A strap-on dildo is used with a harness to fasten it against the body, primarily for partnered sexual activity (Fig. 4). A hip harness assists in facilitating vaginal or anal penetration in many positions and can be used by patients across the gender and sexual orientation spectrums. Strap-on anal penetration of a cisgender male partner is colloquially called “pegging.” Other harness models exist, including thigh and hand harnesses, which can be an asset for patients with limited mobility.
Patients can use vibrators and dildos safely for anal stimulation and penetration as long as specific safety features are addressed. Anal devices should have a flared base to prevent the device from being drawn into the rectum and personal lubrication should always be used to prevent traumatic injury.10 Additionally, they should be designed from nonporous materials to prevent spread of rectal flora. Glass anal devices should be avoided completely; broken glass in the rectum constitutes a surgical emergency.
Anal plugs are triangular devices that are designed with a narrowing to be held in the rectum by the external anal sphincter (Fig. 5). Although many anal plugs are specifically designed for those seeking prostate stimulation, patients without a prostate may also derive pleasure from anal stimulation. Cisgender men and transgender women may also achieve prostate stimulation with other types of receptive anal sexual device penetration.
Air Pulsation Devices
Devices using mild air pulsations for clitoral stimulation produce a unique sensation distinct from vibrators or manual stimulation (Fig. 6). Patented in 2013, air pulsation devices are a relatively new addition to the market. These may represent alternative options for patients who cannot achieve orgasm with other types of sex or sexual device use.
Collision Dyspareunia Aids
Collision dyspareunia aids are protective, donut-shaped bumpers that rest around the base of a penis or dildo (Fig. 7). These aids assist patients who experience difficulty with deep penetration owing to pain, structural limitations (eg, stenosis, shortening, insufficient dilation) or partner size mismatch.
Because sexual devices are primarily used on mucosal surfaces, using safe and nontoxic materials is essential. Generally, nonporous materials are preferable, because porous surfaces allow the passage of liquids and particles, thus preventing effective disinfection.
Nonporous materials include items such as medical-grade silicone, hypoallergenic metals, borosilicate glass, or acrylonitrile butadiene styrene plastic. Silicone is soft, nonporous, moldable for different anatomic needs and easily disinfected. Additionally, human papillomavirus (HPV) may be less likely to persist on silicone devices more than 24 hours after cleaning.11 Of note, products may be falsely marketed as “silicone” despite an overall low fraction of silicone. Hypoallergenic metals, including stainless steel and titanium, are commonly used to make Grafenberg spot or anal stimulation devices. Glass devices, popular for their smooth surfaces and appealing aesthetics, should be made from borosilicate glass rather than untreated soda-lime glass. Borosilicate glass is stronger with a reduced risk of breakage from thermal or mechanical stress. Regardless, glass devices should be used with extreme caution in the vagina and avoided in the rectum, given concerns regarding lacerations or perforations warranting immediate evaluation. Plastic, most frequently used for vibrators, is inexpensive and widely available. Plastic sexual devices should be made from hard, nontoxic plastics, such as acrylonitrile butadiene styrene, that do not contain bisphenols (BPA, BPS and BPF) given their association with adverse reproductive outcomes.12 Although plastic is nonporous, it has limited disinfection options owing to heat intolerance and the corrosive effects of chemical disinfectants.
Among porous devices, thermoplastic rubber and thermoplastic elastomer are generally considered nontoxic and body safe. Unfortunately, the majority of sexual devices sold are composed of porous, inexpensive rubber polymers of unknown composition that may be highly toxic or breakdown easily. Patients with latex allergies or those susceptible to contact dermatitis should be cautious when using these products. Rubber devices may breakdown if exposed to latex condoms and should instead be covered with polyurethane or nitrile barriers. Rubber devices should be stored individually in cool locations to avoid melting or distortions.
When used and cleaned appropriately, sexual devices are overall very safe with only rare adverse side effects. Safety concerns or adverse side effects generally fall into two categories: traumatic injury or infection.
Although overall rare, traumatic injuries due to sexual devices have been documented.8,13,14 Objects retained in the rectum may be challenging to remove and sometimes require intervention from colorectal surgeons to facilitate removal.10 Sexual devices also can be retained in the vagina, though these usually can be removed in the office with bimanual, rectovaginal, or speculum examination. Long-term vaginal retention of a sexual device may serve as a nidus for infection if made from porous or quickly degrading material. Retained silicone sexual devices carry risks similar to pessaries, such as vaginal erosions, malodorous discharge, and bleeding. Long-term vaginal retention may rarely lead to vesicovaginal fistula.14
The risk of traumatic injury secondary to vigorous sexual device use has not been well studied. A large study found that 98.9% of women who had used a vibrator never experienced lacerations or physical injuries.2 Moreover, 71.5% of those surveyed never experienced any type of adverse genital effect whatsoever.2 Among the almost 30% of patients who experienced any side effects, these were generally self-resolving, and with no long-term implications.2 Side effects that did occur included self-resolving numbness, irritation, inflammation and, rarely, pain.2 Among those who experienced trauma, injuries self-resolved within a week.2 Patients experiencing recurrent vulvovaginal irritation may have a contact dermatitis secondary to dyes or other chemicals in poorly manufactured devices.
Sexually transmitted infection, including viral and bacterial infections, can be transmitted through sexual device use. Human papillomavirus is of particular concern, because it can be detected on porous sexual devices more than 24 hours after cleaning and is associated with genital-to-oral autoinoculation with sexual devices.11,15 Though not yet investigated, herpes simplex virus transmission through sexual devices is similarly plausible. Patients should be instructed to avoid use during herpes simplex virus outbreaks. One case of human immunodeficiency virus transmission between cisgender women through vigorous shared sexual device use was documented.16 As they are commonly present in bodily fluids, chlamydia, gonorrhea, syphilis, and trichomoniasis also represent infections transmissible through noncoital sexual activity. Patients should be discouraged from sharing sexual devices with nonmonogamous partners and encouraged to disinfect sexual devices between partners and use barriers as risk reduction strategies.
In women who have sex with women, bacterial vaginosis represents an STI and is associated with sharing sexual devices, increased frequency of use, and infrequent cleaning.17–19 Women who have sex with women should be strongly encouraged to clean sexual devices after each use and, if diagnosed with bacterial vaginosis, disinfect devices and abstain from use during treatment to prevent persistent infection.
Barriers and Personal Lubricants
Condoms play a substantial role in sexual device safety, though use is uncommon in studied cohorts of women who have sex with women.20–22 Other barriers, such as gloves, may also be repurposed to cover sexual devices. Some devices may have a “topper” option, in which a textured silicone covering is placed over the part of the device that touches the genitals. Condoms and other barriers reduce the infectious risks associated with multi-partner use and increase ease of cleaning and disinfecting. Studies on sheath-covered vaginal ultrasound probes, however, have shown high levels of persistent bacterial and viral contamination even after low level disinfection.23,24 Thus, it can be extrapolated that barrier use with insertive devices does not completely eliminate the risk of STI transmission.
Personal lubricants decrease the risk of discomfort or tears during sexual device use but should be chosen to ensure compatibility with both the material of the device and the barrier used. Silicone sexual devices should not be used with silicone lubricants, including silicone prelubricated condoms, because the chemical interaction can cause material breakdown. Similarly, oil-based lubricants, polyisoprene or latex condoms, and latex or rubber sexual devices are all noncompatible and may cause condom breakage or material degradation. Water-based lubricants are compatible with all materials and all condoms. Table 1 illustrates lubricant compatibilities.
CLEANING AND DISINFECTION
Patients commonly have questions about how and when to clean or disinfect sexual devices.21,25 Whereas cleaning involves removal of discharge and debris with soap and water, disinfection refers to processes that remove transmissible pathogens. Women report that a primary motivation to clean sexual devices is to avoid transmission of STIs.21 Little research exists regarding efficacy for cleaning and disinfection techniques of sexual devices. Available research show persistence of HPV on porous and nonporous devices after washing and suggests only limited cleaning by most users.2,11,21 As such, patients should be counseled to clean sexual devices after every use. Sexual devices can be cleaned with mild soap and warm water with either submersion (if waterproof) or wiping with a washcloth. Harsh soaps with fragrance may linger on devices and cause vulvovaginal irritation. Patients who experience irritation after use of sexual devices designed from hypoallergenic materials may benefit from more thorough rinsing. Although specific sexual device cleaning soaps and wipes can be purchased, it has not been studied whether these are more effective than soap and water.
As there are no research studies directly supporting any specific sexual device disinfection techniques, patients should be counseled to use barriers, such as condoms, if sharing sexual devices.26 Recommendations can be extrapolated from disinfection of other medical devices, and patients should be counseled to use disinfection methods between nonmonogamous partners or if diagnosed with a STI, vulvovaginal candidiasis, or bacterial vaginosis. Only nonporous materials can be disinfected. Complete destruction of all microbes and spores is only achievable with an autoclave or other high level chemical sterilants, though this is not feasible for the vast majority of patients.27 Per the Centers for Disease Control and Prevention, disinfection of home care items can be performed by submersion in a dilute household bleach (0.5% sodium hypochlorite) solution for 3 minutes or 70% isopropyl alcohol for 5 minutes.28 Isopropyl alcohol however, may not inactivate HPV.29 Patients should be counseled to thoroughly wash devices after disinfecting with chemicals before contact with mucosal surfaces.
Device manufacturers and retailers commonly recommend disinfection of silicone or stainless steel devices using boiling water or a dishwasher on sanitize mode. Though most enteric bacteria are destroyed by boiling, this temperature is far lower than that of an autoclave. Glass and plastic devices and those with internal electrical components are heat sensitive and should not be boiled. Bleach and alcohol may be corrosive to some products and patients should consult manufacturers' recommendations. Ultraviolet light sterilization units specifically for sexual devices are now being sold. Although ultraviolet light is effective to inactivate HPV, it is not possible for consumers to verify the authenticity of these products.30 Sexual device disinfection methods commonly recommended by manufacturers and retailers and their limitations are outlined in Table 2.
SPECIFIC PATIENT POPULATIONS
Pregnancy and Postpartum
Conditions in pregnancy such as placenta previa or presence of cerclage may preclude penetrative sexual activity. In this setting, external stimulation from a vibrator can be helpful to maintain partner intimacy. Some providers may be concerned regarding theoretical risk of orgasm-induced uterine contractions, however this has not been well studied and no adverse fetal outcomes have been reported.31,32 Pregnant women without contraindication to sexual activity or vaginal penetration may benefit from sexual device use during a time when a gravid uterus can hinder certain sexual positions or make intercourse and masturbation more challenging.32
The hypoestrogenism of the postpartum period coupled with discomfort and postoperative healing from an obstetric laceration may delay resumption of vaginal penetration. Although external stimulation using a vibrator may be beneficial for this population, vaginal or anal penetration devices should be avoided, particularly after anal sphincter injury. A personal lubricant may facilitate sexual activity, including sexual device use, particularly for women who are hypoestrogenic owing to breastfeeding.
Disorders of Sexual Function
This category includes women who experience difficulty during any stage of normal sexual activity including desire, arousal, or orgasm as well as patients whose partners experience sexual dysfunction including erectile dysfunction.6 Although there is not one specific solution for all patients, anorgasmia can be treated with sexual devices, particularly external vibrators.5,33 Patients who prefer internal stimulation may benefit from a curved device designed for Grafenberg spot stimulation. Partner erectile dysfunction is a contributing factor to decreased sexual activity, and sexual devices can help couples expand their repertoire of noncoital sexual activity. Cisgender male partners can use strap-on dildos to continue familiar sexual activities, with some men reporting sexual pleasure and even orgasm.34 Many other sexual device options exist for cisgender men with erectile dysfunction, including anal penetration devices, however a full review of such devices is outside the scope of the guide.
Pelvic Floor Dysfunction
Patients with pelvic floor dysfunction, including pain disorders, pelvic floor muscle hypertonus and spasm, vaginal stenosis, or prolapse may find benefit from nonpenetrative sexual device use.35 External clitoral, vulvar, or anal stimulation devices should be considered, as well as devices designed to increase pleasure for their partner (eg, penetration sleeves or prostate stimulation devices). Patients with pelvic floor disorders who are undergoing pelvic floor physical rehabilitation may use vibrators as alternatives to medical dilators. Finally, patients with female genital mutilation may be able to stimulate remnant clitoral tissue beneath the prepuce using vibration.
The hypoestrogenic state of menopause can negatively affect libido, genital sensitivity, and arousal. In addition, vaginal atrophy and dryness can induce dyspareunia and make penetrative sex challenging. Educating postmenopausal women on lubrication and sexual devices can help improve their sexual experience. Postmenopausal women can have difficulties with masturbating due to arthritis, limited mobility, and vision loss. Vibrators and dildos designed with more user-friendly handles and larger buttons exist for this population.
Sexual dysfunction is widely prevalent among cancer survivors, approaching 90% in gynecologic cancers, as a result of chemotherapy, pelvic radiation, and surgery.36 Physical changes may occur after treatment of gynecologic cancers, including vaginal stenosis secondary to radiation, partial or complete vulvectomy or vaginectomy, or reduced arousal-associated vaginal blood flow due to damaged hypogastric nerves at the time of radical hysterectomy.37,38 Medications such as anastrozole and tamoxifen may affect libido and vaginal lubrication, and gonadotoxic chemotherapy or oophorectomy may put young women into symptomatic early menopause.36,39 For these patients, sexual aids represent part of a comprehensive treatment for their sexual disorders.39
Disability and Chronic Illness
Congenital and acquired disability may affect patients' ability to express and enjoy themselves sexually by affecting patients' sexual function, sensation, and overall mobility.41,42 Type of sexual devices used varies for different disabilities, but is associated with improved sexual function.41 Patients with arthritis or limited dexterity can use hand or thigh harnesses to use penetrative devices if unable to move their hands, fingers, or hips effectively. Bolsters and straps designed to aid in positioning are also available, some of which include mounts for vibrators or dildos. Box 4 lists common conditions that affect sexual function and which may benefit from sexual device use.
Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, and Asexual Patients
Patients in the LGBTQIA community report greater sexual device use than their cisgender heterosexual counterparts.22,43–44 Clinicians should be wary of the tendency to label certain devices as “gay” sexual devices as this may be negatively perceived by LGBTQIA patients and undermines the benefit such devices may have for cisgender heterosexual patients. Dildos or strap-on devices can be used in circumstances where the insertive partner does not have a penis or has a penis incapable of sufficient erection for penetration. For example, same-sex partnered women may find that using a strap-on dildo allows for hands-free vaginal penetration. Transgender men and gender nonconforming individuals may use a strap-on device for gender-congruent sexual expression. Transgender women may be unable to achieve erection while on estrogen therapy or have undergone penectomy but still desire an insertive sexual role.
Similar to adults, adolescents may want to use sexual devices for masturbation or with partners. Laws vary by state; however, adolescents rarely have the ability or access to purchase sexual devices online or in adult stores. Regardless, adolescents may still use sexual devices either purchased by a friend or family member or repurposed from a nonsexual item (eg, vibrating back massager, vibrating toothbrush). Gynecologists have a crucial role to inform and educate adolescents regarding safe sexual device use while maintaining confidentiality and a nonjudgmental environment.
Providers are uniquely positioned to assist patients in making safe sexual device purchases. Sexual devices are largely sold online, in adult retail shops, in some pharmacies, and at “home sex toy parties” (facilitated parties to learn about and purchase sexual devices).25,45 Although it is unrealistic for clinicians to know about all sexual devices on the market, referring patients to stores with explicit educational missions or that employ sex educators for store-based classes can help patients navigate this unregulated industry.45 Similarly, patients can be referred to websites with safety-minded inventory or medical professional oversight, or vetted home parties arranged by facilitators with sexual health knowledge.25
Knowledge about sexual devices is important for obstetrics and gynecology clinicians to help educate patients regarding use, counsel about cleaning and disinfection, and assist in safe material and product selection. Discussions about a patient's sexual wellness may also engender provider trust and facilitate rapport. Screening for sexual device use is an important aspect of preventative women's health, given the adverse consequences of improper use, handling, and hygiene. In certain patient populations, sexual devices can be beneficial for sexual health.
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