Douching After Sex.
Five of 14 men used douches after sex for hygiene and to avoid leakage. Men thought that douching after sex provided STI protection. For some men, douching decreased guilt of engaging in unprotected RAI. When a condom was used or the partner had not ejaculated inside them, participants reported being less likely to douche.
Fleet enemas, water, or soapy solutions were used applied with enema bottles or plastic or rubber bulbs. A few participants reported that enemas resulted in bloating and discomfort.
Some Did Not Douche.
Those who did not douche gave as reasons not liking it, experiencing uncomfortable feelings after douching and, in 1 case, “liking it dirty.” One man mentioned not douching because he was aware it could be harmful.
Poor Adherence to Request Not to Douche.
Although men reporting regular (twice a week or more) RD were excluded from stage 1 of the study, and men were instructed not to douche during the volume escalation trial, 8 of the 14 participants reported douching on at least one RAI occasion, either beforehand or afterwards. The main reason for RD during the trial was hygiene, at times per the partner's request due to leakage caused by the placebo gel.
Having observed that, regardless of the request not to douche, men did it anyhow, we removed the douching exclusion criterion for stage 2 and did not ask participants to abstain from douching.
Participants in stage 2 were 105 men, on average 39 years old (SD = 10.45), and had completed high school. Two-thirds were employed, having a median income in the $10,001 to $20,000 range. Two-thirds identified as white, and three-quarters identified as gay.
All but 2 participants reported having had at least one male sexual partner in the prior 2 months with whom they had engaged in RAI; 83 (75.2%) men had had unprotected RAI. On average, participants reported having 4.31 (SD = 5.12) male sex partners and engaging in 10.70 occasions (SD = 13.81) of RAI, slightly more than half of them unprotected (M = 6.36, SD = 12.52), during the prior 2 months; 78% of participants also reported having insertive anal intercourse (IAI), with 63 men (60%) doing it unprotected. On average, participants had 6.37 (SD = 10.58) IAI occasions and 2.16 (SD = 2.28) partners. Sixty percent of IAI occasions were unprotected. Forty percent of participants reported having an HIV-positive male partner or not knowing the HIV status of a male partner with whom they engaged in unprotected anal sex. Men who douched in the past 6 months were compared to those who did not on all demographic and sex risk variables. No significant differences were found.
Half of the sample (N = 54; 51%) reported using RD in the past 6 months, generally in more than one occasion (M = 14.20, SD = 14.45, Md = 1). The most common places to do douche were the toilet (N = 22; 40.7%) or shower/tub (N = 31; 57.4%).
Most men douched in preparation for sex (N = 49; 91%; Table 2). Over two-thirds of men who douched before sex did it frequently (N = 18; 36.7%) or always (N = 20; 40.8%). The mean age of onset for douching before sex was 28 years (SD = 9.51; Md = 25). On average, men douched about 2 hours before sex (SD = 2.91; Md = 1 hour) because they wished to be clean (N = 38; 77.6%), were encouraged by their partner (N = 15; 30.6%) or had discussed it with a friend (N = 13; 26.5%).
Approximately half of men who reported douching had used RD following sex (N = 26; 48%). Two-thirds of these men did it always (N = 7; 26.9%) or frequently (N = 10; 38.5%). The mean age of onset for douching following sex was 28 years (SD = 11.18; Md = 25). These men douched on average about 1 hour after sex (SD = 1.72; Md = 30 minutes) to clean themselves (N = 23; 88.5%) or to prevent getting STIs from their sex partners (N = 4; 15.4%) (Table 2).
Douching Products and Application.
Of the 54 men who douched in the past 6 months, 42 (77.8%) used a hose apparatus and 33 (66.1%) a prepackaged bulb apparatus. Among the former, 32 (76.2%) used a nondisposable douche or enema bag system, and 26 (61.9%) used a showerhead hose and nozzle. A few men used a portable rubber or vinyl hose attached to a sink (sinker; N = 6; 14.3%). Most men reported running water for an average duration of approximately 6 minutes (SD = 9.7).
Among the 33 men who used a prepackaged bulb apparatus, 28 (84.8%) used an over-the-counter disposable enema product, 17 (51.5%) a reusable bulb enema, and 7 (21.2%) some other kind of apparatus. More than half of the 33 participants who used prepackaged products indicated they douched more than once per event (N = 19; 57.6%).
Men douched standing (N = 19; 35.2% of 54 men who douched), kneeling (N = 15; 27.8%), squatting or seated over a toilet or tub (N = 16; 29.6%), or lying on their sides (N = 4; 7.4%); 9 men (16.7%) inserted the applicator 1 inch into the rectum, 19 men (35.2%) inserted it between 1 to 2 inches, 14 men (25.9%) inserted it 2 to 3 inches, and 12 men (22.2%) more than 3 inches. Twenty-three men (42.6%) reported cramps or discomfort when douching, yet most experienced it infrequently (N = 19; 35.2%). One participant noted injury due to the use of a rectal douche or enema product.
This study explored behavioral aspects of RD in association with sexual intercourse among MSM who engage in sexual risk behaviors. Douching behavior appears to be very ingrained among those who practice it as evidenced by the refusal to abandon it among participants in stage 1 of our study (who were asked not to douche), those who reported douching despite side effects (like cramps), and those who reported abstaining from intercourse if they had not douched. Using mixed (qualitative and quantitative) methods, we found that half of HIV-uninfected men in our sample who had RAI douched frequently or always before RAI, mainly for hygiene and the relaxation experienced when feeling clean and able to enjoy sex with a partner. Consideration for one's partner, who may react negatively to exposure to feces, is also an important factor, and men who have RAI report that their partners support, encourage, and at times demand that they douche. Half of the men who douched did it after sexual intercourse, mainly for hygiene but in some cases also believing it decreased chances of acquiring STIs.
The implications of these douching practices are 2-fold. First, if douching behavior can have negative health effects but is unlikely to be abandoned, as has been the case among women who use vaginal douches, it is of paramount importance to continue identifying douches likely to result in less harmful side effects.9 Studies are currently underway to establish the mucosal effect of hypo-osmolar, iso-osmolar, and hyper-osmolar rectal douches (C. Hendrix, personal communication, January 2009). Findings should be used to educate MSM on the safest products.
Second, if douches that incorporate HIV/STI preventive agents can be developed January 26, 2009, RD before or after sexual acts can become an important alternative prevention tool. A liquid vehicle carrying a microbicidal agent may be well-suited for difficult-to-reach areas of the intestine, and provide more extensive mucosal coverage than a gel. Furthermore, a microbicidal douche (MD) could precede the use of microbicidal lubricant gel during sex to increase protection. To reshape an existing behavior to which some men strongly adhere, like douching, by suggesting the use of one type of douche over another may be more successful than trying to move MSM to engage in behaviors they never practiced before or those they resist (e.g., condom use). The fact that douching occurs, on average, 2 hours before the anticipated sexual encounter or 1 to 2 hours after the encounter means that, in most cases, douching does not compete in the “heat of the moment” with ongoing sexual behavior. Furthermore, although different types of douching apparatus are used, prepackaged bulb apparatus or disposable enemas appeared to be the most popular, again a good omen for the eventual development of MDs. Nevertheless, habitual behavioral patterns should be carefully analyzed to understand how they could impact the use of a potential MD. For example, participants used more than one douche application in preparation for sex; this raises questions about dosage for douches containing microbicides (if 1 application is recommended, would 3 applications result in overdose?). Maybe a solution would be to use an MD after using a safe douche for cleansing purposes, as the last step of the presex preparation process. Another issue highlighted in our results is that the nozzle of the douching device may be introduced up to several inches into the rectum. Given that the rectal epithelium consists of a single layer of columnar or cuboidal epithelial cells that may be vulnerable to abrasion, could manipulation of the douching device result in mucosal damage that may facilitate viral entry? This issue needs to be explored.
The results of our study should be taken with caution. First, ours was a sample of volunteers living in an urban setting (Boston, MA) who participated in a microbicide study not specifically designed for the study of RD. Findings of this study may not be generalizable, yet they are similar to another sample of urban MSM recruited in New York City at about the same time.14 Because urban centers are the localities where the highest incidence of HIV is found, evidence of widespread RD by MSM living in those areas underscores the need to explore their HIV prevention potential. A much larger study with a target N of 850 is currently underway with samples recruited on both the East and West Coasts (P. Gorbach, personal communication, May 10, 2009); this study will cast some light on the generalizability of our results.
Second, individuals with frequent RD were excluded in stage 1, thus curtailing our qualitative exploration of the higher end of the spectrum. However, stage 2 prevalence estimates include this portion of the population. Finally, men were on average in their late 30s, had a college education and earned between $10,000 and $30,000 in annual income; generalizability of findings to other samples of MSM is unknown. As vaginal douching practices among women vary across racial/ethnic and socioeconomic status,19 interethnic differences in RD practices among men need to be studied.
The relentless incidence of HIV among MSM in the United States20 documents that sexual risk behavior continues to exist, despite a quarter of a century of condom promotion. Biomedical and behavioral strategies to decrease HIV/STI incidence and the promotion of means of protection other than condoms are urgently needed for sexually active MSM. The development of douches with less harmful biochemical properties and protective properties may decrease the risks of HIV/STI acquisition. Clearly, not every person engaging in RAI will douche, nor will people who use douches use them every time they have anal intercourse. Yet, if we are ever going to control the HIV epidemic, it will be by increasing the availability of a wide array of behavioral and medical prevention tools that match the diversity of the populations who must adopt them.
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