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Try out PMC Labs and tell us what you think. Learn More. However, few studies have explored enema use practices. Through online surveys, we examined personal, behavioral, and environmental 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 sex 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 PEG-ES enemas.
Similarly, in a study comparing an iso-osmolar and a hyperomolar commercial lubricant, epithelial denudation in the distal colon was ificantly 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, While both studies found similarsuggesting 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 enema lover. Carballo-Dieguez et al. On all these measures, HIV-positive participants were ificantly 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, the 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 enema lover provide some of the first data on the douching practices of MSM, enema lover 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 web 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 a man, being 18 years or older, 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. Of the 6, eligible enrollees, 5, Enema lover 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 of items depending on responses and skip patterns maximum of questions.
The mean survey completion time was 71 minutes. A refuse to answer response option 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 also provided information on drug use in past three months. If participants indicated they engaged enema lover anal sex in past three months with a partner s met online or offline, they were asked to report the of partner sand the 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 enema loverwell-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. In 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 sex 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 most common product used by Hygiene or cleanliness issues were the most commonly cited reasons for enema use, both before sex Most black 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 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 also 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 commonly cited reasons for not using enemas were preferring sex to be spontaneous, not 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 the 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 of 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 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 ificantly associated with Enema lover status and a STI diagnosis. Our are consistent with 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 of variables, which are associated with enema lover risk of both HIV and STI acquisition.
Our are similar to Easterbrook et al. Easterbrook et al. That versatile- 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 anal 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.
However, we could find no studies examining the effects of water-based lubricants on the anal enema lover, a gap in research that needs to be filled. The data on the negative effects of water-based enemas suggests that HIV prevention, as a field, may need to step back to consider not just the effects of such products on the condom, but also on the anal epithelium.
Prior to community-based agencies developing educational materials about enemas, there needs to be national leadership in establishing evidence-based recommendations, and then issuing new recommendations based on the current evidence. There are three principal limitations to consider when evaluating these data. First, this is a cross-sectional study and, as such, causality enema lover be assumed. Second, all the data are by self-report. Because of the socially-sensitive nature of the topic, we caution that rates are likely under-estimates of the true incidence of use.
Third, while a strength of this study is that it reports the first large sample to investigate enema use in a general sample of MSM, the sample was neither a national sample nor a representatively-chosen one. Hence, the generalizability of findings is not known. We highlight four potential directions for future research. First, clinical research should study the effects of douching as undertaken by MSM on the anal squamous and rectal columnar mucosa. Second, depending on the from these clinical studies, the frequent use of enemas prior to sex by many MSM suggests the development and promotion of a non-damaging enema for use in anal sex is needed and should be prioritized.
Such a product may also have a major role to play as a rectal microbicide. Two single items to examine enema use before and after anal sex should be sufficient to monitor douching behavior. Fourth, in terms of prevention education, the seemingly enema lover recommendations that water-based lubricant is good for anal sex but water-based enemas are dangerous because they damage the anal lining need to be reconciled into a single consistent message.
Once this apparent contradiction is resolved, then new recommendations for enema use can be developed and testing the effects of enema education can be proposed. National Center for Biotechnology InformationU. Arch Sex Behav. Author manuscript; available in PMC May 1. Syed W NoorPh. Author information Copyright and information Disclaimer.
Copyright notice. The publisher's final edited version of this article is available at Arch Sex Behav. See other articles in PMC that cite the published article. Enema use In this analysis, our primary outcome of interest was lifetime and recent enema use. Alcohol and substance use Participants were asked to provide information about their alcohol consumption. Data Analysis Summary statistics were used to describe the study sample and to calculate the prevalence of ever and recent enema use among the participants.
Table 1 Demographic, sexual, and behavioral characteristics of SILAS participants and recent enema use in the past 90 days.Enema lover
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