Douching practices among women at high risk of HIV infection in the United States: implications for microbicide testing and use

Condoms, Lubricants and Rectal Cleansing: Practices Associated with Heterosexual Penile-Anal Intercourse Amongst Participants in an HIV Prevention Trial in South Africa, Uganda and Zimbabwe

We investigated condom and lubricant use, rectal cleansing and rectal gel use for penile-anal intercourse (PAI), during in-depth interviews with women from South Africa, Uganda and Zimbabwe who formerly participated in VOICE, a five-arm HIV prevention trial of two antiretroviral tablets and a vaginal gel. Few studies have addressed practices related to PAI among women; existing data from Africa on condom and lubricant use for PAI, as well as preparatory practices of PAI such as rectal cleansing, are limited to men who have sex with men. Women demonstrated a lack of awareness of HIV transmission risks of PAI and none of the participants reported using condom-compatible lubricants for PAI. Participants described a variety of preparatory rectal cleansing practices. Some participants disclosed rectal use of the vaginal study gel. Understanding practices related to PAI in Africa is critical to microbicide development, as these practices are likely to influence the acceptability, feasibility, and use of both vaginal and rectal microbicide products.

Examining targets for HIV prevention: intravaginal practices in Urban Lusaka, Zambia

Intravaginal practices (IVP) are the introduction of products inside the vagina for hygienic, health, or sexuality reasons. The influence of men and Alengizis, traditional marriage counselors for girls, in promoting IVP has not been explored. We conducted gender-concordant focus groups and key informant interviews with Alengizis. The responses were conducted grouped into three themes: (1) cultural norms, (2) types and reasons for IVP, and (3) health consequences. We found that IVP were used by all participants in our sample and were taught from generation to generation by friends, relatives, or Alengizis. The reasons for women to engage in IVP were hygienic, though men expect women to engage in IVP to enhance sexual pleasure. Approximately 40% of women are aware that IVP can facilitate genital infections, but felt they would not feel clean discontinuing IVP. All men were unaware of the vaginal damage caused by IVP, and were concerned about the loss of sexual pleasure if women discontinued IVP. Despite the health risks of IVP, IVP continue to be widespread in Zambia and an integral component of hygiene and sexuality. The frequency of IVP mandates exploration into methods to decrease or ameliorate their use as an essential component of HIV prevention.

ACIDFORM: a review of the evidence

OBJECTIVE

ACIDFORM is a candidate microbicide with spermicidal properties. A large Phase 3 trial is underway, and it is anticipated that this product will be approved for contraceptive use and marketed soon in the United States. The goal of this article is to critically review the evidence supporting the properties, safety profile and different uses of ACIDFORM gel.

STUDY DESIGN

We searched PubMed and Medline for any published literature on ACIDFORM.

RESULTS

ACIDFORM is an acidifying agent that works by lowering the vaginal pH to enhance the normal vaginal defenses. In addition to strong acid-buffering properties, ACIDFORM has high bioadhesive and viscosity-retaining properties. Several Phase 1 clinical trials have demonstrated the vaginal safety of ACIDFORM used alone or in combination with a diaphragm, although dose-dependent side effects appear to be present. Studies investigating the efficacy of ACIDFORM against sexually transmitted infections (STIs) are promising, but further trials are needed.

CONCLUSIONS

The properties of ACIDFORM offer many advantages for use, either alone or in combination with another active ingredient, such as Tenofovir. Potential applications for ACIDFORM include use as a personal lubricant, a vaginal contraceptive (alone or with a barrier method) and a microbicidal product or as a formulation vehicle for an active ingredient.

IMPLICATIONS

ACIDFORM is a candidate female-controlled vaginal preparation with microbicidal and spermicidal properties. A dual protection method could prevent unwanted pregnancies and reduce the risk of STI acquisition.

Ethnicity, family socioeconomic inequalities, and prevalence of vaginal douching among college students: the implication for health

OBJECTIVE

This study assessed the association between ethnicity and family socioeconomic status (SES) as it relates to the prevalence of vaginal douching among female undergraduates in a university community.

PARTICIPANTS AND METHODS

This was a cross-sectional survey conducted between September 2011 and February 2012 among 1,535 female undergraduates using a semistructured behavioral questionnaire adapted by the authors from previous research related to vaginal douching practice.

RESULTS

The overall prevalence of vaginal douching was 79.35% and the practice was significantly associated with the mother's age, ethnicity, low SES (educational level, occupation, and monthly income), and area of residence. The father's age and SES were statistically nonsignificant.

CONCLUSION

Ethnicity and low SES of mothers were significantly associated with a higher prevalence of douching in daughters. These factors should be considered among others in any intervention to discourage vaginal douching among college women.

Genital immunology and HIV susceptibility in young women

Women account for a substantial majority of HIV infections in endemic regions, where women are also infected at a much younger age than men. Part of this epidemiological skewing is due to socio-cultural factors, but it is clear that biological factors enhance the susceptibility of women--particularly young women--to HIV acquisition after sexual exposure. These factors, including important differences in mucosal immunology at the site of genital HIV exposure, are the focus of this concise review. Compared to heterosexual men, women have an increased surface area of mucosal HIV exposure, increased mucosal expression of the HIV co-receptor CCR5 and a greater probability of virus exposure on the rectal mucosa. Differences that are specific to young women include a pro-inflammatory immune environment and a proportionate increase in single-cell, columnar genital epithelium. These important biological reasons for enhanced HIV susceptibility in young women highlight the need for targeted HIV prevention within this vulnerable population.

Anal sex, vaginal practices, and HIV incidence in female sex workers in urban Kenya: implications for the development of intravaginal HIV prevention methods

Multiple intravaginal HIV prevention methods, including microbicide gels, barriers, and intravaginal rings, are in clinical development in Africa. Development of intravaginal HIV prevention products requires an understanding of sexual behavior, sexually transmitted infection (STI), and vaginitis prevalences, and sexual and vaginal practices in potential target populations. We assessed these factors in a cohort of Kenyan female sex workers (FSW). Women who reported exchanging sex for money/gifts at least three times in the past month and who were HIV uninfected were enrolled and followed for 6 months. STI prevalence and HIV incidence were analyzed by multivariate logistic regression analysis, controlling for demographic and behavioral factors. Thirty-seven percent (74/200) reported having had anal sex. Frequency of anal sex was higher with regular and casual partners than with primary partners. Women were less likely to use condoms for anal sex than for vaginal sex with regular or casual partners. Vaginal washing was universal (100%). HIV incidence was 5.6 per 100 person-years (95% CI 1.62, 11.67). HIV incidence was not associated with any demographic or risk behavior. The relatively high rate of anal sex and universal vaginal washing may complicate both safety and efficacy evaluation of intravaginal products and should be taken into account in trial design. This FSW population had significant HIV incidence and needs continued HIV prevention interventions.

Effect of treatment assignment on intravaginal cleansing in a randomized study of the diaphragm with candidate microbicide

BACKGROUND

Intravaginal cleansing may predispose women to adverse health outcomes and may interfere with the effectiveness and safety of female-initiated methods for preventing sexually transmitted infections (STIs). In a 4-week randomized study of 192 Malagasy sex workers, we evaluated associations between self-reported intravaginal cleansing and randomization assignment: diaphragm with viscous candidate microbicide gel (Acidform™, TOPCAD, Chicago, IL, licensed to Instead, Coppell, TX), diaphragm with placebo hydroxyethylcellulose gel (HEC, ReProtect LLC, Baltimore, MD), Acidform alone, or HEC alone.

METHODS

Women were counseled to avoid intravaginal cleansing and were blinded to gel assignment. We evaluated changes in self-reported intravaginal cleansing across the study and assessed the effects of treatment assignment and covariates on frequent (more than once daily) intravaginal cleansing. Significant predictors in domain-specific models were evaluated in an all-domain multiple regression model.

RESULTS

The proportion of women reporting intravaginal cleansing decreased from baseline (97%) to week 1 (82%) (p < 0.001). Self-reported frequent intravaginal cleansing decreased from baseline (87% to 56%) during the same time period (p < 0.001). In adjusted analyses, the Acidform-diaphragm group had 60% lower odds of frequent intravaginal cleansing during the study (odds ratio [OR] 0.4, 95% confidence interval [CI] 0.2-0.8) compared to the control group (HEC only). HEC-diaphragm and Acidform only users did not differ from controls. Living on the coast of Madagascar, not cohabiting, frequent intravaginal cleansing at enrollment, and high coital frequency predicted frequent intravaginal cleansing during follow-up.

CONCLUSIONS

Gel characteristics and the diaphragm's presence likely influenced women's cleansing. Viscous gel delivered by a cervical barrier (such as a diaphragm) may minimize the likelihood of frequent intravaginal cleansing.

Discussions of vaginal douching with family members

PURPOSE

This study examined women's personal douching history and the information they were given by others.

METHODS

Participants in the study (N=199; mean age=28.92) completed a 48-question survey on douching practices and attitudes.

RESULTS

Fifty-seven percent of participants had douched and 39% currently douche. The majority of women reported douching after menstruation, before or after sex, or as needed. Reasons for douching included maintaining cleanliness, feeling good and fresh, eliminating vaginal odor, and removing menstrual blood. Most women (69%) had at least one discussion about douching, with 49% having a discussion with their mother and 22% with a health care provider (HCP). Of the women who currently do not douche, 47% stopped after a HCP instructed them to quit; whereas, 100% of women whose HCP encouraged douching went on to douche. Furthermore, 66% of women planned to discuss douching with a younger girl, with 57% encouraging or being neutral and 43% discouraging it. Women who have previously douched were more likely to discuss and encourage douching than women who had never douched. Also, women who have received a discussion about douching or were encouraged to douche were more likely to douche than women who had not received a discussion or were discouraged.

CONCLUSIONS

Results from this study suggest that younger generations may be taught about or encouraged to douche by their mothers. By giving women accurate information and discouraging douching, women may be less likely to douche or encourage douching in their daughters.

The use of rectal douches among HIV-uninfected and infected men who have unprotected receptive anal intercourse: implications for rectal microbicides

Although some rectal douches result in surface epithelium loss and potential increase of HIV transmission, men who have sex with men (MSM) continue to use them. We describe the prevalence of this practice among MSM engaging in unprotected receptive anal intercourse (URAI) in risky circumstances. A multiethnic sample with overrepresentation of HIV-negative MSM who had URAI in the previous year was recruited exclusively through the Internet. Participants were 105 MSM (78 HIV-negative, 27 HIV-positive). A total of 53% of HIV-negative and 96% of HIV-positive men douched in preparation for sex, most of them frequently or always, mainly for hygienic purposes. 27% of HIV-negative and 44% of HIV-positive douched after sex, partly believing douching protected from infections. Douching practices started around age 25. Regression analyses found the association between HIV status and douching occasions persisted after controlling for demographic characteristics and number of URAI occasions. Rectal douching in preparation for sex is common among men who practice URAI. This population could benefit from alternatives to condoms, such as rectal microbicides. Given the popularity of pre-coital douching and its frequency, a harmless rectal douche that could deliver a rectal microbicide could have great acceptability.

Vaginal douching among Latinas: practices and meaning

OBJECTIVES

Vaginal douching is widely practiced by American women, particularly among minority groups, and is associated with increased risk of pelvic and vaginal infections. This research sought to investigate vaginal hygiene practices and meaning associated with them among Latina women and adolescents. Study results would guide development of an intervention to decrease douching among Latinas.

METHODS

In depth qualitative interviews conducted with English- and Spanish-speaking women aged 16-40, seeking care for any reason who reported douching within the last year (n = 34). Interviews were audiotaped, transcribed and analyzed using qualitative methods. One-third of interviews were conducted in Spanish.

RESULTS

Two explanatory models for douching motives emerged: one stressed cosmetic benefits; the other, infection prevention and control. Most women reported douching to eliminate menstrual residue; a small number reported douching in context of sexual intercourse or vaginal symptoms. Many were unaware of associated health risks. Respondents typically learned about douching from female family members and friends. Male partners were described as having little to no involvement in the decision to douche. Women varied in their willingness to stop douching. Two-thirds reported receiving harm reduction messages about "overdouching". About half indicated previous discussion about douching with health care providers; some had reduced frequency in response to counseling. A number of previously unreported vaginal hygiene practices and products were described, including use of a range of traditional hygiene practices, and products imported from outside the US.

CONCLUSIONS

Respondents expressed a range of commitment to douching. Counseling messages acknowledging benefits women perceive as well as health risks should be developed and delivered tailored to individual beliefs. Further research is needed to assess prevalence and safety of previously unreported practices.

Vaginal douche practices among black women at risk: exploring douching prevalence, reasons for douching, and sexually transmitted disease infection

OBJECTIVE

The objective of this study was to identify douching patterns and their relation to sexually transmitted disease (STD) among black women seeking an STD evaluation.

STUDY DESIGN

This study was a cross-sectional survey with biologic testing for chlamydia and gonorrhea infection.

RESULTS

Of 891 participants, 46.1% were current douchers. Commonly identified reasons for douching were to cleanse after menses (65.4%) and to feel fresh (42.2%). Frequent douching was associated with douching after sex (P<0.001), to alleviate an itch (P<0.001), and to feel fresh (P<0.001). Women who douched during menses (adjusted odds ratio [AOR]=4.78; 95% confidence interval [CI]=1.13-20.13) and to alleviate an itch (AOR=3.66; 95% CI=1.00-13.41) were more likely to have a current chlamydial infection.

CONCLUSIONS

Douching was common among this high-risk population of black women. Prospective studies are needed to determine the consequences of douching and any mediating effects of women's motivation for the behavior on reproductive health.

Vaginal douches and other feminine hygiene products: women's practices and perceptions of product safety

OBJECTIVE

Use of vaginal douche products has been linked with a variety of reproductive health problems; nonetheless, the practice of douching persists. The goals of this study were to 1) determine the use of vaginal douches and other feminine hygiene products, 2) ascertain how safe women think vaginal douche products are, and 3) evaluate women's readiness to stop douching.

METHODS

A random-digit-dial computer-assisted telephone survey was conducted among US women between the ages of 18 and 44.

RESULTS

Of the 2,602 women interviewed, 11.8% (n = 307) engaged in regular douching (White: 9.1%; African American: 27.7%; Hispanic: 15.0%). Women who douched, compared to women who did not douche, used other feminine hygiene products significantly more often (vaginal sprays [ p < .0001], wipes/towelettes [ p < 0.01], vaginal powder [ p < 0.0001] and bubble bath for feminine cleansing [ p < 0.001]). Women who douched also were more likely than nondouchers to agree with the statement, "Douche products are safe to use; otherwise they wouldn't be on the market" (70.3% vs. 33.4%, respectively; p < 0.0001). Nearly all women (90.0%) who douched had no intention to discontinue the practice.

CONCLUSION

Compared with women who do not douche, women who douche use other feminine hygiene products at a much higher rate and also believe that douche products are safe. Women who douche will remain resistant to stopping the practice without innovative interventions. Given that most women start douching in adolescence, teens should be targeted for prevention efforts.

Distinguishing the temporal association between women's intravaginal practices and risk of human immunodeficiency virus infection: a prospective study of South African women

Cross-sectional studies have suggested that intravaginal practices, such as douching or "dry sex," may increase women's susceptibility to infection with human immunodeficiency virus (HIV). The authors examined the temporal nature of this association in a cohort of South African women. At enrollment (2001-2002), 4,089 women were tested for HIV infection. Participants reported their intravaginal practices at a 6-month follow-up visit and were followed with repeat HIV testing for up to 24 months. Among the 3,570 women who were HIV-negative at enrollment, 26% reported some type of intravaginal practice, mostly washing inside the vagina with water and/or cloth as part of daily hygiene. During follow-up, 85 incident HIV infections were observed. Intravaginal practices were associated with prevalent HIV at enrollment (adjusted odds ratio = 1.50, 95% confidence interval: 1.22, 1.85), but during follow-up there was no association between intravaginal practices and incident HIV (adjusted hazard ratio = 1.04, 95% confidence interval: 0.65, 1.68). These findings may be explained by a reversal of the causal sequence assumed for this association, since intravaginal practices may be undertaken in response to vaginal infections that occur more commonly among HIV-infected women. Intravaginal practices appear unlikely to be a cofactor in the male-to-female transmission of HIV in this setting.

Sex preparation and diaphragm acceptability in sex work in Nairobi, Kenya

Background: Women in sex work stand to benefit if the contraceptive diaphragm alone or combined with a microbicide proves to be an effective barrier method against HIV and sexually transmissible infection (STI). Currently, contraceptive diaphragm users are advised to leave the diaphragm in situ without concomitant use of other intravaginal substances for at least 6 h after intercourse. Methods: We conducted in-depth interviews on sexual behaviour including post-coital intravaginal practices with 36 women in sex work and 26 of their clients and held two focus-group discussions, each with 10 women. Results: The women described adapting several potentially harmful substances, such as cloth and soapy water, for post-coital vaginal use to ensure personal hygiene, disease prevention and client pleasure. Some wanted to clean themselves and remove the diaphragm early, fearing exposure to HIV infection for themselves and their subsequent clients. Clients indicated their desire for ‘dry sex’, vaginal cleanliness and reduced risk of infection through vaginal cleaning. Conclusions: The diaphragm as a female-controlled barrier method for HIV/STI prevention may have limited acceptability among women in sex work if its effectiveness depends on a 6-h post-coital wait before removal, along with avoidance of concomitant use of intravaginal substances. In keeping with the beliefs of the the female sex workers and their needs and practices, alternative intravaginal substances and modes of insertion that will not disrupt vaginal flora, injure vaginal epithelium, damage the diaphragm or counteract potentially beneficial effects of microbicides are needed. The possibility of removing the diaphragm sooner than the recommended 6 h for contraception should be further studied.

Intravaginal practices, bacterial vaginosis, and women's susceptibility to HIV infection: epidemiological evidence and biological mechanisms

Intravaginal practices such as "dry sex" and douching have been suggested as a risk factor that may increase women's susceptibility to HIV infection. These behaviours appear common in different populations across sub-Saharan Africa, where practices include the use of antiseptic preparations, traditional medicines, or the insertion of fingers or cloths into the vagina. We systematically review the evidence for the association between women's intravaginal practices and HIV infection. Although a number of cross-sectional studies have shown that prevalent HIV infection is more common among women reporting intravaginal practices, the temporal nature of this association is unclear. Current evidence suggests that bacterial vaginosis, which is a likely risk factor for HIV infection, may be a mediator of the association between intravaginal practices and HIV. Although biologically plausible mechanisms exist, there is currently little epidemiological evidence suggesting that intravaginal practices increase women's susceptibility to HIV infection. Further research into factors that increase women's susceptibility to HIV will help to inform the design of vaginal microbicides and other HIV prevention interventions.

Preferences and practices related to vaginal lubrication: implications for microbicide acceptability and clinical testing

BACKGROUND

Research on vaginal microbicides for HIV prevention is progressing rapidly; the first large-scale effectiveness trials were launched in 2004. The majority of candidate microbicides are formulated as gels, which will act as lubricants when used during sex. Preferences and practices regarding lubrication during sex, therefore, likely influence microbicide acceptability and use. Researchers seek to maximize consistent and correct use of candidate microbicides during clinical trials to enable valid estimates of product effectiveness, and if proven effective, microbicides will be widely used only if acceptable.

METHODS

We conducted a comprehensive literature review and interviewed 13 key informants from nine countries in Africa, Asia, Latin America, and North America.

RESULTS

We found that norms and practices regarding lubrication during sex exist in many different countries. Despite significant variation, common themes emerged. In the majority of countries, women's genital hygiene is highly valued, and women are expected to achieve a moderate amount of vaginal lubrication during sex that is neither excessive nor inadequate. Women may try to achieve this by engaging in a wide variety of vaginal practices.

CONCLUSIONS

Even though some informants expressed concerns about the acceptability of lubricating microbicides in some settings, they thought that microbicides should be developed, that women and men may be willing to accept a certain level of increased lubrication in exchange for protection from HIV, and that lubricating microbicides may be considered more acceptable when perceived as genital hygiene products. Recommendations are made on how to take vaginal practices into account during clinical testing of microbicides.

Vaginal douching: personal practices and public policies

BACKGROUND

Vaginal douching is associated with adverse reproductive health outcomes, yet both health providers and women are often poorly informed about details of this practice.

METHODS

We searched the English language articles in the MEDLINE database (1965-March 2004) to describe vaginal douching products, policies of professional organizations, predictors of douching practice, douching methods used, timing of use, and motivation. A key report was obtained from the Food and Drug Administration (FDA) via the Freedom of Information Act. Additional product information was obtained from manufacturers. Primary key terms for the literature search included (vagina OR vaginal) and (douche OR douching). Health effects of douching are reviewed briefly; personal practices and public policies are highlighted.

RESULTS

From the literature search, we identified 432 papers, of which 150 were reviewed in detail. Contrary to the assumptions of many health professionals, douching products are only loosely regulated by the FDA. Few professional organizations have clearly stated policy statements regarding douching. In the United States, the prevalence of douching varies considerably by race (more common among African Americans) and age cohort (more common in women born earlier). Internationally, vaginal douching is common in some cultures and is rare in others. Opinions of mothers, peers, and health professionals, in addition to marketing of commercial products, affect douching behavior.

CONCLUSIONS

Regulation of vaginal douching products and public education efforts on douching behavior need to be reassessed. Because of the preponderance of evidence that suggests an association between vaginal douching and adverse reproductive health outcomes, professional and public health associations should consider educational and policy activities to discourage women from douching.

Vaginal douching among adolescent and young women: more challenges than progress

The practice of vaginal douching dates back centuries. Numerous studies have shown that douching is quite prevalent and often begins during adolescence. Motivation for the initiation and maintenance of this practice appears complex, and presents challenges to the intervention efforts. The practice of douching remains controversial. Douching has been implicated in numerous adverse reproductive health outcomes such as increased risk for pelvic inflammatory disease, ectopic pregnancy, reduced fertility, and bacterial vaginosis. However, recent studies in developing countries have suggested that in certain circumstances, douching may actually be beneficial. We summarize key findings from the review of published literature and ongoing research, as well as highlight research challenges to our understanding of the role of vaginal douching in reproductive health.

Intravaginal Practices, HIV and Other Sexually Transmitted Diseases Among South African Women

BACKGROUND AND OBJECTIVES

Intravaginal practices, including wiping, douching, or inserting substances into the vagina, have been hypothesized to increase women's risk of HIV infection. However, data on the prevalence of these practices, and associations with HIV and other sexually transmitted diseases (STD), are limited.

STUDY DESIGN

We interviewed 2,897 women participating in a gynecologic screening study in Cape Town, South Africa, about their intravaginal practices. After clinical examination, cervical and blood samples were collected and tested for HIV and other STD [corrected].

RESULTS

Of the 831 (29%) women reporting some type of intravaginal practice, 48% reported using only water and cloth to clean inside the vagina, whereas 17% reported using antiseptics or detergents. Most women (53%) reported practices as part of regular hygiene. Intravaginal practices were strongly associated with behavioral risk factors, and recent multiple sexual partners [corrected]. Intravaginal practices were associated with prevalent HIV infection (adjusted odds ratio, 1.74; 95% confidence interval, 1.37-2.20), but were not associated with other STDs.

CONCLUSION

Prospective studies that include detailed measurements of correlated sexual risk behaviors are required to discern whether this association is causal in nature; if so, these behaviors could represent an important area for future HIV prevention interventions.

Early onset of vaginal douching is associated with false beliefs and high-risk behavior

BACKGROUND

Vaginal douching in young women has been linked to a variety of adverse reproductive health consequences.

OBJECTIVES

To explore associations with early onset (< or =15 years old) of douching.

STUDY DESIGN

A confidential survey was self-administered to convenience samples of women attending seven primary care clinics.

RESULTS

The mean age of the 726 evaluable participants was 27.9 years (ranges, 14-63 years). Twenty-two percent of participants believed douching "kills germs that cause infections," and 27% agreed that "women believe douching prevents pregnancy." A history of having ever used douching products was reported by 73%. Of those who had douched, 24% began the practice at age < or =15 years. Compared with those who began at a later age, those who began at age < or =15 years were also more likely to have begun sexual intercourse under 16 years of age (AOR 2.63; P<0.001), to believe that douching kills germs that cause STDs (AOR=2.15 P=0.004), and to currently douche more than once per month (AOR=2.08; P=0.009).

CONCLUSION

This study indicates that early onset of vaginal douching is associated with false beliefs and sexual debut at younger age.

Douching behaviors reported by adolescent and young adult women at high risk for sexually transmitted infections

STUDY OBJECTIVE

To describe frequency of douching and reasons as timing to menses, vaginal symptoms, and coitus and the association of these behaviors to the diagnosis of three sexually acquired infections.

DESIGN, SETTING, PARTICIPANTS

The study involved 160 females between the ages of 14 and 25 yrs attending a STD clinic and/or community adolescent health clinics. Subjects were eligible to enter the study if they had a positive test(s) for and/or were a contact of chlamydia, gonorrhea, trichomonas, and/or nongonococcal urethritis (NGU). Reevaluation for these infections occurred at the 1-month, 4-month, and 7-month visit with one-dose antibiotic treatment provided for positive tests. Data on douching was collected at the 7-month visit only.

MAIN OUTCOME MEASURE

Results of tests for STI's using urine-based DNA-amplification techniques for chlamydia and gonorrhea and using self-obtained vaginal swabs for trichomonas culture.

RESULTS

Nearly two-thirds (106/160) of the subjects ages 14-25 yrs completing the 7-month visit reported douching, with 67.7% (69/102) reporting douching once a month or more. Douching was more common in older, black participants, using injectable progestins for contraception. Douching was more common in those reporting more recent sexual partners. Douching related to menses was not associated with any of the three infections, while douching related to symptoms and coitus was associated with positive tests for infections.

CONCLUSIONS

Results suggest that for this subset of teens at high risk for sexually acquired infections, douching is a commonly reported behavior. This study suggests that the linkage of douching and sexually acquired infections is associated with contraceptive choices, self-treatment of vaginal symptoms, and sexual risk behaviors but not menstrual hygiene.