Archives of Sexual Behavior

, Volume 43, Issue 4, pp 755–769 | Cite as

Enema Use Among Men Who Have Sex with Men: A Behavioral Epidemiologic Study with Implications for HIV/STI Prevention

  • Syed W. NoorEmail author
  • B. R. Simon Rosser
Original Paper


Enema use or douching is a risk factor for HIV/STI in men who have sex with men (MSM). However, few studies have explored enema use practices. We examined the frequency of enema use, type of products used, and reasons to use and not to use before and after receptive anal sex in a large sample of MSM (N = 4,992) recruited from 16 U.S. cities. Through online surveys, we examined personal, behavioral, and environmental factors associated with enema use. Most (52 %) participants reported having douched at least once and 35 % reported douching within the last 3 months. While most (88 %) reported enema use before receptive anal sex, 28 % douched after receptive anal sex. Most participants (65 %) used water to douche, 24 % added salt, soap, and/or antibacterial products to water, and 30 % reported using commercially available products. Being a man of color, HIV-positive, diagnosed with an STI, identifying as “versatile” in sex, and having more than two unprotected sex partners were significantly associated with recent enema use. Douching behavior appears closely associated with HIV/STI risk. Douching with water may be a concern since it may increase HIV/STI infection by damaging the epithelium. Development and promotion of a non-damaging, non-water based enema specifically for use in anal sex are recommended. In addition, the seemingly contradictory recommendations that water-based lubricant is recommended for anal sex but water-based enemas are dangerous need to be reconciled into a single consistent message.


Men who have sex with men Enema use Rectal douching SILAS HIV 



This research was funded by the National Institute on Alcohol Abuse and Alcoholism (Grant # R01AA016270-01A1) and conducted under the oversight of the University of Minnesota Institutional Review Board (#0610S93786).


  1. Bandura, A. A. (1986). Social foundations of thought and action: A social cognitive theory. Englewood Cliffs, NJ: Prentice-Hall.Google Scholar
  2. Carballo-Dieguez, A., Bauermeister, J. A., Ventuneac, A., Dolezal, C., Balan, I., & Remien, R. H. (2008). The use of rectal douches among HIV-uninfected and infected men who have unprotected receptive anal intercourse: Implications for rectal microbicides. AIDS and Behavior, 12, 860–866. doi: 10.1007/s10461-007-9301-0.PubMedCentralCrossRefPubMedGoogle Scholar
  3. Carballo-Dieguez, A., Bauermeister, J., Ventuneac, A., Dolezal, C., & Mayer, K. (2010). Why rectal douches may be acceptable rectal-microbicide delivery vehicles for men who have sex with men. Sexually Transmitted Diseases, 37, 228–233. doi: 10.1097/OLQ.0b013e3181bf9b2d.PubMedCentralPubMedGoogle Scholar
  4. de Vries, H. J., van der Bij, A. K., Fennema, J. S., Smit, C., de Wolf, F., Prins, M., … Morre, S. A. (2008). Lymphogranuloma venereum proctitis in men who have sex with men is associated with anal enema use and high-risk behavior. Sexually Transmitted Diseases, 35, 203–208. doi: 10.1097/OLQ.0b013e31815abb08.
  5. Easterbrook, P. J., Chmiel, J. S., Hoover, D. R., Saah, A. J., Kaslow, R. A., Kingsley, L. A., … for the Multicenter AIDS Cohort Study. (1993). Racial and ethnic differences in human immunodeficiency virus type 1 (HIV-1) seroprevalence among homosexual and bisexual men. American Journal of Epidemiology, 138, 415–429.Google Scholar
  6. Fuchs, E. J., Lee, L. A., Torbenson, M. S., Parsons, T. L., Bakshi, R. P., Guidos, A. M., … Hendrix, C. W. (2007). Hyperosmolar sexual lubricant causes epithelial damage in the distal colon: Potential implication for HIV transmission. Journal of Infectious Diseases, 195, 703–710. doi: 10.1086/511279.Google Scholar
  7. Heiligenberg, M., Rijnders, B., Schim van der Loeff, M. F., de Vries, H. J., van der Meijden, W. I., Geerlings, S. E., et al. (2012). High prevalence of sexually transmitted infections in HIV-infected men during routine outpatient visits in the Netherlands. Sexually Transmitted Diseases, 39, 8–15. doi: 10.1097/OLQ.0b013e3182354e81.CrossRefPubMedGoogle Scholar
  8. Horvath, K. J., Weinmeyer, R., & Rosser, S. (2010). Should it be illegal for HIV-positive persons to have unprotected sex without disclosure? An examination of attitudes among US men who have sex with men and the impact of state law. AIDS Care, 22, 1221–1228. doi: 10.1080/09540121003668078.PubMedCentralCrossRefPubMedGoogle Scholar
  9. Jones-Webb, R., Smolenski, D., Brady, S., Wilkerson, M., & Rosser, B. R. S. (2013). Drinking settings, alcohol consumption, and sexual risk behavior among gay men. Addictive Behaviors, 38, 1824–1830. doi: 10.1016/j.addbeh.2012.11.011.PubMedCentralCrossRefPubMedGoogle Scholar
  10. Ndimbie, O. K., Kingsley, L. A., Nedjar, S., & Rinaldo, C. R. (1996). Hepatitis C virus infection in a male homosexual cohort: Risk factor analysis. Genitourinary Medicine, 72, 213–216.PubMedCentralPubMedGoogle Scholar
  11. Pequegnat, W., Rosser, B. R. S., Bowen, A., Bull, S., DiClemente, R., Bockting, W., … Zimmerman, R. (2007). Conducting internet-based HIV/STD prevention survey research: Considerations in design and evaluation. AIDS and Behavior, 11, 505–521. doi: 10.1007/s10461-006-9172-9.
  12. Phillips, D. M., Taylor, C. L., Zacharopoulos, V. R., & Maguire, R. A. (2000). Nonoxynol-9 causes rapid exfoliation of sheets of rectal epithelium. Contraception, 62, 149–154. doi: 10.1016/S0010-7824(00)00156-6.CrossRefPubMedGoogle Scholar
  13. Rabe-Hesketh, S., Skrondal, A., & Pickles, A. (2004). Generalized multilevel structural equation modeling. Psychometrika, 69, 167–190. doi: 10.1007/BF02295939.CrossRefGoogle Scholar
  14. Rabe-Hesketh, S., Skrondal, A., & Pickles, A. (2005). Maximum likelihood estimation of limited and discrete dependent variable models with nested random effects. Journal of Econometrics, 128, 301–323. doi: 10.1016/j.jeconom.2004.08.017.CrossRefGoogle Scholar
  15. Rosser, B. R. S., Miner, M., Bockting, W., Ross, M., Konstan, J., Gurak, L., … Coleman, E. (2009). HIV risk and the internet: Results of the men’s internet sex (MINTS) study. AIDS and Behavior, 13, 746–756. doi: 10.1007/s10461-008-9399-8.
  16. Schmelzer, M., Schiller, L. R., Meyer, R., Rugari, S. M., & Case, P. (2004). Safety and effectiveness of large-volume enema solutions. Applied Nursing Research, 17, 265–274. doi: 10.1016/j.apnr.2004.09.010.PubMedGoogle Scholar
  17. Smolenski, D. J., Diamond, P. M., Ross, M. W., & Rosser, B. R. (2010). Revision, criterion validity, and multigroup assessment of the Reactions to Homosexuality scale. Journal of Personality Assessment, 92, 568–576. doi: 10.1080/00223891.2010.513300.PubMedCentralCrossRefPubMedGoogle Scholar
  18. StataCorp. (2010). Stata statistical software: Release 11. College Station, TX: StataCorp LP.Google Scholar
  19. Tinmouth, J., Gilmour, M. W., Kovacs, C., Kropp, R., Mitterni, L., Rachlis, A., … Wood, H. (2008). Is there a reservoir of sub-clinical lymphogranuloma venereum and non-LGV chlamydia trachomatis infection in men who have sex with men? International Journal of STD & AIDS, 19, 805–809. doi: 10.1258/ijsa.2008.008260.
  20. Winkelstein, W.,Jr, Lyman, D. M., Padian, N., Grant, R., Samuel, M., Wiley, J. A., … Levy, J. A. (1987). Sexual practices and risk of infection by the human immunodeficiency virus. The San Francisco Men’s Health Study. Journal of the American Medical Association, 257, 321–325.Google Scholar
  21. Zhang, W., O’Brien, N., Forrest, J. I., Salters, K. A., Patterson, T. L., Montaner, J. S., … Lima, V. D. (2012). Validating a shortened depression scale (10 item CES-D) among HIV-positive people in British Columbia, Canada. PloS One, 7(7), e40793. doi: 10.1371/journal.pone.0040793.

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  1. 1.Division of Epidemiology and Community HealthUniversity of Minnesota School of Public HealthMinneapolisUSA

Personalised recommendations