Objectives To assess vaginal cleansing and lubricant use among female sex workers (FSW) in Kenya participating in a 6-month, prospective study of the acceptability of the use of the diaphragm.
Methods The study is based on 140 FSW in Nairobi, who completed 140 baseline visits and 390 bi-monthly follow-up visits. Participants were instructed to wear the diaphragm for all coital acts during follow-up and to refrain from vaginal cleansing while wearing the diaphragm. Logistic regression was used to identify predictors of recent vaginal cleansing to ‘tighten’ the vagina reported at baseline; recent vaginal cleansing to prevent infection reported at baseline; recent vaginal cleansing with the diaphragm in place reported during follow-up; and recent use of oil-based lubricant during coitus reported at baseline.
Results At baseline, 99% of women reported vaginal cleansing in the previous 2 weeks for purposes of hygiene or to remove evidence of past coitus. Approximately 41% of women also reported cleansing in the past 2 weeks to ‘tighten’ the vagina. Women reported vaginal cleansing with the diaphragm in place in the past 2 weeks at 14% of follow-up visits in which the diaphragm was used. Predictors of such cleansing included young age, 6-month study visit, being divorced or widowed and higher educational level.
Conclusions While vaginal cleansing is a modifiable behaviour, given that cleansing for hygiene was almost universal among this study population at baseline and that more women reported cleansing while wearing the diaphragm as the study progressed, the complete eradication of the practice would probably be difficult.
- HIV/sexually transmitted infection prevention
- sex workers
- vaginal cleansing
- vaginal diaphragm
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Women perform intravaginal practices, such as vaginal cleansing and lubrication, for a range of reasons, including hygiene, prevention of pregnancy or infectious disease, alleviation of vaginal symptoms and enhancement of their own or their partner's sexual pleasure.1 2 For example, social norms might drive female sex workers (FSW) to cleanse vaginally to prevent their partners from detecting evidence of past coitus. These practices could have adverse health consequences. Vaginal cleansing has been linked in prospective studies to changes in vaginal flora, bacterial vaginosis, pelvic inflammatory disease and sexually transmitted infections (STI), including HIV3–7; however, the evidence is inconsistent.8–16 The use of oil-based lubricants can weaken the integrity of latex condoms,17 and frequent use of lubricants containing nonoxynol-9 could directly enhance the acquisition of HIV.18
Intravaginal practices could also affect the development and evaluation of female-initiated methods of HIV/STI prevention.19 20 For example, the evaluation of a candidate microbicide to prevent the acquisition of HIV could be compromised if women prematurely remove or dilute the product by cleansing internally either before or after coitus. Furthermore, the effectiveness of an eventual microbicide could be limited if women outside of the research setting continue to cleanse vaginally. On the other hand, the acceptability of the use of lubricant could be an influential factor in the successful adoption of the use of a microbicide. A better understanding of vaginal cleansing and lubricant use is thus important because of their possible contribution to the acquisition of HIV/STI and their role in the development and use of devices and products to prevent these infections. We assessed predictors of intravaginal practices (ie, vaginal cleansing to ‘tighten’ the vagina or to prevent infection, vaginal cleansing with the diaphragm in place and the use of oil-based lubricants during coitus) among FSW in the Kibera settlement in Nairobi who participated in a 6-month, prospective study of the acceptability and safety of the diaphragm.21
Women were recruited for this study from former participants in a randomised trial of monthly chemical prophylaxis for STI control.22 Eligible women were 18–57 years of age and reported trading sex for money or gifts in the previous 2 weeks. Exclusion criteria included reporting consistent condom use for the previous 2 months and current pregnancy or other contraindications to diaphragm use. Participants received a pelvic examination at baseline and the 6-month follow-up visit. They were fitted for and counselled on diaphragm use, and were instructed to use the diaphragm, using a small amount of K-Y Jelly (Johnson & Johnson; New Brunswick, New Jersey, USA) to ease insertion, for all coital acts. They were instructed to keep the diaphragm in place for 6 h or more following sex (but not >24 h) and to refrain from cleansing vaginally during this time. They were supplied with diaphragms, K-Y Jelly and male condoms. At baseline and at follow-up visits occurring 2, 4 and 6 months afterwards, women were counselled on safer sex practices, were tested for pregnancy and urinary tract infection, received syndromic treatment for STI and reproductive tract infections, and completed a self-administered questionnaire on the frequency of the recent use of diaphragm, gel and condoms. At the baseline and bi-monthly follow-up visits, staff interviewed participants on demographics, sexual behaviours, diaphragm use, vaginal cleansing and lubricant use.
For the purpose of this analysis, all ‘recent’ behaviours are defined as those behaviours performed in the 2-week period preceding the interview. We constructed bivariable and multivariable logistic regression models to identify predictors separately for each of the following: (1) recent vaginal cleansing to ‘tighten’ the vagina reported at baseline; (2) recent vaginal cleansing to prevent infection reported at baseline; (3) recent vaginal cleansing with the diaphragm in place reported during follow-up; and (4) recent use of oil-based lubricant during coitus reported at baseline. The first two outcomes were selected because they were common reasons that participants in the present study cited for their recent cleansing; we could not assess predictors of cleansing for general hygiene or to remove evidence of past coitus because all women who recently cleansed reported these reasons. Because participants were to use a study lubricant, their use of oil-based lubricants during the study follow-up might have been affected. Therefore, we did not assess predictors of oil-based lubricant during follow-up. For the analysis of cleansing during follow-up, we used generalised estimating equations (specifying the exchangeable working correlation matrix) to account for repeated measurements. We fit models with all of the possible predictors and then performed manual backward elimination of factors that were not predictive based on a p value of 0.05.23
We assessed the following as possible predictors: age (18–29 years, ≥30 years); marital status (divorced/widowed, cohabiting and not divorced/widowed, not cohabiting and not divorced/widowed); ethnicity (other, Kikuyu); highest level of education completed (0–8 years, 9–12 years); weekly income (>US$9, ≤US$9); parity (0–1, ≥2 children); recent new sex partner (yes, no); recent number of sex partners (≥6, 1–5); frequency of recent coitus (1–5, 6–14, ≥15 acts); recent coital act unprotected by a condom (none, ≥1 acts) and recent use of oil-based lubricant (yes, no). Each of these variables was assessed in all models except that recent use of oil-based lubricant was only included in the models for outcomes measured at baseline. We used SAS 9.1.3 for data analysis. Only women who gave written, informed consent participated.
The study enrolled 140 women from the 180 women who were screened. All participants (N=140) completed the baseline visit. Participants completed the 2-month (N=134), 4-month (N=130) and 6-month visits (N=126). Overall, 390 follow-up visits were completed by 138 women. The mean participant age was 31.6 years (SD 8.1) and 49% were Kikuyu in ethnicity. None of the women was married. Most (69%) were divorced or widowed. Only 19% had completed more than 8 years of education. The primary methods of contraception most often reported at baseline included condoms (36%), injectable contraception (21%), no method (14%) and rhythm method (10%). Women reported a mean age at first intercourse of 16.2 years (SD 2.5). At baseline, women reported a mean of 7.3 (SD 8.0) different sexual partners in the preceding 2 weeks, and approximately 44% of the women reported three or more new partners during this recent period.
Vaginal cleansing at baseline
Almost all of the women (N=138; 98.6%) at baseline reported recent vaginal cleansing (table 1). All women (100%) with recent cleansing described their reason for the act as general hygiene or to remove evidence of past coitus. Additional reasons included to ‘tighten’ the vagina (41%) and to prevent infection (40%). Recent vaginal cleansing was predominantly performed with water and soap (88%), whereas salty water (22%), water only (17%) and water with disinfectant (12%) were also used. The use of other substances was uncommon. Women reported inserting their fingers (84%) and/or cloth (56%) during recent cleansing.
Among women who reported recent vaginal cleansing, the mean frequency of cleansing was 12 in the past 1 week (median 11; range 1–30). Almost all women (N=127; 92.0%) reported that their last act of cleansing occurred less than 1 day ago; eight women reported their last act was 1 day ago and the last act for the remaining three women occurred 2–4 days ago. One quarter of women reported receiving cleansing advice from a FSW friend, whereas 10% reported being advised by a medical practitioner (table 1). Most women reported at baseline that they believed vaginal cleansing to be ineffective in preventing pregnancy (N=124; 88.6%) and preventing STI, including HIV (N=138; 98.6%).
Because all women reported the reason for recent vaginal cleansing at baseline included hygiene or removal of evidence of previous sex, we focused on identifying predictors of vaginal cleansing to ‘tighten’ the vagina and to prevent infection. In bivariable and multivariable analyses, coital frequency and recent use of oil-based lubricant were associated with recent vaginal cleansing at baseline for the purpose of ‘tightening’ the vagina. At baseline, women who reported 15 or more coital acts and women who reported six to 14 coital acts had higher odds of recent cleansing for ‘tightening’ the vagina compared with those reporting fewer coital acts in the past 2 weeks (adjusted odds ratio (aOR) 3.5; 95% CI 1.1 to 11.5 and aOR 3.0; 95% CI 1.0 to 9.1, respectively). In addition, women who reported recent use of oil-based lubricant were more likely than non-users to report recent cleansing for ‘tightening’ purposes at baseline (aOR 2.4; 95% CI 1.1 to 5.0).
Neither coital frequency nor lubricant use was associated with recent cleansing to prevent infection. After adjustment, the odds of cleansing for infection prevention was 2.9 (95% CI 1.4 to 6.0) times greater among women who were non-Kikuyu in ethnicity than among those who were Kikuyu. Also, women reporting a recent new sex partner were more likely to report cleansing for infection prevention than those without a recent new partner (aOR 2.7; 95% CI 1.1 to 6.5). No other factors were associated with recent cleansing to prevent infection in the bivariable and multivariable analyses.
Vaginal cleansing during follow-up
Women at 11 of the follow-up visits reported no diaphragm use. For the remaining 379 follow-up visits in which the diaphragm was used, women at 52 visits (13.7%) reported vaginal cleansing during the past 2 weeks while the diaphragm was inserted (table 1). Vaginal cleansing was reported by 25 women at one follow-up visit, nine women at two follow-up visits and three women at three follow-up visits. Among those reporting recent cleansing, the mean frequency of cleansing in the past 2 weeks was 5.0 (median 3; range 1–42). Similar to baseline, the women who reported recent cleansing during follow-up did so for hygienic reasons and generally used water and soap or water alone (table 1). Also, the insertion of fingers or cloth during cleansing was common.
Predictors of recent vaginal cleansing while wearing the diaphragm during follow-up are shown in table 2. In the bivariable analysis, two factors are associated with vaginal cleansing: age and study visit. These variables remained significant in the multivariable analyses. Women who were 18–29 years of age were more likely to report recent vaginal cleansing than older women (aOR 3.7; 95% CI 1.6 to 8.6). Also, women were more likely to report recent cleansing at the 6-month visit than the 2-month visit (aOR 2.3; 95% CI 1.2 to 4.4). In addition, in the multivariable analysis, women who were divorced or widowed had an odds of recent cleansing 2.7 times (95% CI 1.1 to 6.6) that of women who were not cohabiting and not divorced or widowed. Finally, women who had completed 9–12 years of education were more likely to report recent cleansing (aOR 2.9; 95% CI 1.2 to 7.2) compared with women with less education.
Lubrication at baseline
At baseline, almost half of the women (N=67; 47.9%) reported the use of a lubricant during recent coitus. Among women with recent lubricant use, the most common lubricant was petroleum jelly (N=60) followed by saliva (N=15), oil (N=3), water (N=3) and water-based commercial lubricant (N=2). Women gave the following reasons for lubricant use: to ease painful penetration (N=52), to ‘dry’ the vagina (N=46), to satisfy a client request (N=27), to appear ‘fresh’ to a client (N=14) and to feel ‘fresh’ (N=14). (Women could report multiple types of lubricant used and multiple reasons for use.)
In bivariable and multivariable analyses, high coital frequency was the only predictor of recent use of oil-based lubricant (eg, petroleum jelly or oil) during coitus reported at baseline. Women who reported 15 or more acts in the past 2 weeks were more likely to report recent use of oil-based lubricant (aOR 2.9; 95% CI 1.0 to 8.3) compared with women who reported one to five acts. The odds of oil-based lubricant use did not differ between women who reported the mid-category for coital frequency (six to 14 acts) and those reporting fewer coital acts (aOR 1.2; 95% CI 0.5 to 3.2).
At baseline, almost all women (99%) reported vaginal cleansing within the previous 2 weeks. This is consistent with previous studies conducted among FSW in Kenya, which demonstrated cleansing to be a common practice. Fonck et al24 reported a 72% prevalence of ever vaginal cleansing; two other studies reported a 86–87% prevalence of vaginal cleansing in the past week, and a fourth study reported a 94% prevalence of vaginal cleansing within an unspecified timeframe among FSW in Kenya.6 7 24 25 All of these estimates were measured at baseline before women had the opportunity to change their behaviour in response to study interventions. Also consistent with earlier research,6 7 24 25 the most common cleansing materials were soap and water or water alone, and the predominant cleansing method involved fingers or a cloth.
All participants in the present study who reported cleansing indicated that they did so for hygiene or to remove evidence of past coital acts. A substantial proportion of women (41%) also reported cleansing for ‘tightening’ the vagina. Researchers have raised concerns about the potential health effects from women in Kenya and elsewhere practising ‘dry sex,’26–29 which is described as the application of astringent agents to the vagina before coitus to produce the sensation of heat, dryness, tightness or friction, usually for the purpose of satisfying male preferences. Women in the present study did not report the use of astringent substances; however, they might have failed to report their use if the application of the agents was not considered part of the cleansing process. Of interest, 60% of participants in the current study who reported cleansing to ‘tighten’ the vagina and 51% of women who reported cleansing to ‘dry’ the vagina in the past 2 weeks also reported the use of lubricant in this timeframe. These findings suggest either that women vary their practices according to partner preferences or that cleansing to ‘tighten’ or ‘dry’ the vagina in this context is not synonymous with the practice of ‘dry sex’, as described elsewhere by researchers.
Women were instructed at the baseline visit to refrain from vaginal cleansing while wearing the diaphragm, which was to remain in place for at least 6 h after coitus. Only 14% of women at follow-up visits reported having engaged in recent vaginal cleansing with the diaphragm in place. However, cleansing during follow-up could have been underestimated if social desirability bias caused women to underreport the practice in order to appear to have followed study instructions. Also, cleansing with the diaphragm in place appeared to be greater at the 6-month compared with the 2-month visit. The relatively low level of cleansing with the diaphragm in place might thus not be possible to maintain over a longer period.
Previous qualitative research on the hypothetical acceptance of the diaphragm conducted among the study population suggests that the acceptability and effectiveness of the diaphragm as a method for infection prevention could be limited if women have to avoid vaginal cleansing while wearing the device.30 Similarly, the acceptability and effectiveness of an eventual microbicide could be reduced if the product required women to abstain from vaginal cleansing.
The use of petroleum jelly as a lubricant appeared to be common among participants. We did not collect information by specific coital acts; thus, we do not have data on the frequency of oil-based lubricants used together with latex condoms. After lubrication for comfort, the most common justification for the use of lubricants was to ‘dry’ the vagina. Efforts should be directed towards helping women identify and substitute a water-based lubricant that would provide the desired effect without compromising condom integrity.
While vaginal cleansing has been linked with STI, including HIV,3–7 these associations have not been consistently demonstrated.8–16 Methodological problems, such as the failure to control adequately for confounding, could be responsible for differences in findings. For example, if cleansing were more common among women who are at higher risk of infection, residual confounding could lead to spurious associations. Also, confounding by indication could occur if women cleansed in response to symptoms from infection. In addition, vaginal cleansing can encompass a wide variety of practices, including the product used (eg, water, commercial products intended for vaginal use or non-personal use, or traditional herbal agents); the application method (eg, use of cloth, tissue, or fingers, douching (ie, applying a stream of liquid), or vigorous scrubbing); and the time of cleansing (ie, pre or post-coitus or related to menses). These practices could vary in their risk of acquiring an infection.
In theory, vaginal cleansing is a modifiable behaviour. However, in a population in which cleansing for hygiene is almost universal, efforts to eradicate the practice are unlikely to be successful. FSW in Kenya experience strong norms to cleanse to present as ‘clean’ to their partner and to remove evidence of recent past partners. Furthermore, causal relationships between vaginal cleansing and adverse health consequences are not established; it was even suggested that some vaginal cleansing practices could be beneficial.31–33 Future research should attempt to determine the particular elements of vaginal cleansing (eg, specific products used and the method of insertion) that could potentially cause infection. This could allow public health practitioners to help women modify their practices in an acceptable, sustainable manner while also protecting their health.
Vaginal cleansing (typically involving water with or without soap) was almost universal at baseline among the study population of FSW in Kenya.
Participants reported cleansing for hygiene or to remove evidence of past coitus, to ‘tighten’ the vagina, or to prevent infection.
The use of petroleum jelly for lubrication or to ‘dry’ the vagina was common at baseline.
Predictors of cleansing during follow-up included young age, 6-month study visit, being divorced or widowed and higher educational level.
Anjali Sharma and April J Bell – Affiliation at the time of the research.
Funding This study was funded by the US Centers for Disease Control and Prevention (CDC) through an interagency agreement with the US Agency for International Development and CONRAD. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of CDC, nor does mention of trade names, commercial products, or organisations imply endorsement by the US government.
Competing interests None.
Patient consent Obtained.
Ethics approval This study was conducted with the approval of the ethical review committees at the University of Nairobi, the University of Washington, the University of California, San Francisco, and the US Centers for Disease Control and Prevention.
Provenance and peer review Not commissioned; externally peer reviewed.