MOUNTING EVIDENCE suggests that douching outside of pregnancy increases the risk of bacterial vaginosis, HIV acquisition, pelvic inflammatory disease (PID), and cervical cancer. 1–5 Despite this, the practice of douching remains a common one. As reported in the 1995 National Survey for Family Growth, 27% of US women of reproductive age douched, including 55% of black women, 33% of Hispanic women, and 21% of white women. 6
Several studies have documented the frequency and patterns of douching among women who douche. 7–14 Common patterns include douching after menstruation, around the time of ovulation, in association with sexual intercourse, and for general hygiene. Less is known about motivations for douching. Women have reported that they douche for hygiene, in response to symptoms, to prevent or treat infection, and less commonly for contraception or because a healthcare provider recommended they do so. However, these motivations neither fully explain why many women retain a habit that clinicians and public health practitioners consider harmful nor suggest an intervention strategy that might change douching behavior. Are women aware of the health risks related to douching? Have they heard but not translated such messages into behavior? Can messages be identified that might influence their behavior?
We report here baseline data from the multicenter Gynecologic Infections Follow-Through (GIFT) Study, in which we asked 1200 women about their douching behavior, what motivated them to douche, and what might influence them to consider stopping.
Women 13 to 36 years of age were recruited into the GIFT Study, a cohort investigation of the health consequences of douching, from family planning clinics, university health clinics, gynecology clinics, and STD units at each of five clinical sites (University of Alabama, Birmingham; Boston Medical Center, Boston; Denver Health, Denver; Magee-Women's Hospital, Pittsburgh; and Medical University of South Carolina, Charleston) between May 1999 and June 2001. Approval for use of human subjects was obtained at each participating institution, and all women signed informed consent forms. Women were eligible for the GIFT Study if they were not specifically seeking care for an STD but, on the basis of previous scoring with a risk-stratification paradigm for chlamydial cervicitis, 16 were considered to be at high risk for acquiring a sexually transmitted infection.
Specifically, to be enrolled, a woman had to have a score of 3 points or more on an algorithm wherein points were derived as follows: age 24 years or less = 1; black race = 2; never pregnant = 1; two or more sexual partners = 1; douches at least once per month = 2; and any history of sexually transmitted infection, including with Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis, = 2. Of 2738 women screened for study entry, 853 (31.2%) did not meet these inclusion criteria. An additional 259 (9.5%) were excluded on the basis of a priori criteria: currently pregnant by beta-HCG testing; currently married; never having had sexual intercourse; pelvic tenderness on examination at baseline; prior hysterectomy, salpingectomy, or tubal ligation; or current antibiotic treatment at baseline. Among the 1626 women who were eligible for the study, 1201 (73.9%) agreed to participate and are the focus of these analyses.
About two thirds of women in the study were 19 to 24 years of age, and the great majority were never married. Three quarters were black, and a similar proportion had an income of less than $20,000 per year.
In a standardized 20-minute interview conducted by trained research staff at each center, women were asked whether they had douched in the past 2 months and about the following aspects of their douching behavior: the usual frequency, duration, and reason for douching and the type of product used when douching. They were also asked about motivations for douching, who first recommended the practice, what they liked and disliked about douching, whether they thought douching was good for their health, whether they had ever been advised to stop, any previous attempts at stopping, and what they perceived would happen should they stop. Questions about what women liked and disliked about douching were open-ended, and responses were recorded verbatim. We categorized these responses on the basis of recurrent key words or key concepts, with categories containing two or fewer responses not reported.
The number and proportion of women involved in various douching practices were determined, including prevalence, frequency, duration, product type, who first recommended the behavior, and reason for douching. We also asked women about their perceptions about douching and about stopping. Furthermore, we queried participants about demographic descriptors and lifestyle factors, including race, education, history of sexually transmitted infections (including gonorrhea, chlamydia, PID, and trichomoniasis), and cigarette smoking. We then examined how these subject characteristics, as well as perceived consequences of stopping douching, advisement to stop douching, and site of recruitment, related to whether women considered douching to be good or bad for their health, whether they had been advised to stop douching, and whether they had ever attempted to stop. In all cases, the statistical test used was a chi-square test, and the reported P values are two-sided.
Of the 1200 women we asked about vaginal cleansing within the past 2 months, 236 (19.7%) reported washing the inside of their vagina with a finger, 453 (37.8%) introduced a washcloth, and 532 (44.3%) douched. Among the 532 women who douched, the most common pattern of douching was once per month (Table 1). The duration of douching was typically several years, with about half of women having douched for 5 or more years and almost a quarter having douched for 10 or more years. The great majority of douchers used one of two major store brands. Only 29 women used a homemade product.
Mothers were cited as the person who most commonly first recommended douching. Friends and female relatives also commonly promoted initiation of douching, a finding indicating that, among women who douche, the practice is embraced by female social supports. Advertisements were cited by only 11.7% of women as a reason for initiating douching.
Women gave the following non–mutually exclusive reasons for douching, in order of frequency: to clean after menses, for general hygiene, before or after sex, or to reduce vaginal odor; “it's normal to douche”; for abnormal vaginal discharge; for bleeding between menses; to prevent pregnancy; and because it was recommended by a health professional. The latter two reasons were reported by 3% or less of the population.
When women were asked what they liked and disliked about douching, most women indicated that they douched because they liked the clean feeling (Table 2). Odor reduction and familiarity were also common reasons for douching. Over 60% of women said there was nothing they disliked about douching. When a reason for dissatisfaction was given, the most common was discomfort.
About half of women thought that douching was good for their health, and their explanations for this belief generally included words like “clean” and “fresh.” The half who thought douching was not good generally knew that douching can cause a disruption of the normal vaginal bacteria. However, relatively few linked douching to serious health conditions such as PID, HIV infection, or cancer. Not surprisingly, then, when asked, “What do you think would happen if you stopped douching?” almost all women answered either “nothing” (52.0%) or that they would experience some adverse effect, including feeling less clean, feeling less sexually attractive, or being more likely to get an infection.
Over 40% of women had, at some point, temporarily stopped douching. More than half of current douchers had been advised to stop, and the advice had typically come from a health professional. Nevertheless, over 85% of women claimed that if they were told that douching might cause an STD, infertility, or cancer, they would stop.
Geographic location had an impact on the occurrence and frequency of douching. Women recruited in Denver, Colorado, and Charleston, South Carolina, were more likely to douche than women recruited at other sites. Furthermore, women in Denver and Charleston douched more frequently than other women (data not shown).
There were several determinants of women's perception that douching was good for their health. Women of lower educational attainment who never smoked and had never stopped douching were more likely to assert the healthfulness of douching (Table 3). Those who had been advised by a health professional to stop were much less likely to have a positive perception of douching. Women who perceived douching as healthy were more likely to endorse the notions that stopping would make them less clean and sexually attractive.
The characteristics associated with being advised to stop douching by a health professional were a history of an STD and enrollment in Pittsburgh. Women who never smoked were less likely to be advised to stop douching.
Past stopping attempts were associated with three factors: fewer perceived adverse consequences from douching cessation, being from Pittsburgh, and having been advised by a health professional to stop.
Consistent with previous reports in the literature, women in this study generally reported douching as a long-term habit, often initiated on the recommendation of their mothers or other female relatives. 9,15 Previous observations have suggested that the practice of douching is handed down from one generation to the next around the time the younger women reach sexual maturity. Our data are also consistent with past reports in showing that the reasons most commonly given for douching include cleansing after menses, before and after sex, and for general hygiene. 6,8–14 In the late 1980s and early 1990s at least half of women mixed their own douche solutions. 7,8–11 Since then, however, it appears that commercial products have overtaken the market. Our data can shed little light on why this has occurred. Although advertising apparently rarely prompted douching initiation, it may well have affected product choice.
Women who douche appear to enjoy doing so. Subjects reported that douching made them feel clean and fresh. Indeed, few disliked anything about the habit, and the thought of stopping was averse to most. In focus groups held to help formulate these survey questions, women described douching as being like brushing their teeth. Therefore, douching may not be an easy habit to break.
Nonetheless, advisement by a health professional to stop douching influenced women's perceptions and behavior. Among douching women, those who had been advised to stop by a health professional were less likely to consider douching to be healthful and more likely to have tried to stop. Similarly, in Pittsburgh, where more participants had heard the message to stop douching, women felt less favorably about the healthfulness of douching and were more likely to have tried to stop.
Clearly, douching prevalence can be reduced. Between 1988 and 1995, the nationally representative National Survey for Family Growth showed an overall reduction in the prevalence of douching among women of reproductive age, from 37% to 27%. 6,7 Perhaps health messages are changing behavior even now, but more targeted messages may have an even greater effect. Although the link between douching and bacterial vaginosis was familiar to some women in our study, the links between douching and PID, HIV, and cervical cancer were less familiar. The majority of women claimed that information suggesting a link between douching and STDs, infertility, or cancer would influence them to stop douching. Because our study was attitudinal, the assertion that certain messages might influence behavior is speculative. A behavioral intervention consistent with the findings of this study should be developed to capitalize on gaps in women's knowledge and understanding of the risks associated with douching. Furthermore, our population may not be generalizable to all women who douche. We focused on a high-risk, young, unmarried population of women. Douching is a habit practiced by a much more heterogeneous group of women.
Overall, the more than 500 douching women interviewed here generally reported that douching was well-liked and hygienic. They showed a limited understanding of the adverse health consequences of douching. Information linking douching to significant morbidities, they said, would influence their behavior. Because douching has been associated with acquisition of bacterial vaginosis, HIV, PID, and cervical cancer, we believe that public health interventions to discourage douching should be undertaken. 1–5 Our data should help to inform future interventions.
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