-sectional design of the study inhibits any assertions of potential causal links that otherwise could be drawn with prospective data.
Despite its associations with negative reproductive health outcomes, many women continue to douche. Douching behavior is practiced and enjoyed by many women, is often passed down through generations from female family members, and is an obvious habit influenced by individual perceptions and beliefs. Moreover, many women remain unaware of the impact douching may have on their reproductive health. Public health initiatives are urgently needed to prevent adolescent and young adult women from initiating the behavior and to assist women who douche to modify the behavior. Given the relationship found between douching during menses and to alleviate vaginal itching with chlamydial infection, future research should consider more specific aspects of douching behavior such as the timing and reasons surrounding the behavior to better understand its association with negative reproductive health outcomes.
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