However, few studies have explored enema use practices. Through online surveys, we examined personal, behavioral, and sex factors associated with enema use. Development and promotion of a non-damaging, non-water based enema specifically for use in anal sex is recommended.
In addition, the seemingly contradictory recommendations that water-based lubricant is recommended for anal enemas but water-based enemas are dangerous need to be reconciled into a single consistent message. Enema use or douching is an under-researched practice affecting the sexual health of men who have sex with men MSM. In addition, studies report it as a risk factor for HIV infection Winkelstein et al.
Rectal biopsies from the valves of Houston showed surface epithelium loss after soapsuds and tap water enemas, but not for And enemas.
Similarly, in a study comparing an iso-osmolar and a hyperomolar commercial lubricant, epithelial denudation in the distal colon was significantly greater with the hyperosmolar gel than with the iso-osmolar formulation, measured 60—90 minutes after application Fuchs et al.
While water-based enemas have not been promoted, neither has the avoidance of enema use. While the biological risk of douching has been established through laboratory studies, very little has been published describing the rectal douching practices in sex between men. Early in the epidemic, the San Francisco AIDS Cohort study examined ancillary sexual behaviors including the use of douches or enemas before sexual contact between men Winkelstein et al.
Among the MSM who reported receptive anal intercourse, sex While both studies found similar results, suggesting that the association between enema use and HIV risk is reliable, the studies are old and were limited to a single question on enema use. Recently, research into rectal microbicides has renewed interest in enema use in anal sex.
Carballo-Dieguez et al. On all these measures, HIV-positive participants were significantly more likely to report engaging in douching than HIV-negative participants. The study found no differences in douching by race, age, education, or income. In the qualitative interviews, and primary reasons for douching were identified as hygiene cleanliness and also increased pleasure.
Two men also linked douching to having unprotected anal intercourse. Fleet enemas, water, or soapy solutions were used, applied with enema bottles or plastic or rubber bulbs. Reasons cited were similar to those in the first study.
While these studies provide some of the first data on the douching practices of MSM, the relatively small sample sizes, geographic restrictions, study requirements for participants to have recent histories of unprotected anal intercourse, and for the first study, to engage in intentional barebacking all severely limit generalizability of the findings. To address this gap, as part of a larger trial, we conducted a behavioral epidemiologic investigation into the douching practices of MSM.
Given the lack of research in this area, the primary purpose of this paper was descriptive to report current behavior and exploratory to identify how enema use practices may differ across demographic variables. The webpage included information about the study procedures and a link to the eligibility screener. The eligibility criteria were being a biological male, having prior sexual experience with sex man, being 18 years or and, and reporting a residential zip code in a Metropolitan Statistical Area MSA under study.
Eligible respondents were invited to complete our consent protocol Rosser et al. And the 6, eligible enrollees, 5, We followed a standard developed by our team de-duplication, cross-validation and data cleaning process to exclude participants with impossible or nonsensical data patterns Pequegnat et al. Participants were asked a variable number of items depending on responses and skip patterns maximum of questions.
The mean survey completion time was 71 minutes. A refuse to answer response and allowed participants to opt out of answering any item. Measures relevant to this analysis are described below. In this analysis, our primary outcome of interest was lifetime and recent enema use. Participants who reported ever using enemas and at least once in past three months were identified as recent enema users and the rest of the participants were identified as non-users.
Participants were asked to provide information about their alcohol consumption. We assessed the drinking pattern by combining three items to construct a quantity and frequency drinking typology that ranged from abstinence to frequent heavy drinking. The first question examined if the participant was a life-long abstainer or ex-drinker. Participants sex provided information on drug use in past three months. If participants indicated they engaged in anal sex in past three months with a partner s met online or offline, they were asked to report the number of partner sand the number with whom they had unprotected without condom and protected with condom sex, estimated separately.
We also created a sexual partner meeting variable meets partners only online, only offline, and both online and offline. Alpha reliability for this scale with our sample was 0. Summary statistics were used to describe the study sample and to calculate the prevalence of ever and recent enema use among the participants. We also examined if the two groups differed by behavioral and environmental factors.
Our goal was to assess the association between recent enema use and personal, behavioral, and environmental factors. We wanted to assess the relative contribution of each factor as well as the block of factors on enema use.
Therefore, we used a block regression strategy. All statistical tests were two-tailed, and all analyses were conducted in Stata 11 software StataCorp. Characteristics of the sample are summarized in Table 1. Most participants were young under 35 yearswhite non-Hispanic enemas, well-educated with a college degree or higherearned less than forty-thousand dollars, lived in an urban area and identified politically as either democrats or independents.
While about half Almost Most On the two mental health scales, most reported low internalized homonegativity and low-to-moderate levels of depression. Demographic, sexual, and behavioral characteristics of SILAS participants and recent enema use in the past 90 days. Enemas the last ninety days, Most men reported meeting their sexual partners both online and offline. Most MSM Most of the sample In terms of drugs and alcohol, Median time of using enema before receptive anal enemas was 60 minutes whereas after receptive anal sex median time to use was 30 minutes.
Among participants who reported enema use before anal sex, Water was the enemas common product used by Hygiene or cleanliness issues were and most commonly cited reasons for enema use, both before sex Most sex participants Using only water was the most prevalent type of enema reported by white participants before Commercially-prepared a saline enema product was most used by black participants.
HIV-positive participants were also more likely than HIV-negative participants to report using enema before Participants who reported a STI diagnosis in past year Participants with a recent STI diagnosis were more likely enemas Furthermore, participants who reported a recent or lifetime STI diagnosis were more likely to report using enema before Compared to non-recent enema users, recent enema users were more likely to be older, more educated, with a higher income, men of color, in a long-term relationship, married or in a domestic civil union with a man, HIV-positive MSM, and report a recent STI diagnosis.
We and investigated reasons for non-use of enemas before anal sex among those who stated they did not use them see Table 4. The three most and cited reasons for not using enemas were preferring sex to be spontaneous, sex knowing about douching, and not engaging in receptive anal sex. Then, ten variables six from model 1; and four from model 2 were entered into enemas third and final model see Table 4. To the best of our knowledge and review, this is the first large study of enema use among MSM recruited across the USA.
As reflected in the sample characteristics, the sample is fairly typical for an online study and MSM and large enough to detect demographic, behavioral, and environmental differences in enema use. With just over half of the respondents reporting they had ever used enemas, and over one third using them recently in sex, the key finding is that enema use appears common. This finding is consistent with the data from previous smaller studies over the past twenty years confirming douching as a common behavior.
Despite its frequent practice, almost a quarter of this sample reported not knowing about douching which suggests enema use remains a common yet somewhat taboo topic within the MSM community. In addition, our literature search revealed a dearth of research on this topic, and many HIV prevention programs for MSM do not appear to address it at all.
Such findings are consistent with the state of human knowledge where there are inadequate data and inconsistent recommendations concerning a potentially sensitive or embarrassing topic. The second main finding of the study is that enema use is significantly associated with HIV-positive status and a STI diagnosis. Our results are consistent with previous studies reporting similar associations de Vries et al.
The products most commonly used for douching — water, soap, and saline -- are those, which laboratory and clinical studies have identified as damaging the epithelium. The third main finding of this study is that enema use appears associated with a number of variables, which are associated with increased risk of both HIV and STI acquisition.
Our results are similar enemas Easterbrook et al. Easterbrook enemas al. That sex and bottom-identified men are more likely than tops to use enemas is also not surprising since it is the receptive partner whose anus is the site of concern.
In, addition, the potential relationship between condom use and enema use should be examined in further details. Any educational attempts to reduce the use of enemas will need to address this practical consideration. Three other findings are interesting to consider together. The use of commercial products by HIV prevention researchers may consider at least three approaches to addressing enema risk. We doubt more of the same advice will change douching behavior. A risk reduction approach would entail identifying a less toxic or non-toxic substance e.
This approach holds promise and should be considered. A third approach is to recognize that the data on water-based enemas raises a broader question of the effects of all water-based products on the sex epithelium. Water-based lubricants have been a staple of HIV prevention education, heavily promoted to MSM for all sexual behavior, including anal intercourse, because of their compatibility with latex condoms.
