Rectal Douching Injury in Men Who Have Sex With Men

Heather Boerner

November 21, 2019

PORTLAND, Oregon — Jamey Scott, RN, was meeting with a patient at the Ryan White clinic where she works in Richmond, Virginia, when he mentioned that he "douched" in preparation for sex.

The word stopped her, but Scott kept moving. Her training in HIV taught her that "you can't bat an eye" when patients say things that surprise you. But she did need to know more.

"I asked, 'Are you using like a Summer's Eve–type product or are you using a Fleet [enema]?" she said. "I just put it out there. If they're going to be bold enough to tell me, I'm going to be bold enough to ask."

According to data presented at the Association of Nurses in AIDS Care 2019 Conference, half the gay and bisexual black men in the Deep South have used an enema — or "rectal douche" as it's called in the community — although what they are using to douche is unclear.

For men who are receptive partners, it's even more common. This is despite the conventional wisdom that no one should regularly use an enema unless they have a neurologic condition, such as multiple sclerosis or spinal cord injuries, that necessitates it.

Data also show that enemas, along with other sexual-hygiene practices, could increase the risk for HIV transmission and other sexually transmitted infections (STIs). But there are formulations that are safer, and research is ongoing into medicated formulations.

Increased HIV and STI Risk

This is where healthcare providers come in, said Derek Dangerfield, PhD, from the Johns Hopkins School of Nursing in Baltimore. They can help men who are going to douche anyway do so in a way that's less disruptive to the microbiome and the fragile rectal lining.

"A lot of guys are learning to do this on their own or they are learning through pornography," said Dangerfield. "What we need are harm-reduction strategies for this phenomenon."

Most clinicians see the rectum as just another part of the colorectal system, but for some patients, it's much more than that, said Jonathan Baker, PA-C, from the Laser Surgery Center in New York City.

A lot of guys are learning to do this on their own or they are learning through pornography.

"More than 30% of the general population sees the anus and rectum as sexual organs. And so does my community," said Baker, who is gay, citing survey results.

Baker, who goes by @RectalRockStar on Instagram, treats his patients the way a gynecologist might approach comprehensive sexual health. Patients who report receiving anal sex undergo anal Pap tests to detect high-risk human papillomavirus (HPV), gonorrhea, and chlamydia. The HPV test is especially important for people living with HIV because rates of anal cancer associated with HPV are elevated in that population, he explained.

In addition, Baker said he counsels his patients on how to care for the delicate rectal mucosa, which is only one layer of cells thick, unlike the vaginal lining, which is multiple layers thick.

"It's a fragile lining and it does get damaged easily," he said. "It probably gets damaged from more things than we even realize."

The rectum does have its own line of defense, and you only have to look into a microscope to see it, said Craig Hendrix, MD, from the Johns Hopkins School of Medicine in Baltimore.

There, you'll find a "lush and rich" lining, a row of protective epithelial cells that also make protective mucin, said Hendrix, who studies pharmacokinetics in drug development and is currently working on a medicated douche to prevent the transmission of HIV.

The key is to keep that protective lining in place. Some formulations do that, such as the electrolyte-water injection Normosol-R, which Hendrix's team used to test douche safety.

But many products used as enemas or anal douches, including some of the most popular, don't. And with a lining that's just one layer thick, there is little room for error.

The process of introducing hyperosmolar fluids into the rectum, for instance, means that fluid is forced through the membrane faster and faster. And the lush epithelial layer "literally disappears," said Hendrix. "Most of the epithelial cells are gone, and there's no mucin."

The first step in sexual health is to protect that epithelial layer and mucin, he explained.

Patients and providers usually don't know how to do that, said Baker. And that can lead to layers of risk, when patients, unaware of the impact of hyperosmolar preparations, pile one on top of another.

Take lubricants, for example. Lubricants can reduce friction during sex, preventing tears that could make way for HIV and STI transmission. Recent data suggest that they also reduce the risk of condoms slipping and breaking.

But many lubricants — such as KY Jelly, Astroglide, and Wet Original — are themselves hyperosmolar, as is the nonoxynol-9 spermicide, according to a 2007 study Hendrix was involved in. That team showed that hyperosmolar lubricants "denuded" the cell lining.

However, iso-osmolar lubricants do exist, including Good Clean Love and PRÉ, according to one small study.

Now add in enemas and rectal douching to the equation.

Like lubricants, not all enemas are created equal. And researchers don't really know what patients mean when they say "douching," Dangerfield said.

Douching Concoctions

The people who attended his session confirmed this, reporting the types of douches they knew their patients used, which included commercially available sodium phosphate enemas, like those sold under the brand name Fleet; homemade concoctions of water or soap and water; and mechanical apparatuses that attach to one's shower and fill the rectum with water.

There are also "other feminine hygiene products," like Summer's Eve, which contains vinegar, said Maureen Scahill, NP, RN, from the University of Rochester in New York. "I've never had a patient tell me they use one, but that's a question worth exploring."

And that's to say nothing of laxatives, suppositories, and the use of multiple approaches at one time, added Baker.

"I've heard of all kinds of behaviors — from laxatives to Imodium, suppositories, enemas, shower attachments, and high-end heated bidets — although I do fully support bidets," he said. "People sometimes add things like lemon juice or vinegar, which are acidic and may lead to even more mucosal damage."

Considerable evidence shows that sodium phosphate enemas, like the kind sold commercially as Fleet, have been associated with the dysregulation of electrolytes in the bowel, hyperphosphatemia, severe metabolic disorders, renal damage, and even death. These kinds of hyperosmolar preparations are as bad for the rectal lining in douche form as they are in lubricant form.

So it should be no surprise that rectal douching is associated with an elevated risk for HIV transmission and the acquisition of STIs, such as chlamydia and gonorrhea. One study showed that people who used enemas at least once a week were 3.5 times as likely to already have a rectal infection as those who never used enemas (odds ratio [OR], 3.57; P = .001), and nearly four times as likely to acquire a rectal infection during the study (OR, 3.87; P = .001).

In any case, repeatedly clearing out the rectal cavity increases inflammation, can disrupt the absorption of vitamins, and is associated with increases in the risk for HIV (OR, 2.8) and for STIs (OR, 2.5).

This is where Dangerfield, a sociologist by training, comes in. His interest started simply: "We know the biology; I'm interested in who these folks are."

So Dangerfield partnered with DeMarc Hickson, PhD, principle investigator of the Ecological Study of Sexual Behaviors and HIV/STI Among African American Men Who Have Sex With Men in the Southeastern United States (the MARI study), to figure out who these particular gay and bisexual men are, and how they use anal douching.

Although studies have identified that up to 88% of gay and bisexual men have anally douched, and that up to 64% have done so recently, there are few data on black gay men and black women of trans experience in the Deep South, the people Dangerfield is interested in.

Sex, Sexuality, and Stigma

"Most studies have majority-white samples or are conducted in a European context," he said. But "we all know that black men who have sex with men are disproportionately impacted by HIV. And interestingly, over half of trans women living with HIV are black."

Hickson found that in a cohort of 386 black participants (5.5% of whom were women of trans experience) from Jackson, Mississippi and Atlanta, 52.9% had used a rectal douche at some point — 30.8% at least six times and 28.3% three to five times.

For his part, Dangerfield asked all kinds of demographic questions: age, recent history of STIs, HIV status, income, education level, number of sexual partners, and condom use.

When he analyzed these data for associations with douching, there weren't any. The only thing that affected the likelihood of douching was the role the person played during sex. In the parlance of the gay community, being "versatile" or a "bottom" during sex means sometimes or always being the receptive partner during sex, and being a "top" means always being the insertive partner.

People who said they were versatile were 2.46 times as likely to engage in rectal douching as men who identified as tops. And bottoms were 2.36 times as likely to engage in rectal douching as tops.

Compounded Risk

What emerged was one explanation for the variability in HIV risk in a group that already has a 50-50 chance of acquiring HIV.

There are structural reasons for high rates of HIV in black Americans, like lack of insurance, the inequitable use of HIV pre-exposure prophylaxis, and low rates of viral suppression.

Then add in being a bottom or versatile.

Then layer in repeated studies that show that black gay men are more likely to use condoms than their white counterparts and the damage to the rectal lining that can happen from sex without enough lubrication, or the use of the wrong kind of lubricant.

And then also include the wrong kind of rectal douching, and you have a fertile environment that HIV can exploit.

"This is really nuanced and critical," he said. "This high-risk behavior is going on among folks who are arguably at higher risk. And it creates a high-risk compound factor for STIs and HIV."

The point is not to create alarm or tell men that they can't douche or have anal sex; "that wouldn't be culturally responsive," Dangerfield said. And it probably wouldn't work.

Culturally Responsive Care

Dangerfield's study of men who reported douching showed that among the reasons they cite for doing so are that a partner had asked them to, that they believed that it might increase pleasure, and that douching after sex might prevent transmission of STIs.

More than that, Baker has had patients who have been "blacklisted" from their small, sexual networks for having an accident during sex.

"It can be extremely stigmatizing," he explained. "For some patients, it becomes a necessity. So ignoring it isn't going to help anyone."

In Baker's office, he starts a sexual history with all of this in mind. He asks about sexual positioning, lube, and douche use. When his patients say they "prepare for sex," he asks them how, he said.

Although he informs them that rectal douching, especially regularly, isn't recommended, he sees the conversation as a teaching moment. He recommends against Fleet enemas, and instead suggests simple water enemas using a bulb syringe or an emptied Fleet enema bag.

If the patient uses a shower attachment to insert water into their rectum, he encourages them to look for an inch — that is, to set the water so it starts to separate and cascade at that point — and then gently insert the nozzle.

"We are trying to apply the same amount of liquid as we would with a bulb syringe," he said. More than that and the sheer pressure of the water could cause damage.

Baker also recommends water-soluble or silicone lubricants for people who use condoms and oil-based lubricant for people who do not.

But his favorite thing to talk about, and one that he saves for last, is fiber. He recommends a fiber-rich diet anyway, but also recommends a once- or twice-daily dietary fiber supplement.

"In an ideal world, you'd do all this with dietary fiber, but for a lot of patients, that's probably not realistic," he said. "It's all about harm reduction."

These kinds of conversations can be done in minutes, Dangerfield said. And they could improve the sexual health of patients.

"It's not a heavy lift," he said. "Just understanding this component and how it adds to sexual risk in the context of one's sexuality could be really critical."

Association of Nurses in AIDS Care (ANAC) 2019. Presented November 8, 2019.

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