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Prevalence and Correlates of Rectal Douching and Enema Use Among Black Sexual Minority Men and Black Transwomen in the Deep South

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Prevalence and Correlates of Rectal Douching and Enema Use Among Black Sexual Minority Men and Black Transwomen in the Deep South Archives of Sexual Behavior https://doi.org/10.1007/s10508-019-01605-w ORIGINAL PAPER Prevalence and Correlates of Rectal Douching and Enema Use Among Black Sexual Minority Men and Black Transwomen in the Deep South Derek T. Dangerfeld II1 · Darrin Johnson2 · Shemeka Hamlin‑Palmer3 · Dorothy C. Browne4 · Kenneth H. Mayer5 · DeMarc A. Hickson6 Received: 28 May 2019 / Revised: 30 November 2019 / Accepted: 3 December 2019 © Springer Science+Business Media, LLC, part of Springer Nature 2020 Abstract HIV/STI disparities are highest among Black sexual minority men (BSMM) and Black transwomen (BTW) in the Deep South. Exploring the prevalence and correlates of rectal douching and enema use could provide insights into risk factors and HIV/STI prevention opportunities among these groups. This study explored the prevalence and correlates of rectal douching and enema using Poisson regression models among 375 BSMM and BTW in Jackson, MS, and Atlanta GA. Approximately 95% reported their gender as male/man; 5.6% self-identifed as transwomen. Most reported being single (73.1%) and were unemployed (56.0%); 36.1% were previously diagnosed with HIV. In multivariable models, BSMM and BTW who reported that their typical sexual position during anal sex was “bottom” (aPR = 2.39, 95% CI = 1.48, 3.84) or “versatile” (aPR = 2.46, 95% CI = 1.44, 4.17) had a higher prevalence of rectal douching and enema use than those who reported “top.” Deeper understanding of the contexts of rectal douching, enema use, and sexual positioning practices is needed. Keywords HIV · Sexually transmitted infections · Rectal douching · Men who have sex with men · Transgender · Sexual orientation Introduction Lansky, Mermin, & Hall, 2017). Data also show that 58% of transwomen living with HIV are Black (Centers for Disease Black sexual minority men (BSMM) (i.e., gay, bisexual, and Control and Prevention [CDC], 2018a, b). HIV and STI dis- other men who have sex with men [MSM]) and Black trans- parities are highest in the Deep South, in states such as Geor- women (BTW) experience a disproportionate burden of HIV gia and Mississippi (Centers for Disease Control and Preven- and STI prevalence in the U.S. Estimates suggest that one tion, 2016, 2017, 2018a). Rectal douching and enema use are in two BSMM will acquire HIV in their lifetime if trends in prevalent among sexual minority groups, particularly among prevention, treatment, and care remain unchanged (Hess, Hu, those who practice receptive anal intercourse (RAI) (Carballo- Diéguez, Lentz, Giguere, Fuchs, & Hendrix, 2018). Since rec- * Derek T. Dangerfeld II tal douching and enema use are associated with HIV and STIs [email protected] (Chmiel et al., 1987; Mitchell, Sophus, Lee, & Petroll, 2016; Moss et al., 1987), exploring the prevalence and correlates 1 Johns Hopkins School of Nursing, Baltimore, MD 21205, among BSMM and BTW could provide more insights into risk USA factors and HIV/STI prevention opportunities among these 2 Brothers United, Inc., Indianapolis, IN, USA groups. 3 School of Health Studies, University of Memphis, Memphis, Data show that 88% of MSM who practice RAI douche TN, USA before intercourse (Javanbakht, Stahlman, Pickett, LeBlanc, 4 Department of Maternal and Child Health, University & Gorbach, 2014). A review of the literature on douching of North Carolina, Durham, NC, USA within the context of same-sex sexual behaviors showed that 5 The Fenway Institute of Fenway Health and the Infectious 87–97% of MSM douche before sex and 13–48% douche after Disease Division, Beth Israel Deaconess Medical Center, sex (Carballo-Diéguez et al., 2018). Specifc reasons for rectal Harvard Medical School, Boston, MA, USA douching and enema use include being clean and preparing for 6 Us Helping Us, People Into Living, Inc., Washington, DC, RAI, adhering to requests from sexual partners, and beliefs that USA Vol.:(0123456789)1 3 Archives of Sexual Behavior douching enhances pleasure during RAI (Carballo-Diéguez correlates of rectal douching and enema use among BSMM et al., 2018; Javanbakht et al., 2014). Some MSM also believe and BTW in Jackson and Atlanta is of critical public health that douching after sex provides protection from STIs (Car- importance. This research could better inform targeted and ballo-Diéguez et al., 2018). culturally relevant prevention strategies for vulnerable sub- Using rectal douches before or after anal sex could disrupt populations in this region of the U.S. and lead to a better under- the rectal mucosa and increase HIV/STI risk among BSMM standing of their sexual health practices that precede or are and BTW. Many commonly used douching products can dam- concurrent with anal sex, such as rectal douching. age rectal epithelial tissue, cause short-term denudation of the rectal epithelium, and subsequently create an infammatory environment that increases the susceptibility to HIV acquisi- Method tion (Schmelzer, Schiller, Meyer, Rugari, & Case, 2004). A rectal douche, however, could be a good vehicle to deliver Participants HIV pre-exposure prophylaxis (Carballo-Dieguez et al., 2018; Leyva et al., 2013; Maisel et al., 2015); topical administration Data were derived from a population-based study initiated of a protective drug could result in higher drug concentra- in Jackson, MS, and Atlanta, GA, to identify multi-level cor- tions in the colon tissue target cells than oral administration relates of HIV risk among BSMM (Hickson et al., 2015). (Carballo-Diéguez et al., 2017). A safe and efective rectal Locally, the study was referred to as “The MARI Study,” douche formulated to deliver rectal microbicides could poten- but was not afliated with the Minority HIV/AIDS Research tially decrease HIV and STI risk among BSMM and BTW Initiative sponsored by the CDC (Sutton et al., 2013). Briefy, (Carballo-Dieguez et al., 2018). However, if rectal microbi- participants were recruited with a combination of active and cides are efcacious in reducing HIV incidence, uptake among passive recruitment strategies. Active recruitment included BSMM and BTW will be contingent upon a better understand- direct contact with individuals at community events, local ing of their sexual health practices, such as rectal douching— bars and clubs frequented by BSMM, and community-based a behavior similar to that needed for rectal application of a activities hosted by the study partner organizations (Open microbicide douche (Mitchell et al., 2016). Arms Healthcare Center in Jackson, AID Atlanta, and The sociodemographic, behavioral, and contextual fac- NAESM in Atlanta). Passive recruitment involved posting tors of rectal douching have received increased attention in ads on social networking websites such as Facebook and the role of HIV prevention and sexual health promotion for geospatial networking apps (i.e., Jack’d), positing advertise- populations of sexual minority men (Achterbergh et al., 2017; ments at local colleges and universities, adult bookstores, Carballo-Diéguez et al., 2018, 2019; Galea et al., 2016; Schil- bars and clubs, and community-based organizations that ser- der, Orchard, Buchner, Strathdee, & Hogg, 2010). Studies vice BSMM, and uncompensated word-of-mouth referrals report that a positive HIV-serostatus, a history of an STI in from study participants and local CBO staf who were not the past 12 months, and sexual roles (i.e., “bottom” or “versa- afliated with the study. Inclusion criteria required a self- tile”) are associated with rectal douching (Carballo-Diéguez report of Black or African-American race, male sex at birth, et al., 2018; Schilder et al., 2010). Douching is also associated being ≥ 18 years of age, and engaging in oral or anal sex with femininity and relates to gendered sexual roles in same- with another man in the 6 months prior to study enrollment. sex relationships among sexual minority men (Schilder et al., All participants provided written informed consent prior to 2010). Rectal douching may be more common among sexual study participation. minority men who report substance use during sex than among those who do not (Carballo-Diéguez et al., 2018; Javanbakht et al., 2014). However, little is known about the prevalence and Measures correlates of rectal douching and enema use among BSMM and BTW, especially in the Deep South. Rectal Douching and Enema Use To fll this gap, this study explored the prevalence and cor- relates of rectal douching and enema use among BSMM and Participants were asked to indicate whether they had ever BTW in Jackson, MS, and Atlanta GA. Although studies have used a rectal douche or enema in their lifetime and whether explored the prevalence of douching among some samples of they had used an enema after sex in the past 6 months. Par- MSM, many studies included majority white or international ticipants were also asked to indicate how often they used a samples (Carballo-Dieguez et al., 2018; Easterbrook et al., rectal douche in the past 6 months. Response options were 1993; Mitchell et al., 2016). Even less is known about rectal “never,” “once or twice,” “three times or more,” “six times douching and enema use among transwomen. Therefore, infer- or more,” or “don’t know.” Finally, participants were asked ences about BSMM and BTW are limited. Since disparities how many times in the past 6 months they had used a douche persist in the U.S. Deep South, quantifying the prevalence and 1 3 Archives of Sexual Behavior in preparation for sex: “never,” “once or twice,” “three times to estimate the relative probability of the correlates of rectal or more,” “every time,” or “don’t know.” douching and enema use. Variables with a p value < .20 in the unadjusted analyses were then included in the fnal adjusted Sex/Gender model. All statistical analyses were conducted in SAS 9.4 (SAS Institute Inc., Cary, NC). Participants were asked to identify the sex/gender they consider themselves. Responses were “male,” “female,” or “transgender.” Results Sexual Orientation A total of 386 BSMM and BTW were enrolled in “The MARI Study” between July 2013 and December 2014.
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