Enema use among men who have sex with men: A behavioral epidemiologic study with implications for HIV/STI prevention

Background:Enema use or douching has been reported as a risk factor for several sexually transmitted infections (STIs) including HIV in men who have sex with men (MSM). Methods:We examined the frequency of enema use, type of products used, and reasons to use and not to use before and after receptive anal sex in a large sample of MSM (N=4992) recruited from sixteen US cities through the Internet. Through online surveys, we examined personal, behavioral, and environmental factors associated with recent enema use in past three months. Results:Of the sample, 52% reported ever using rectal enema/douching and 35% reported douching within last three months. While most men (88%) reported enema use before receptive anal sex, 28% reported using it after receptive anal sex. Most participants (65%) reported using water for douching, with around a quarter (24.4%) reporting adding salt, soap, and antibacterial product with water. Being a man of color (p<0.05); being HIV-positive (p<0.001); being diagnosed with an STI (p<0.01); identifying as “versatile” in sex (p<0.001); and having more than two unprotected sex partners (p<0.001) were significantly associated with recent enema use. Conclusions:Results suggest douching behavior with water products is common. Since douching with water may increase HIV and STI infection by damaging the epithelium, development and promotion of a non-damaging, non-water based enemas specifically for use in anal sex should be prioritized. In addition, the seemingly contradictory recommendations that water-based lubricant is recommended for anal sex but water-based enemas are dangerous need to be reconciled into a single consistent message.