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. Eleven were Participants were asked to self-identify their sexual orien- excluded due to missing data and extreme values of reported tation from five options: “gay/homosexual,” “bisexual,” main and/or casual partners in the past 12 months (> 50), leav- “straight/heterosexual,” “questioning,” or “I don’t identify ing an analytic sample of 375. A total of 354 self-reported their with any of these.” Sexual orientation was recoded into a gender as male or man; 21 self-identifed as transwomen and 1 three-category variable: “gay/homosexual,” “bisexual,” and self-reported being a female or woman. The average age of par- “other” in the regression model due to item sparseness. ticipants was 30.3 years (range 18–62, SD = 11.1). Most iden- tifed as gay or homosexual (67.5%), reported being single or Sexual Positioning Practices not in a committed relationship (73.1%), and were unemployed (56.0%). A total of 134 (36.1%) were previously diagnosed with Participants were asked to indicate their typical sexual posi- HIV; 27.2% reported being diagnosed with an STI in the past tioning practice for anal sex with men. Response options were 12 months (Table 1). “top,” “bottom,” “versatile,” and “other.” Prevalence of Rectal Douching/Enema Use Gender Nonconformity Table 2 shows the prevalence of and reported reasons for rectal Gender nonconformity was assessed using two items assess- douching and enema use among BSMM and BTW. Over half ing socially assigned gender expression (Wylie, Corliss, Bou- (52.9%) reported ever using a rectal douche or enema. Among langer, Prokop, & Austin, 2010): “How do you think people those with a history of enema use, 93.4% reported use in the describe your appearance, style, or dress?” and “How do you past 6 months. For those who reported enema use in the past think people describe your mannerisms?” Response options 6 months, 34.3% reported rectal douche or enema use once or for both questions ranged on a seven-point scale from “very twice before sex, 28.3% reported three times or more before sex, feminine” to “very masculine” and coded 1 to 7. Mean scores and 45.6% reported rectal douching every time before sex. A from both items were calculated and used to indicate gender total of 31.8% reported rectal douche or enema use every time nonconformity (Cronbach’s alpha = 0.93). after sex in the past 6 months.

HIV Status and STI History Correlates of Rectal Douching and Enema Use

Participants were asked to self-report the results of their last Table 3 shows the relative probabilities of rectal douching and HIV test as “positive,” “negative,” or “don’t know.” Partici- enema use history among BSMM and BTW. In multivariable pants were also asked to indicate whether a doctor or health models, BSMM and BTW who self-reported that their typi- department ofcial told them that they had an STI in the past cal sexual position during anal sex was “bottom” (aPR = 2.39, 12 months and to specify the type of infection(s). Responses 95% CI = 1.48, 3.84) or “versatile” (aPR = 2.46, 95% CI = 1.44, were dichotomized as having “any” = 1 or “no” = 0 STI his- 4.17) had a higher prevalence of rectal douching and enema tory in the past 12 months. use than those who reported “top” as their typical sexual posi- tion during anal sex. No other correlates reached statistical Statistical Analysis signifcance, and no correlates of rectal douching and enema use in the past 6 months were identifed. To build a multivariable model exploring the correlates of rectal douching and enema use, a manual forward selection procedure was used to sequentially identify potentially sig- nifcant variables. Specifcally, a series of unadjusted Pois- son regression models with robust standard errors were ft

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Table 1 Demographic and behavioral characteristics among BSMM Table 1 (continued) and BTW in Jackson, MS, and Atlanta, GA, 2013–2014 (n = 375) n (%) n (%) Condom use for anal sex w/main partners past 12 months** Age, years Always 66 (23.4) Range 18–62 Most the time 39 (13.8) Mean (SD) 30.3 (11.1) About half the time 17 (6.0) 18–24 157 (41.9) Rarely or occasionally 33 (11.7) 25–29 75 (20.0) Never 127 (45.0) ≥ 30 143 (38.1) Condom use for anal sex w/main partners last sex* Gender Yes, the entire time 156 (55.1) Male/man 354 (94.4) Part of the time 41 (14.5) Female/woman 1 (0.3) No 86 (30.4) Transgender 21 (5.5) Number of casual partners, past 12 months* Sexual orientation Range 0–50 Homosexual/gay 253 (67.5) Mean (SD) 4.0 (5.9) Bisexual 97 (25.9) Condom use for anal sex w/casual partners past 12 months** Heterosexual/straight 12 (3.2) Always 177 (60.6) Other 13 (3.4) Most the time 52 (17.8) Relationship status About half the time 27 (9.3) Single 274 (73.1) Rarely or occasionally 15 (5.1) In a relationship w/a woman 6 (1.6) Never 21 (7.2) In a relationship w/a man 67 (17.9) Condom use for anal sex w/casual partners last sex** Married to a woman 4 (1.1) Yes, the entire time 201 (68.8) Married to a man 3 (0.8) Some of the time 47 (16.1) Divorced or separated 17 (4.5) No 44 (15.1) Widowed 4 (1.1) Alcohol use before/during sex, past 12 months 185 (49.3) Highest level of education Drug use before/during sex, past 12 months* 139 (37.2) Less than high school 26 (6.9) Gender nonconformity (Mean [SD])]* 4.69 (1.66) High school graduate or GED 128 (34.1) Study site Some college 144 (38.4) Jackson, MS 219 (58.4) College graduate or more 131 (20.5) Atlanta, GA 156 (41.6) Employment status *Due to missing at random, some total equal less than 375 Full time 91 (24.3) Part time 74 (19.7) **Less than the analytic sample Unemployed 210 (56.0) Annual household income* Discussion Less than $5,000 146 (40.0) $5000–$19,999 123 (33.7) To our knowledge, this study is the frst to explore the preva- $20,000 and above 96 (26.3) lence and correlates of rectal douching and enema use among Self-reported HIV status* BSMM and BTW in the Deep South. We found a high preva- HIV-positive 134 (36.1) lence of rectal douching and enema use before anal sex and that HIV-negative 237 (63.9) the typical sexual position for anal sex was the only covariate STI history past 12 months 102 (27.2) that was signifcantly associated with the prevalence of rectal Typical sexual positioning practice* douching/enema use history among BSMM and BTW. Specif- Top 111 (29.8) cally, those who reported “versatile” and “bottom” as typical Versatile 164 (43.8) sexual roles during anal sex had a signifcantly higher preva- Bottom 93 (25.0) lence of enema use history than those who reported “top” as Other 5 (1.3) their typical anal sex position. Findings suggest that anal sex Main partners, past 12 months* roles could be targeted for intervention. The high prevalence of Range 0–15 rectal douching and enema use also suggests the feasibility of Mean (SD) 1.7 (1.8) rectal douches and enemas as an intervention modality among BSMM and BTW.

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Table 2 Rectal douching and n (%) enema history among BSMM and BTW in Jackson, MS, Ever used a rectal douche or enema 198 (52.9) and Atlanta, GA, 2013–2014 Rectal douche/enema use, past 6 months (n = 375) Never/none 13 (6.6) Once or twice 68 (34.3) Three to fve times 56 (28.3) Six or more times 61 (30.8) Rectal douching/enema use before sex, past 6 months* Never 6 (3.3) Once or twice 63 (34.2) Three times or more 31 (16.8) Every time 84 (45.6) Reason for rectal douche/enema use before sex* To be clean 177 (95.6) My sex partner suggested it 3 (1.6) Other reason 3 (1.6) Rectal douche/enema use after sex, past 6 months 89 (44.9) Frequency of rectal douche/enema use after sex, past 6 months* Never 8 (9.1) Once or twice 39 (44.3) Three times or more 13 (14.8) Every time 28 (31.8) Reason for rectal douche/enema use after sex* To be clean 76 (86.4) To prevent getting any STIs from my partner 3 (3.4) Other reason 2 (2.3)

*Due to missing data, some totals are less than analytic samples

Other research has found similar associations related to rec- To identify potential harm reduction strategies among tal douching and sexual roles among SMM (Carballo-Dieguez BSMM and BTW patients, healthcare providers should et al., 2018, 2019; Galea et al., 2016; Javanbakht et al., 2014). explore rectal douching and enema use along with typical This is an important fnding since the risk for HIV and STIs sexual positioning practices. Although enema use immediately varies by sexual positioning practices. Specifcally, SMM who prior to anal sex increases the risk of infections, it is likely that typically practice RAI are more likely than those who only this practice will continue among BSMM and BTW. However, practice IAI to acquire HIV and rectal STIs (Baggaley et al., clarifying patients’ histories, motivations, and contexts of rec- 2018; Dangerfeld II, Smith, Williams, Unger, & Bluthenthal, tal douching and/or enema use will provide better insight into 2017; Jin et al., 2010). A more nuanced understanding of the how providers can support safer-sex strategies for BSMM and relationship between rectal douching, enema use, and sexual BTW who practice RAI or versatility for anal sex. Limited roles on HIV vulnerability is needed. Adding more understand- awareness and understanding about sexual minority sexual ing about rectal douching and enema use by sexual position- health behaviors is a barrier to providing optimal healthcare ing practice could provide more insight into relative HIV/STI (Gee, 2006; Patton et al., 2014). Healthcare providers could risks for BSMM and BTW. Moreover, SMM who take receptive be crucial in providing harm reduction strategies and dispel- roles for anal sex are more willing to use rectal douches than ling myths about rectal douching and enema use in the role of those who do not (Mitchell et al., 2016). Therefore, targeting hygiene and sexual health. However, a deeper understanding of anal sex roles for biomedical intervention and harm reduction the types of enema and douches that BSMM and BTW use is strategies could be useful (Dangerfeld II et al., 2017; Wilton needed. Further information about the diferent types of rectal et al., 2009). Healthcare providers could provide prevention douches and enemas on infection risk is also needed. or harm reduction information to those who report typically Limitations should be considered relative to the strengths of practicing RAI or versatility for a more nuanced comprehensive this study. First, our ability to draw causal inferences was lim- healthcare assessment for sexual minority patients. ited due to the cross-sectional study design. Additionally, the 12-month recall period for many of the sexual behaviors and

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Table 3 Demographic and uPR (95% CI) aPR (95% CI) socioeconomic characteristics, sexual behaviors associated Age, years with rectal douche (enema use) 18–24 REF – history ever among BSMM and 1.40 (0.99, 1.98) BTW, 2013–2014 25–29 1.30 (0.90, 1.88) 30 and above 0.91 (0.66, 1.27) 0.93(0.63, 1.36) Transwoman/female 1.68 (0.84, 3.34) Sexual orientation Homosexual/Gay 2.77 (1.22, 6.24)* 2.07 (0.83, 5.10) Bisexual 1.03 (0.42, 2.52) 1.18 (0.44, 3.18) Other REF – Relationship status Single REF In relationship 0.96 (0.68, 1.35) Other 0.52 (0.23,1.18) Education Less than high school REF High school grad or GED 1.11 (0.58, 2.11) Some college 1.29 (0.69, 2.44) College or more 1.47 (0.75, 2.83) Employment status Unemployment REF Full time 1.26 (0.91, 1.75) Part time 1.11 (0.77, 1.60) Income Less than $5000 REF – $5000–$19,000 1.36 (0.96, 1.90) 1.26 (0.89, 1.80) $20,000 or more 1.37 (0.96, 1.97) 1.32 (0.89, 1.95) HIV status HIV-negative REF – HIV-positive 1.45 (1.10, 1.92)** 1.20 (0.87, 1.65) STI history past 12 months 1.28 (0.95, 1.71) Typical sexual position during anal sex Top REF – Versatile 3.11 (1.98, 4.88)** 2.46 (1.44, 4.17)*** Bottom 3.53 (2.19, 5.66)** 2.39 (1.48, 3.84)*** Other 0.96 (0.13, 7.14) 1.14 (0.15, 8.58) Number of main partners 1.02 (0.94, 1.10) Condom use with main male partners Never REF Always 1.07 (0.65, 1.75) Most of the time 0.92 (0.52, 1.60) Half of the time 1.26 (0.67, 2.33) Rarely or occasionally 1.13 (0.58, 2.20) Number of casual male partners 0.98 (0.96, 1.00) Condom use with casual partners Never REF Always 1.30 (0.63, 2.69) Most of the time 1.41 (0.64, 3.10) Half of the time 1.45 (0.61, 3.43) Rarely or occasionally 1.75 (0.69, 4.43) Alcohol use before/during sex 0.98 (0.74, 1.30) Drug use before/during sex months 0.90 (0.67, 1.12)

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Table 3 (continued) uPR (95% CI) aPR (95% CI)

Gender nonconformity 0.87 (0.80, 0.94)** 0.95 (0.86, 1.05) Study site Atlanta, GA 1.01 (0.76, 1.34) Jackson, MS REF –

Statistically signifcant values (p < 0.05) are given in bold Marginally statistically signifcant values are given in italics *p < .05; **p < .01, ***p < .001 history of diagnosed STIs could have introduced recall bias, Ethical Approval All procedures performed in studies involving human measurement error, or misclassifcation. We also relied on self- participants were in accordance with the ethical standards of the insti- tutional and/or national research committee and with the 1964 Helsinki reported HIV status in these analyses, which could decrease the Declaration and its later amendments or comparable ethical standards. precision of the measurement since some might have unknow- ingly been living with HIV. Also, our measure for perceived Informed Consent Informed consent was obtained from all individual gender was limited. Our measure for sexual positioning was participants included in this study. also limited and might not be an accurate assessment of sexual behavior. The sample was also drawn solely from two U.S. cit- ies in the Deep South, limiting the generalizability of fndings References to BSMM and BTW in other U.S. regions. Despite limitations, this study ofers novel insight into the sexual health of BSMM Achterbergh, R. C. A., van der Helm, J., van den Boom, W., Heijman, and BTW for future research and prevention activities. T., Stolte, I. G., van Rooijen, M., & de Vries, H. (2017). Is rectal Future research should explore the motivations and con- douching and sharing douching equipment associated with anorec- texts of rectal douching and enema use among BSMM and tal chlamydia and gonorrhoea? A cross-sectional study among men who have sex with men. Sexually Transmitted Infections, 93(6), BTW in other U.S. contexts. Future eforts should also include 431–437. https​://doi.org/10.1136/sextr​ans-2016-05277​7. longitudinal studies that explore the extent to which HIV/STI Baggaley, R. F., Owen, B. N., Silhol, R., Anton, P., McGowan, I., van risk and prevention behaviors change over time as BSMM and der Straten, A., & Boily, M.-C. (2018). Per act HIV transmis- sion risk through anal intercourse: An updated systematic review BTW age, change sexual partners, and enter new relationships. and meta-analysis. Presented at the HIV Research for Prevention Qualitative research would be a useful method to explore the meeting, Mardi, Spain. Retrieved November 21, 2018 from http:// motivations and contexts of these behaviors among BSMM and www.natap.org/2018/HIVR4​ P/Bagga​ leyEt​ AlPos​ terR4​ P_2018.pdf​ BTW. More research is also needed to discern the diferences Carballo-Diéguez, A., Balán, I. C., Brown, W., Giguere, R., Dolezal, C., in rectal douching and enema use for this population. Spe- Leu, C.-S., & Cranston, R. D. (2017). High levels of adherence to a rectal microbicide gel and to oral pre-exposure prophylaxis (PrEP) cifcally, little is known about the relative prevalence of rectal achieved in MTN-017 among men who have sex with men (MSM) douching and enema use among BSMM and BTW separately. and transgender women. PLoS ONE, 12(7), e0181607. https://doi.​ Additionally, little is known about the relative risk of enema org/10.1371/journ​al.pone.01816​07. use modalities. Healthcare providers and HIV/STI interven- Carballo-Dieguez, A., Giguere, R., Lentz, C., Dolezal, C., Fuchs, E. J., & Hendrix, C. W. (2019). Rectal douching practices associ- tionists should have more insight into the contexts of sexual ated with anal intercourse: Implications for the development of a health decision making among BSMM and BTW. behaviorally congruent HIV-prevention rectal microbicide douche. AIDS and Behavior, 23, 1484–1493. https://doi.org/10.1007/s1046​ ​ Acknowledgements The authors gratefully thank The MARI Study 1-018-2336-6. participants for their time and participation in the study. Carballo-Diéguez, A., Lentz, C., Giguere, R., Fuchs, E. J., & Hendrix, C. W. (2018). Rectal douching associated with receptive anal inter- course: A literature review. AIDS and Behavior, 22(4), 1288–1294. Funding This study was funded by the Centers for Disease Control and https​://doi.org/10.1007/s1046​1-017-1959-3. Prevention as part of the Minority HIV/AIDS Research Initiative (Coop- Centers for Disease Control and Prevention. (2016). HIV surveillance erative Agreement: U01PS003315). This work was also supported, in report, 2015 (Vol. 27). http://www.cdc.gov/hiv/libra​ry/repor​ts/ part, by the National Institutes of Health (Grant #: R21MH083620 and hiv-surve​illan​ce.html K01MH118943). Centers for Disease Control and Prevention. (2017). Sexually Transmit- ted Disease Surveillance, 2016. Retrieved October 5, 2017, from Compliance with Ethical Standards https://www.cdc.gov/std/stats​ 16/CDC_2016_STDS_Repor​ t-for50​ ​ 8WebS​ep21_2017_1644.pdf Conflict of interest All authors declare that they have no confict of Centers for Disease Control and Prevention. (2018a). Gonorrhea—2017 interest. Sexually Transmitted Diseases Surveillance. Retrieved October 16, 2018, from https​://www.cdc.gov/std/stats​17/gonor​rhea.htm

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