Anal Health: Social and Behavioral Aspects

ANAL SEX PRACTICES AND HEALTH: Use of rectal douches, lubricants, sexual toys and other practices

Alex Carballo-Diéguez, Ph.D. Columbia University ANAL SEX HAS BEEN DOCUMENTED SINCE ANCIENT TIMES

Warren Cup, British Museum

ANAL SEX AND PLEASURE ANAL SEX AND HEALTH

1. Douching 2. Lubricant use 3. Use of sexual toys 4. Other anal sex practices 1. RECTAL DOUCHING FOR HYGIENE

- Galea JT, Kinsler JJ, Imrie J, Nureña CR, Sánchez J, Cunningham WE. Rectal douching and implications for rectal microbicides among populations vulnerable to HIV in South America: a qualitative study. Sex Transm Infec 2014;90(1):33-5. - Javanbakht M, Stahlman S, Pickett J, LeBlanc MA, Gorbach PM. Prevalence and types of rectal douches used for anal intercourse: results from an international survey. BMC Infect Dis 2014;13:95. - Kinsler JJ, Galea JT, Lama JR, Segura P, Peinado J, Casapia M, Ortiz A, Nadjat- Haiem C, Montano SM, Sanchez J. Rectal douching among Peruvian men who have sex with men, and acceptability of a douche-formulated rectal microbicide to prevent HIV infection. Sex Transm Infec 2013;89(1):62. FREQUENCY OF DOUCHING

Study N % ever % Frequency of Before or douched douched douching After RAI recently Noor et al 4992 US 2275/4992 1748/2275 980/1748 (56%) 88% before, (2014) MSM (52%) (77%)1 frequently to 28% after always Javanbakht 1725 Int’l N/A 1070/1725 N/A 97% before, et al (2014) men and (62%)1 36% after women Carballo- 105 US N/A 54/105 N/A 91% before, Diéguez et MSM (51)%2 48% after al (2010) Calabrese 11,766 US N/A 40-53%3 N/A Only asked (2013) MSM about before Kinsler et al 824 222 (27%) N/A N/A N.A (2013) Peruvian MSM

1in last 3 months 2in last 6 months 3prior to last receptive sex act RECTAL DOUCHING METHODS RECTAL DOUCHE FORMULATIONS

Non-commercial products (used by 93%) - water (82%) - water and soap (11%) - water and salt (5%) - alcohol (1%) Commercial products (used by 31%) - saline-based products (56%) - sodium phosphate-based (32%) - mineral oil/glycerin-based (22%) - laxative-based (19%)

Source: Javanbakht M, Stahlman S, Pickett J, LeBlanc MA, Gorbach PM. Prevalence and types of rectal douches used for anal intercourse: results from an international survey. BMC Infect Dis 2014;14:95. RECTAL DOUCHING AND ANAL HEALTH

Rectal douching may be associated with anal pathologies and sexual transmission of HIV, Hep. B and C: • de Vries HJ, van der Bij AK, Fennema JS, Smit C, de Wolf F, Prins M, Coutinho RA, Morré SA. Lymphogranuloma venereum proctitis in men who have sex with men is associated with anal enema use and high-risk behavior. Sex Transm Dis 2008;34(2):203-8. • Schreeder MT, Thompson SE, Hadler SC, et al. Hepatitis B in homosexualmen: Prevalence of infection and factors related to transmission.J Infect Dis 1982; 146:7–15. • Ndimbie OK, Kingsley LA, Nedjar S, Rinaldo CR. Hepatitis C virusinfection in a male homosexual cohort: Risk factor analysis. GenitourinMed 1996; 72:213–216. • Noor SW, Rosser BR. Enema use among men who have sex with men: A behavioral epidemiologic study with implications for HIV/STI prevention. Arch Sex Behav 2014;43(4):755-69. • Carballo-Diéguez A, Bauermeister J, Ventuneac A, Dolezal C, Balan I, Remien RH. The use of rectal douches among HIV-uninfected and infected men who have unprotected receptive anal intercourse: Implications for rectal microbicides. AIDS Behav 2008;12(6):860-866. Formulation matters: • Douching with water may increase infection by damaging the epithelium: • Isoosmolar enema formulations are safest: Leyva FJ, Bakshi RP, Fuchs EJ, Li L, Caffo BS, Goldsmith AJ, Ventuneac A, Carballo-Diéguez A, Du Y, Leal JP, Lee LA, Torbenson MS, Hendrix CW. Isoosmolar enemas demonstrate preferential gastrointestinal distribution, safety, and acceptability compared with hyperosmolar and hypoosmolar enemas as a potential delivery vehicle for rectal microbicides. AIDS Res Hum Retrovirus 2013;29(11):1487-1495. • Propylene glycol electrolyte solutions show no epithelial damage • Schmelzer M, Schiller LR, Meyer R, Rugari SM, Case P. Safety and effectiveness of large-volume enema solutions. Appl Nurs Res 2004;17(4):265-74. HELP IS ON ITS WAY

• Development of rectal enema as microbicide (DREAM) • Work is underway to identify not toxic rectal douches that could carry anti HIV agents to prevent transmission.

2. ANAL LUBRICANTS

AJPH

-Butler LM, Osmond DH, Graves Jones A, Martin JN. Use of saliva as a lubricant in anal sexual practices among homosexual men. JAIDS 2009;50(2):162-167. -Clark JL, Salvatierra HJ, Segura ER, et al. Frequency, patterns, and preferences of lubricant use during anal intercourse within male sexual partnerships in Lima, Peru: Implications for a rectal microbicide HIV prevention intervention. AIDS Care 2013;25(5):579-585. -Dodge B, Hubach RD, Schick V, Herbenick D, Reece M, Sanders SA, Fortenberry JD. Lubricant use at last sexual encounter with a male partner: findings from a nationally representative sample of self-identified gay and bisexual men in the United States. Sexual Health 2015;12(4):300-307. -Javanbakht M, Murphy R, Gorbach P, LeBlanc M-A, Pickett J. Preference and practices relating to lubricant use during anal intercourse: implications for rectal microbicides. Sexual Health 2010;7(2):193-198. -Kinsler JJ, Galea JT, Peinado J, Segura P, Montano SM, Sánchez J. Lubricant use among men who have sex with men reporting receptive anal intercourse in Peru: implications for rectal microbicides as an HIV prevention strategy. Int J STD AIDS 2010;21:567-572. -Pines HA, Gorbach PM, Reback CJ, Landovitz RJ, Mutchler MG, Mitsuyasu R. Commercial lubricant use among HIV-negative men who have sex with men in Los Angeles: implications for the development of rectal microbicides for HIV Prevention. AIDS Care 2014;26(12):1609-18.

FREQUENCY OF LUBRICANT USE

Study N % used Frequency of recently lubricant Pines et al 179 US MSM 106/179 (59%)1 63/106 (59%) always 2014 used Clark et al 547 Peruvian 275/547 (50%)2 95/275 (35%) 2013 MSM consistently used

Dodge et al 333 US MSM 163/333 (49%)3 N/A 2015 Javanbakht et 6124 Int’l men N/A 3601/6124 (59%) al 2010 and women always used4

1past month during RAI 2past two months during AI 3at last sex act 4past six months during AI RECTAL LUBRICANT APPLICATION LUBRICANT FORMULATIONS

• Water-based

• Silicone-based

• Oil based

LUBRICANTS AND ANAL HEALTH

• Consistent users of lubricant during receptive anal intercourse had higher prevalence of STI than inconsistent users: • Gorbach PM, Weiss RE, Fuchs E, Jeffries RA, Hezerah M, Brown S, Voskanian A, Robbie E, Anton P, Cranston RD. The slippery slope: lubricant use and rectal sexually transmitted infections: a newly identified risk. Sex Transm Dis 2012;39(1):59-64. • Water-based sexual lubricants are hyperosmolar and may cause epithelial injury: • Rebe KB, De Swardt G, Berman PA, Struthers H, McIntyre JA. Sexual lubricants in South Africa may potentially disrupt mucosal surfaces and increase HIV transmission risk among men who have sex with men. S Afr Med J 2013;104(1):49-51. HELP IS ON ITS WAY

• Isoosmolar and silicone-based lubricants appear safer: • Dezzutti CS, Brown ER, Moncla B, Russo J, Cost M, Wang L, Uranker K, Kunjara Na Ayudhya RP, Pryke K, Pickett J, LeBlanc MA, Rohan LC. Is wetter better? An evaluation of over-the-counter personal lubricants for safety and anti-HIV-1 activity. PLoS One 2012;7(11):e48328. • Carraguard and methylcellulose do not exhibit rectal cytotoxicity • Sudol KM & Phillips DM. Relative safety of sexual lubricants for rectal intercourse. Sex Transm Dis 2004;31(6):346-349.

3. SEXUAL TOYS 4. OTHER PRACTICES

• Fingering • Fisting • Analingus • Introduction of foreign objects

FREQUENCY OF USE TOYS, FINGERING, FISTING AND ANALINGUS

Richters et al 2003: 19,307 Australian men and women in the past year… 12% of men and 14% of women had used a sex toy 17% of men and 14% of women had engaged in anal stimulation with fingers 0.6% of men and 0.5% of women had engaged in fisting 5.5% of men and 3.3% of women had engaged in analingus