Original research article
Douching practices among female sex workers in Phnom Penh, Cambodia
International Journal of STD & AIDS 2015, Vol. 26(4) 238–242 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0956462414533098 std.sagepub.com
Thanh Cong Bui1, Ly TH Tran2, Michael W Ross1 and Christine M Markham1
Summary Several studies indicate that douching has few benefits but numerous adverse health outcomes, including increased risk for sexually transmitted infections and HIV. No published study explores douching practices among Cambodian female sex workers. This report provides preliminary data about the prevalence and frequency of douching among female sex workers in Phnom Penh, Cambodia. Survey data were obtained from 81 female sex workers who were taken into custody due to engagement in commercial sex from March to June 2011. Results showed that 91% of participants douched. The mean numbers of times douched before sex and after sex per 10 sex episodes were 4.43 (SD ¼ 3.87) and 4.63 (SD ¼ 3.94), respectively. Half of the participants thought that douching could help to prevent sexually transmitted infections including HIV; 24% were unsure about this. Usually, douching after sex was associated with ever obtaining an HIV test (p ¼ .012) and was marginally associated (although not statistically significant) with a higher average number of clients per week (p ¼. 063) and consistent condom use with clients (p ¼ .053). This suggests that these practices may be related to individual perceptions of sexually transmitted infections/HIV risk or susceptibility. Given the commonness of douching and related misperceptions among Cambodian female sex workers, future studies and interventions are needed to prevent adverse health problems.
Keywords Intravaginal cleansing, douching, sexually transmitted infections, HIV, AIDS, female sex workers, Cambodia Date received: 6 December 2013; accepted: 30 March 2014
Introduction Vaginal douching or intravaginal cleansing with liquids has been associated with adverse health outcomes in numerous studies.1 The health consequences of douching include increased risk of bacterial vaginosis,2–5 pelvic inflammatory disease,6 bacterial sexually transmitted infections (STIs),7 non-regression of low-grade squamous intraepithelial lesion8 and cervical cancer,9 after controlling for demographics and sexual behaviours. Intravaginal cleansing also increases the risk of viral STIs such as HSV-2,10 HPV11 and HIV-1 infection.12 In a meta-analysis of 14,874 sub-Saharan African women from 13 prospective longitudinal studies, Low et al.12 found that intravaginal use of cloth or paper and intravaginal cleaning with soap were associated with HIV acquisition (pooled adjusted hazard ratios 1.47, 95% CI 1.18–1.83 and 1.24, 95% CI 1.01–1.53, respectively). Findings from a systematic review of 15 studies conducted in sub-Saharan Africa and the US suggested that the plausible pathway between
intravaginal cleansing and HIV infection was through a higher risk of bacterial vaginosis or vaginal bacterial infections (e.g. Trichomonas vaginalis) that increased susceptibility to HIV infection.13,14 Additionally, vulnerability to HIV infection has been hypothesised to result from physical abrasions or disruption of the vaginal stratified squamous epithelium, which may be caused by douching equipment, cloth used in wiping15,16 or chemicals used (e.g. soaps, detergents, antiseptics).17 1 Division of Health Promotion and Behavioral Sciences, School of Public Health, The University of Texas - Health Science Center at Houston, Houston, TX, USA 2 Division of Epidemiology, Human Genetics & Environmental Sciences, School of Public Health, The University of Texas – Health Science Center at Houston, Houston, TX, USA
Corresponding author: Thanh Cong Bui, Division of Health Promotion and Behavioral Sciences, School of Public Health, The University of Texas - Health Science Center at Houston, 7000 Fannin Street, UCT 2610C, Houston, TX, 77030, USA. Email: [email protected]
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Women with lower levels of education in Africa and young urban women in Asia were more likely to douche.18 Common reasons for douching included hygienic purposes (e.g. perceived cleanliness, eliminating vaginal odor), removing vaginal symptoms (e.g. itching, discharge and irritation), preventing or self-treating suspected infections, enhancing sexual pleasure and expectations from sexual partners.1,18–20 Aside from hygienic outcomes such as feelings of cleanliness or eliminating vaginal odor, no health benefits of intravaginal cleansing or douching have been documented. Thus, douching is generally discouraged.1 Despite several health problems due to intravaginal cleansing, only one study has explored this practice in Cambodia.21 With a sample of 451 women aged 15–49 attending 17 health clinics in Cambodia, this study found that 76.7% of participants douched at least once a week, 65.6% douched more than once a day, and 88.4% used only water for douching. Most previous studies on douching among female sex worker (FSWs) populations suggested that douching was very common and frequent. For example, the prevalence of intravaginal cleansing was as high as about 90% in Kenyan FSWs,2,12 76% in high-risk women in Tanzania12 and 65% in Chinese FSWs.22 It has also been documented that vaginal douching in FSWs was associated with lower condom use,22 perhaps due to the belief that douching could help to prevent STIs. Nevertheless, no published study explores douching practices among Cambodian FSWs. Therefore, this brief report aims to provide preliminary data about the prevalence and the frequency of douching among FSWs in Phnom Penh, Cambodia.
received ethical approvals from the Phnom Penh Department of Social Affairs, Veteran & Youth Rehabilitation, and from the University of Texas Health Science Center’s Institutional Review Board (HSC-SPH-10-0689). Participants were asked about their demographic and sex-work characteristics (e.g. age, education level, age engaging in the sex trade, locations for sex work and average number of clients per week).23 Consistent condom use with clients was assessed on a 5-point Likert scale, ranging from 1 ¼ none to 5 ¼ always. This variable was dichotomised as ‘always’ versus all other responses in current analysis. Participants were asked if they had ever been diagnosed with several named STIs, including HIV. Douching was defined to participants as washing inside the vagina, by such ways as using a device to introduce a stream of water/solutions or using their fingers with water/solutions. Participants were asked whether they douched (with ‘yes/no’ responses), how many times they douched on average before/after every 10 acts of sexual intercourse and what solutions they mostly used for douching.24 Participants were also asked whether they thought that douching could prevent STIs including HIV, with responses on a 5-point Likert scales of ‘absolutely yes, yes, not sure, no, and absolutely no.’ Chi square tests were used to examine associations between douching and demographic or sex-work characteristics; Fischer’s exact tests were used when >25% of cells had an expected observation of less than five. Statistical analyses were performed using SPSS Statistics 20.0 (http://www-03.ibm.com/software/pro ducts/en/spss-stats-standard/).
Methods
Results
This report employed data from a parent cross-sectional survey which aimed to examine condom use and negotiation strategies among FSWs in Phnom Penh, Cambodia. Details of this survey have been described elsewhere.23 In brief, 81 FSWs who were taken into custody due to engagement in commercial sex from March to June, 2011 were recruited. Inclusion criteria were: female, at least 18 years old and able to communicate in Khmer, Vietnamese or English. Eligible FSWs were contacted and invited to participate in the survey during their stay at the Phnom Penh Department of Social Affairs, Veteran & Youth Rehabilitation, waiting for referrals to receive social support from social centers or nongovernment organisations. Face-to-face interviews in Khmer (Cambodia’s national language) were conducted in a private setting by Cambodian trained social workers. Informed consent was obtained from all participants prior to the interviews. The study
Demographic characteristics of the participants were reported in our preceding publication.23 In brief, participants’ mean age was 25 years (SD ¼ 5.5), 40% did not attend elementary school, 91.4% were Khmer and the remaining were Vietnamese. Seventy-five percent were street-based sex workers and 35% had been engaged in sex work for 1 year or less. The average number of clients per week was eight. Eighty-five percent reported always using a condom with clients, 53% reported ever being diagnosed with an STI, 13.6% reported being HIV-positive and 21% had never been tested for HIV. Ninety-one percent (n ¼ 70) of participants douched. The mean numbers of times douched before sex and after sex per 10 sex episodes were 4.43 (SD ¼ 3.87) and 4.63 (SD ¼ 3.94), respectively. Of those who douched, 80% used store-bought solutions, 10% used water and salt and 6.7% used water and soap. Responding to the question whether they thought
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douching can prevent STIs including HIV, 42.7% answered ‘absolutely yes,’ 6.7% said ‘yes’ and 24% were unsure. This belief was not associated with age, education level, years in the sex trade and consistent condom use with clients (p values >. 340). The distribution of douching frequencies after sex per 10 sex episodes showed that 68.8% reported douching five times or less, 31.2% reported 8–10 times. Thus, we dichotomised the values for this variable by grouping an average of 8–10 times as ‘usually douched after sex’ versus the other values. This dichotomised variable ‘usually douched after sex’ was used to investigate binary associations between frequencies of douching after sex and demographic or behavioural characteristics (Table 1). Usually douching after sex was not associated with age, ethnicity, education level, being a street-based sex worker, being a sex worker for one year or less, ever being diagnosed with a STI and HIV status. Usually douching after sex was not associated with the belief that douching could help to prevent STIs. However, usually douching after sex was associated with ever obtaining an HIV test (p ¼ .012) and was marginally associated (although not statistically significant) with a higher average number of clients per week (p ¼ .063) and consistent condom use with clients (p ¼ .053).
Discussions These preliminary data revealed that 91% of FSWs in Phnom Penh, Cambodia, douched and about half of FSWs believed that douching could help to prevent STIs including HIV. Existing studies and systematic reviews have documented almost no benefits of intravaginal cleansing but several adverse health outcomes, including STIs/HIV infection. Therefore, interventions to reduce douching practices in this population are needed. In order to develop appropriate and effective interventions for this behaviour, further studies are needed to examine characteristics of intravaginal cleansing (e.g. timing), other related intravaginal practices (e.g. wiping) and determinants of these practices. In this analysis, douching after sex was performed regardless of the personal belief about whether this practice could prevent STIs. This suggests that FSWs might perform douching because of other reasons as suggested in literature, such as outcome expectancies (e.g. hygiene purposes, sexual pleasure), incorrect beliefs related to douching (e.g. therapeutic value) or perceived expectations from sexual partners or clients.18,24 The association between intravaginal practices and condom use has been a concern to many researchers.19 In one particular aspect, if women believe that douching can help to prevent STIs including HIV, they may substitute douching for condom use to
Table 1. Associations between usually douching after sex and demographic or sex-work characteristics.
Variables Age 25 >25 Ethnicity Khmer Vietnamese Highest education level Did not go to elementary school Other Location types of sex workers Street-based Other Years in sex trade 1 year >1 year Average numbers of clients per week 7 >7 Consistent condom use with clients No Yes Ever being diagnosed with a STI No Yes Ever had an HIV test No Yes HIV status Negative Positive Believed that douching could prevent STIs Absolutely yes/Yes Not sure No/Absolutely no
Usually douched after sexa, n (%) p Values
14 (27.5) 11 (37.9)
.331
24 (32.9) 1 (14.3)
.292
15 (31.2) 10 (31.2)
.998
20 (33.0) 5 (25)
.486
8 (40.0) 12 (30.8)
.478
11 (23.9) 13 (40.6)
.063
1 (8.3) 24 (35.8)
.053
13 (37.1) 10 (24.4)
.170
1 (6.2) 24 (37.5)
.012
21 (39.6) 3 (27.3)
.341
13 (35.1) 6 (33.3) 6 (30.0)
.926
STI: sexually transmitted infection. a Defined as douching 8–10 times on average after every 10 acts of sexual intercourse. Bold text denotes the value is the significance value (p-value).
prevent STIs. Our results suggest the opposite association: those who reported consistent condom use were more likely to usually douche after sex. A similar association was observed for obtaining an HIV test. These might be due to individual perceptions of STI/HIV risk or susceptibility, e.g. those who perceived themselves at a high risk for STI/HIV or cared more about their
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health might be more likely to douche after sex, to consistently use a condom and to get HIV tests. These psychological constructs need to be investigated in future studies in order to guide interventions. This analysis has some limitations. Because the primary aims of the parent study were not about douching, measures of douching and of its potentially associated socio-psychological determinants were limited. The moderate sample size and the low prevalence of those FSWs who did not douche might have reduced the statistical power to detect associations in bivariate analyses. Although recruitment methods significantly aided to the practicality and feasibility of this study, they may have constrained the representativeness and generalisability of results. In conclusion, despite some limitations, these preliminary data indicate that intravaginal cleansing among FSWs in Phnom Penh, Cambodia, was very common. Misperceptions related to intravaginal cleansing were presumably common as well. Current literature has indicated almost no benefits but several adverse health consequences due to intravaginal cleansing. Future studies about intravaginal practices in this population and appropriate interventions are needed in order to avoid potential short- and long-term health problems associated with these practices. Acknowledgements Thanh C Bui’s post-doctoral training has been supported by the UTHealth, School of Public Health, Center for International Training on AIDS Research (funded by NIH grant # AITRP D43 TW007669) and the UTHealth Innovation for Cancer Prevention Research (funded by Cancer Prevention and Research Institute of Texas grant #RP101503). Ly T Tran’s education has been supported by the Vietnam Education Foundation Fellowship, Philanthropic Educational Organization International Peace Scholarship, American Association of University Woman and Margaret McNamara Memorial Fund. We especially thank the staff at the Psycho-Social Service Association, Activities Social Welfare Office, Department of Social Affairs, Veteran & Youth Rehabilitation in Phnom Penh for their assistance with data collection. The content of the manuscript is solely the responsibility of the authors and does not necessarily represent the official views of the funding agencies.
Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this
article: This research received internal funding from the UTHealth, School of Public Health, Center for International Training on AIDS Research (externally funded by NIH grant # AITRPD43 TW007669).
References 1. Cottrell BH. An updated review of evidence to discourage douching. MCN Am J Matern Child Nurs 2010; 35: 102–107. 2. Hassan WM, Lavreys L, Chohan V, et al. Associations between intravaginal practices and bacterial vaginosis in Kenyan female sex workers without symptoms of vaginal infections. Sex Transm Dis 2007; 34: 384–388. 3. Holzman C, Leventhal JM, Qiu H, et al. Factors linked to bacterial vaginosis in nonpregnant women. Am J Public Health 2001; 91: 1664–1670. 4. Myer L, Kuhn L, Stein ZA, et al. Intravaginal practices, bacterial vaginosis, and women’s susceptibility to HIV infection: epidemiological evidence and biological mechanisms. Lancet Infect Dis 2005; 5: 786–794. 5. Ness RB, Hillier SL, Richter HE, et al. Douching in relation to bacterial vaginosis, lactobacilli, and facultative bacteria in the vagina. Obstet Gynecol 2002; 100: 765–772. 6. Simpson T, Merchant J, Grimley DM, et al. Vaginal douching among adolescent and young women: more challenges than progress. J Pediatr Adolesc Gynecol 2004; 17: 249–255. 7. Tsai CS, Shepherd BE and Vermund SH. Does douching increase risk for sexually transmitted infections? A prospective study in high-risk adolescents. Am J Obstet Gynecol 2009; 200: 38.e1–38.e8. 8. Chu T-Y, Hsiung CA, Chen C-A, et al. Post-coital vaginal douching is risky for non-regression of low-grade squamous intraepithelial lesion of the cervix. Gynecol Oncol 2010; 120: 449–453. 9. Zhang J, Thomas AG and Leybovich E. Vaginal douching and adverse health effects: a meta-analysis. Am J Public Health 1997; 87: 1207–1211. 10. Wang H, Wang N, Chen RY, et al. Prevalence and predictors of herpes simplex virus type 2 infection among female sex workers in Yunnan Province, China. Int J STD AIDS 2008; 19: 635–639. 11. Sun CA, Hsiung CA, Lai CH, et al. Epidemiologic correlates of cervical human papillomavirus prevalence in women with abnormal Pap smear tests: a Taiwan cooperative oncology group (TCOG) study. J Med Virol 2005; 77: 273–281. 12. Low N, Chersich MF, Schmidlin K, et al. Intravaginal practices, bacterial vaginosis, and HIV infection in women: individual participant data meta-analysis. PLoS Med 2011; 8: e1000416. 13. Hilber AM, Francis SC, Chersich M, et al. Intravaginal practices, vaginal infections and HIV acquisition: systematic review and meta-analysis. PLoS One 2010; 5: e9119. 14. McClelland RS, Sangare L, Hassan WM, et al. Infection with Trichomonas vaginalis increases the risk of HIV-1 acquisition. J Infect Dis 2007; 195: 698–702. 15. Kilmarx PH, Limpakarnjanarat K, Supawitkul S, et al. Mucosal disruption due to use of a widely-distributed
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International Journal of STD & AIDS 26(4) commercial vaginal product: potential to facilitate HIV transmission. AIDS 1998; 12: 767–773. Shattock RJ and Moore JP. Inhibiting sexual transmission of HIV-1 infection. Nat Rev Microbiol 2003; 1: 25–34. van de Wijgert JHHM, Morrison CS, Cornelisse PGA, et al. Bacterial vaginosis and vaginal yeast, but not vaginal cleansing, increase HIV-1 acquisition in African women. J Acquir Immune Defic Syndr 2008; 48: 203–210. Hull T, Hilber AM, Chersich MF, et al. Prevalence, motivations, and adverse effects of vaginal practices in Africa and Asia: findings from a multicountry household survey. J Womens Health (Larchmt) 2011; 20: 1097–1109. Hilber AM, Hull TH, Preston-Whyte E, et al. A cross cultural study of vaginal practices and sexuality: implications for sexual health. Soc Sci Med 2010; 70: 392–400. Lees S, Zalwango F, Andrew B, et al. Understanding motives for intravaginal practices amongst Tanzanian
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and Ugandan women at high risk of HIV infection: the embodiment of social and cultural norms and well-being. Soc Sci Med 2014; 102: 165–173. Heng LS, Yatsuya H, Morita S, et al. Vaginal douching in Cambodian women: its prevalence and association with vaginal candidiasis. J Epidemiol 2010; 20: 70–76. Wang B, Li X, Stanton B, et al. Vaginal douching, condom use, and sexually transmitted infections among Chinese female sex workers. Sex Transm Dis 2005; 32: 696–702. Bui TC, Markham CM, Tran LT, et al. Condom negotiation and use among female sex workers in Phnom Penh, Cambodia. AIDS Behav 2013; 17: 612–622. Markham CM, Tortolero SR, Addy RC, et al. Factors associated with frequent vaginal douching among alternative school youth. J Adolesc Health 2007; 41: 509–512.
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Douching practices among female sex workers in Phnom Penh, Cambodia
International Journal of STD & AIDS 2015, Vol. 26(4) 238–242 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0956462414533098 std.sagepub.com
Thanh Cong Bui1, Ly TH Tran2, Michael W Ross1 and Christine M Markham1
Summary Several studies indicate that douching has few benefits but numerous adverse health outcomes, including increased risk for sexually transmitted infections and HIV. No published study explores douching practices among Cambodian female sex workers. This report provides preliminary data about the prevalence and frequency of douching among female sex workers in Phnom Penh, Cambodia. Survey data were obtained from 81 female sex workers who were taken into custody due to engagement in commercial sex from March to June 2011. Results showed that 91% of participants douched. The mean numbers of times douched before sex and after sex per 10 sex episodes were 4.43 (SD ¼ 3.87) and 4.63 (SD ¼ 3.94), respectively. Half of the participants thought that douching could help to prevent sexually transmitted infections including HIV; 24% were unsure about this. Usually, douching after sex was associated with ever obtaining an HIV test (p ¼ .012) and was marginally associated (although not statistically significant) with a higher average number of clients per week (p ¼. 063) and consistent condom use with clients (p ¼ .053). This suggests that these practices may be related to individual perceptions of sexually transmitted infections/HIV risk or susceptibility. Given the commonness of douching and related misperceptions among Cambodian female sex workers, future studies and interventions are needed to prevent adverse health problems.
Keywords Intravaginal cleansing, douching, sexually transmitted infections, HIV, AIDS, female sex workers, Cambodia Date received: 6 December 2013; accepted: 30 March 2014
Introduction Vaginal douching or intravaginal cleansing with liquids has been associated with adverse health outcomes in numerous studies.1 The health consequences of douching include increased risk of bacterial vaginosis,2–5 pelvic inflammatory disease,6 bacterial sexually transmitted infections (STIs),7 non-regression of low-grade squamous intraepithelial lesion8 and cervical cancer,9 after controlling for demographics and sexual behaviours. Intravaginal cleansing also increases the risk of viral STIs such as HSV-2,10 HPV11 and HIV-1 infection.12 In a meta-analysis of 14,874 sub-Saharan African women from 13 prospective longitudinal studies, Low et al.12 found that intravaginal use of cloth or paper and intravaginal cleaning with soap were associated with HIV acquisition (pooled adjusted hazard ratios 1.47, 95% CI 1.18–1.83 and 1.24, 95% CI 1.01–1.53, respectively). Findings from a systematic review of 15 studies conducted in sub-Saharan Africa and the US suggested that the plausible pathway between
intravaginal cleansing and HIV infection was through a higher risk of bacterial vaginosis or vaginal bacterial infections (e.g. Trichomonas vaginalis) that increased susceptibility to HIV infection.13,14 Additionally, vulnerability to HIV infection has been hypothesised to result from physical abrasions or disruption of the vaginal stratified squamous epithelium, which may be caused by douching equipment, cloth used in wiping15,16 or chemicals used (e.g. soaps, detergents, antiseptics).17 1 Division of Health Promotion and Behavioral Sciences, School of Public Health, The University of Texas - Health Science Center at Houston, Houston, TX, USA 2 Division of Epidemiology, Human Genetics & Environmental Sciences, School of Public Health, The University of Texas – Health Science Center at Houston, Houston, TX, USA
Corresponding author: Thanh Cong Bui, Division of Health Promotion and Behavioral Sciences, School of Public Health, The University of Texas - Health Science Center at Houston, 7000 Fannin Street, UCT 2610C, Houston, TX, 77030, USA. Email: [email protected]
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Women with lower levels of education in Africa and young urban women in Asia were more likely to douche.18 Common reasons for douching included hygienic purposes (e.g. perceived cleanliness, eliminating vaginal odor), removing vaginal symptoms (e.g. itching, discharge and irritation), preventing or self-treating suspected infections, enhancing sexual pleasure and expectations from sexual partners.1,18–20 Aside from hygienic outcomes such as feelings of cleanliness or eliminating vaginal odor, no health benefits of intravaginal cleansing or douching have been documented. Thus, douching is generally discouraged.1 Despite several health problems due to intravaginal cleansing, only one study has explored this practice in Cambodia.21 With a sample of 451 women aged 15–49 attending 17 health clinics in Cambodia, this study found that 76.7% of participants douched at least once a week, 65.6% douched more than once a day, and 88.4% used only water for douching. Most previous studies on douching among female sex worker (FSWs) populations suggested that douching was very common and frequent. For example, the prevalence of intravaginal cleansing was as high as about 90% in Kenyan FSWs,2,12 76% in high-risk women in Tanzania12 and 65% in Chinese FSWs.22 It has also been documented that vaginal douching in FSWs was associated with lower condom use,22 perhaps due to the belief that douching could help to prevent STIs. Nevertheless, no published study explores douching practices among Cambodian FSWs. Therefore, this brief report aims to provide preliminary data about the prevalence and the frequency of douching among FSWs in Phnom Penh, Cambodia.
received ethical approvals from the Phnom Penh Department of Social Affairs, Veteran & Youth Rehabilitation, and from the University of Texas Health Science Center’s Institutional Review Board (HSC-SPH-10-0689). Participants were asked about their demographic and sex-work characteristics (e.g. age, education level, age engaging in the sex trade, locations for sex work and average number of clients per week).23 Consistent condom use with clients was assessed on a 5-point Likert scale, ranging from 1 ¼ none to 5 ¼ always. This variable was dichotomised as ‘always’ versus all other responses in current analysis. Participants were asked if they had ever been diagnosed with several named STIs, including HIV. Douching was defined to participants as washing inside the vagina, by such ways as using a device to introduce a stream of water/solutions or using their fingers with water/solutions. Participants were asked whether they douched (with ‘yes/no’ responses), how many times they douched on average before/after every 10 acts of sexual intercourse and what solutions they mostly used for douching.24 Participants were also asked whether they thought that douching could prevent STIs including HIV, with responses on a 5-point Likert scales of ‘absolutely yes, yes, not sure, no, and absolutely no.’ Chi square tests were used to examine associations between douching and demographic or sex-work characteristics; Fischer’s exact tests were used when >25% of cells had an expected observation of less than five. Statistical analyses were performed using SPSS Statistics 20.0 (http://www-03.ibm.com/software/pro ducts/en/spss-stats-standard/).
Methods
Results
This report employed data from a parent cross-sectional survey which aimed to examine condom use and negotiation strategies among FSWs in Phnom Penh, Cambodia. Details of this survey have been described elsewhere.23 In brief, 81 FSWs who were taken into custody due to engagement in commercial sex from March to June, 2011 were recruited. Inclusion criteria were: female, at least 18 years old and able to communicate in Khmer, Vietnamese or English. Eligible FSWs were contacted and invited to participate in the survey during their stay at the Phnom Penh Department of Social Affairs, Veteran & Youth Rehabilitation, waiting for referrals to receive social support from social centers or nongovernment organisations. Face-to-face interviews in Khmer (Cambodia’s national language) were conducted in a private setting by Cambodian trained social workers. Informed consent was obtained from all participants prior to the interviews. The study
Demographic characteristics of the participants were reported in our preceding publication.23 In brief, participants’ mean age was 25 years (SD ¼ 5.5), 40% did not attend elementary school, 91.4% were Khmer and the remaining were Vietnamese. Seventy-five percent were street-based sex workers and 35% had been engaged in sex work for 1 year or less. The average number of clients per week was eight. Eighty-five percent reported always using a condom with clients, 53% reported ever being diagnosed with an STI, 13.6% reported being HIV-positive and 21% had never been tested for HIV. Ninety-one percent (n ¼ 70) of participants douched. The mean numbers of times douched before sex and after sex per 10 sex episodes were 4.43 (SD ¼ 3.87) and 4.63 (SD ¼ 3.94), respectively. Of those who douched, 80% used store-bought solutions, 10% used water and salt and 6.7% used water and soap. Responding to the question whether they thought
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douching can prevent STIs including HIV, 42.7% answered ‘absolutely yes,’ 6.7% said ‘yes’ and 24% were unsure. This belief was not associated with age, education level, years in the sex trade and consistent condom use with clients (p values >. 340). The distribution of douching frequencies after sex per 10 sex episodes showed that 68.8% reported douching five times or less, 31.2% reported 8–10 times. Thus, we dichotomised the values for this variable by grouping an average of 8–10 times as ‘usually douched after sex’ versus the other values. This dichotomised variable ‘usually douched after sex’ was used to investigate binary associations between frequencies of douching after sex and demographic or behavioural characteristics (Table 1). Usually douching after sex was not associated with age, ethnicity, education level, being a street-based sex worker, being a sex worker for one year or less, ever being diagnosed with a STI and HIV status. Usually douching after sex was not associated with the belief that douching could help to prevent STIs. However, usually douching after sex was associated with ever obtaining an HIV test (p ¼ .012) and was marginally associated (although not statistically significant) with a higher average number of clients per week (p ¼ .063) and consistent condom use with clients (p ¼ .053).
Discussions These preliminary data revealed that 91% of FSWs in Phnom Penh, Cambodia, douched and about half of FSWs believed that douching could help to prevent STIs including HIV. Existing studies and systematic reviews have documented almost no benefits of intravaginal cleansing but several adverse health outcomes, including STIs/HIV infection. Therefore, interventions to reduce douching practices in this population are needed. In order to develop appropriate and effective interventions for this behaviour, further studies are needed to examine characteristics of intravaginal cleansing (e.g. timing), other related intravaginal practices (e.g. wiping) and determinants of these practices. In this analysis, douching after sex was performed regardless of the personal belief about whether this practice could prevent STIs. This suggests that FSWs might perform douching because of other reasons as suggested in literature, such as outcome expectancies (e.g. hygiene purposes, sexual pleasure), incorrect beliefs related to douching (e.g. therapeutic value) or perceived expectations from sexual partners or clients.18,24 The association between intravaginal practices and condom use has been a concern to many researchers.19 In one particular aspect, if women believe that douching can help to prevent STIs including HIV, they may substitute douching for condom use to
Table 1. Associations between usually douching after sex and demographic or sex-work characteristics.
Variables Age 25 >25 Ethnicity Khmer Vietnamese Highest education level Did not go to elementary school Other Location types of sex workers Street-based Other Years in sex trade 1 year >1 year Average numbers of clients per week 7 >7 Consistent condom use with clients No Yes Ever being diagnosed with a STI No Yes Ever had an HIV test No Yes HIV status Negative Positive Believed that douching could prevent STIs Absolutely yes/Yes Not sure No/Absolutely no
Usually douched after sexa, n (%) p Values
14 (27.5) 11 (37.9)
.331
24 (32.9) 1 (14.3)
.292
15 (31.2) 10 (31.2)
.998
20 (33.0) 5 (25)
.486
8 (40.0) 12 (30.8)
.478
11 (23.9) 13 (40.6)
.063
1 (8.3) 24 (35.8)
.053
13 (37.1) 10 (24.4)
.170
1 (6.2) 24 (37.5)
.012
21 (39.6) 3 (27.3)
.341
13 (35.1) 6 (33.3) 6 (30.0)
.926
STI: sexually transmitted infection. a Defined as douching 8–10 times on average after every 10 acts of sexual intercourse. Bold text denotes the value is the significance value (p-value).
prevent STIs. Our results suggest the opposite association: those who reported consistent condom use were more likely to usually douche after sex. A similar association was observed for obtaining an HIV test. These might be due to individual perceptions of STI/HIV risk or susceptibility, e.g. those who perceived themselves at a high risk for STI/HIV or cared more about their
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health might be more likely to douche after sex, to consistently use a condom and to get HIV tests. These psychological constructs need to be investigated in future studies in order to guide interventions. This analysis has some limitations. Because the primary aims of the parent study were not about douching, measures of douching and of its potentially associated socio-psychological determinants were limited. The moderate sample size and the low prevalence of those FSWs who did not douche might have reduced the statistical power to detect associations in bivariate analyses. Although recruitment methods significantly aided to the practicality and feasibility of this study, they may have constrained the representativeness and generalisability of results. In conclusion, despite some limitations, these preliminary data indicate that intravaginal cleansing among FSWs in Phnom Penh, Cambodia, was very common. Misperceptions related to intravaginal cleansing were presumably common as well. Current literature has indicated almost no benefits but several adverse health consequences due to intravaginal cleansing. Future studies about intravaginal practices in this population and appropriate interventions are needed in order to avoid potential short- and long-term health problems associated with these practices. Acknowledgements Thanh C Bui’s post-doctoral training has been supported by the UTHealth, School of Public Health, Center for International Training on AIDS Research (funded by NIH grant # AITRP D43 TW007669) and the UTHealth Innovation for Cancer Prevention Research (funded by Cancer Prevention and Research Institute of Texas grant #RP101503). Ly T Tran’s education has been supported by the Vietnam Education Foundation Fellowship, Philanthropic Educational Organization International Peace Scholarship, American Association of University Woman and Margaret McNamara Memorial Fund. We especially thank the staff at the Psycho-Social Service Association, Activities Social Welfare Office, Department of Social Affairs, Veteran & Youth Rehabilitation in Phnom Penh for their assistance with data collection. The content of the manuscript is solely the responsibility of the authors and does not necessarily represent the official views of the funding agencies.
Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this
article: This research received internal funding from the UTHealth, School of Public Health, Center for International Training on AIDS Research (externally funded by NIH grant # AITRPD43 TW007669).
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