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

Enema use or douching is a risk factor for HIV/STI in men who have sex with men (MSM). However, few studies have explored enema use practices. 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 = 4,992) recruited from 16 U.S. cities. Through online surveys, we examined personal, behavioral, and environmental factors associated with enema use. Most (52 %) participants reported having douched at least once and 35 % reported douching within the last 3 months. While most (88 %) reported enema use before receptive anal sex, 28 % douched after receptive anal sex. Most participants (65 %) used water to douche, 24 % added salt, soap, and/or antibacterial products to water, and 30 % reported using commercially available products. Being a man of color, HIV-positive, diagnosed with an STI, identifying as "versatile" in sex, and having more than two unprotected sex partners were significantly associated with recent enema use. Douching behavior appears closely associated with HIV/STI risk. Douching with water may be a concern since it may increase HIV/STI infection by damaging the epithelium. Development and promotion of a non-damaging, non-water based enema specifically for use in anal sex are 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.