Background: Women persist in vaginal douching despite known negative health consequences associated with its practice. Women often douche due to being taught by their mothers and grandmothers or their perceived sexual partner’s preferences. However, little is known about men’s knowledge and attitudes regarding douching. This study examined male’s knowledge of female vaginal douching and discussions they have had about douching.

Methods: Participants completed a 45 question survey on douching exposure, knowledge, and attitudes. Undergraduate and graduate males (N=89; Mage=27.20) were approached by researchers during class-change periods.

Results: Most men (62%) reported exposure to douching and knew someone who douches (41%) but just 39% reported having a discussion about douching. Only 3% discouraged douching in this discussion and many recommended douching to help with cleanliness (50%) or vaginal odor (25%). Though most men (83%) were willing to discuss douching, only 14% would discourage it. Reasons for not discussing douching with a partner included not knowing what to say (46%), feeling it was not their place to discuss it (45%), discomfort with the subject (34%), and that their spouse did not want to hear about it from them (36%).

Conclusions: Previous research suggests males could influence female douching and hygiene; however, college males may not believe they have a role in these discussions and may not have the knowledge of douching needed to have such discussions. Providing education about the risks and consequences of douching, for the health of both partners, should be encouraged to promote dialogue and discussions of feminine hygiene.

Vaginal douching , Male knowledge, Douching discussions, Feminine hygiene

 Black WR, Short MB (2017) College Men’s Knowledge of Vaginal Douching. JSM Women’s Health 2(1): 1006.

STI: Sexually Transmitted Infection;

HCP: Health Care Provider

Previous research has shown that douching may affect a several aspects of a woman’s gynecological and reproductive health, such as increasing her risk cervicitis [1,2], endometritis, upper genital tract infection [3], ectopic pregnancy [4-8], premature or low-birth weight delivery [9,10], pre-term labor [11], and infertility [12,13]. Douching has also been shown to increase the risk of contracting sexually transmitted infections (STIs) [14], human immunodeficiency virus (HIV) [1,2,14-18], the genital human papillomova virus (HPV) [19], ovarian cancer [20], pelvic inflammatory disease [7,8,10,11,15,21-14], and bacterial vaginosis [10,25-33].

Despite these risks, many women continue douching practices. Approximately 15.7% of 15-19 year-olds and 25.7% of 20-24 year-olds have douched within the last 12 months (i.e., currently douche) [34] and between 64% and 79% of 12- 25 year-olds that have ever douched [1,35-37]. These estimates are substantially lower compared to some African countries, where as many as 90% of women engage in “vaginal cleaning” practices [38]. Therefore vaginal douching is a relatively widespread practice in adolescent and young adult women, despite well demonstrated and reported negative health consequences.

However, getting women to discontinue douching has been difficult. Many women perceive douching as beneficial, reporting that it makes them feel fresh, clean, or confident [1,27,37-43]. This likely leads to increased douching during their menstrual cycle and after coitus [1,27,37,39,40,42,44-46], or to alleviate symptoms of a STI or vaginal infection [27,36,39,45]. Despite knowledge of health-risks associated with douching, women may be resistant to the cessation of douching, even though the practice of douching itself may contribute to and perpetuate their symptoms [40,47,48].

In order to prevent the practice of douching, it is important to understand its influencing factors. Previous research indicates that a young female’s likelihood of douching is affected by whether they have had conversations about douching with women that douche [27,40-42,45,48-52]. Unfortunately, conversations are most likely to happen with women who either currently or have previously douched, encouraging its future practice [52]. Women also are likely to look to their health care provider (HCP) for information pertaining to sexual health and hygiene [42,43,52]. However, little is known about men’s potential impact on female douching and hygiene. Previous research has demonstrated that men’s preferences impact female sexual hygiene differently among various cultures [38,53]. One study found that Latino men support douching due to a cultural value of vaginal cleanliness, thus increasing the likelihood that Latino women will douche [54]. Other studies have found that despite an increased risk for infection and STI contraction, women in Africa engage in dry sex due to male preference [55,56]. Also, among topical microbicide research, women report that their partner has an influence in their use of topical microbicides [57,58]. For example, Montgomery et al., [57] found that though topical microbicides are intended to be a “woman-controlled” contraceptive, men played a large role in determining whether and how it was used. However, while someone women endorse a role for male partners to play in topical microbicide use, attitudes vary [59].

These studies suggest that women do not make completely independent decisions regarding different aspects of sexual hygiene and health, and they are likely to consider the preferences of their partners in their decision making. Therefore, in order to decrease the incidence of vaginal douching, educating men about the ill-effects of douching and altering their attitudes and opinions may be an effective strategy. However, before focusing on men as a possible point of intervention to decrease female douching, more information is needed men’s knowledge and attitudes about female douching. Therefore this study aims to explore the experience with, knowledge of, and attitudes of vaginal douching in college males.

Participants

Male undergraduate and graduate-level students attending the University of Houston-Clear Lake were asked to voluntarily participate in a study on douching exposure, knowledge, and attitudes. The university is a non-traditional institution in which some students transfer to the school after completing requisite hours of education at a community college, or after their sophomore year at the University of Houston. Additionally, many of the students have already had a career and have returned to school later in life. Therefore, the university’s undergraduate students tend to be older than other universities.

Ethics, Consents, Permissions. Informed consents were obtained from each participant and the study was explained. Men who consented completed an anonymous and confidential survey. This study was approved by the Institutional Review Board at the University of Houston-Clear Lake.

Procedures

Participation consisted of a 10 minute, 45 question survey regarding race, education level, and sexual history. The survey is descriptive in nature and was adapted from previous literature [52] and to reflect men’s experience with, attitudes,and knowledge about douching. Questions targeted previous experience and knowledge with douching, previous and/or planned conversations that have been had about douching, opinions about the usefulness or harmfulness of douching, and their attitudes regarding the relevance of female douching to their lives. Participants were asked about previous exposure to the subject of douching (i.e., “Have you ever been exposed to feminine douching?”, and if previous exposures or discussions were had, where did the exposure come from (e.g., TV, friend, family member, girlfriend/spouse), and what information was discussed. Individuals also estimated what percentage of women douche and indicated why women should (e.g., hygiene/ cleanliness, health, infections) or should not douche (e.g., harmful, not needed, “none of my business.” Men also indicated what they have said to women or would say to women about douching (e.g., her problem or issue, do it if she wants to, for sexual hygiene, it treats vaginal infection), and rated how the relevance of douching to their lives. Some questions were in a yes/no format (e.g., “Do you know someone who has douched previously?”, “Have you ever had a discussion about feminine douching?”), while others were presented as a list of choices and the participant was asked to “choose only one” or to “choose all that apply.” Several questions provided space for participants to describe an “other” response. These responses were independently coded and compared for inter-rater agreement. Disagreements were resolved by the lead author.

Statistical analysis

Data were analyzed using Statistical Analysis Software v. 13.1 (SAS). Descriptive statistics were calculated for each response. Chi-squared tests of independence were used to compare responses by men who know someone who currently douches or has previously douched to those who do not, and men who are willing to discuss douching to those who are not. A p<.05 was considered to be significant for all analyses.

Demographic information

Eighty-nine men participated in the study (Mage = 27.2 years, SD = 7.94, range 20 to 63). Sixty-three percent were Caucasian, 22% Hispanic, 7% Asian, 5% Indian/Middle Eastern, and 3% African-American. Fifty-one percent of the participants had attained an associate’s degree, 29% a Bachelors degree, 17% reported some college, and 3% were pursuing post-graduate degrees.

Sexual Relationship history

Eighty-nine percent of participants reported ever engaging in sexual intercourse. Those who had engaged in intercourse reported between 1 and 50 lifetime partners (n = 72, m = 10.89, sd = 15.16) and 1 and 100 intimate relationships (n = 86, m = 10.5, sd = 19.27). Of those relationships, on average 4.96 (n = 79, sd = 12.59) were with friends and 5.41 (n = 85, sd = 10.52) were considered girlfriends.

Douching exposure, knowledge, and attitude

Sixty-two percent of men indicated that they had been exposed to douching, most commonly by a television advertisement (49%), seeing a douching product in the cabinet (38%), a conversation (38%), learning about it in class (25%), seeing a douching product in a magazine (19%), or the internet (10%). “Other” responses (38%) included exposure through others (i.e. mothers, family, and significant other. Most individuals (81%, n = 74) exposed to douching reported the information gained was positive or neutral.

When asked to report the percentage of women that they think douche, 26% of men thought that between 1 and 20% of women douche, 34% said between 20 and 40%, 28% between 40 and 60%, and 12% felt that 60% or more of women douche. Several (41%) reported knowing a woman that douches, including a girlfriend (n =12), spouse (n = 7), mother (n = 17), sister (n = 7), friend (n = 15), aunt (n = 7), relative (n = 3), or grandmother (n = 1).

Participants were also asked to indicate whether they would want their significant other to douche. A little over half (53%) said no, while the others said yes (42%) or do not care. The men were then asked to indicate why they do or do not want their partner or women in general to douche (Table 1). Sixty-five percent said women should douche and 30% said no. Of those that would want their partner to douche, the most common reasons included cleanliness, vaginal odor, and feeling good and fresh (see Table 2). Additionally, men who knew a current doucher were more likely to think that women should douche (80%) than men who did not know a doucher (56%), χ2(3)= 10.527, p = .015.

Douching discussions given to subject

Participants also were asked to provide information on whether they had ever been involved in a discussion about douching. Thirty-nine percent reported receiving at least one discussion on douching, with the first discussion occurring between 10 and 48 years of age (m = 18.39, sd = 6.61). This discussion most commonly occurred with their girlfriend or spouse (42%), friend (30%), or mother (15%). Other responses (6%) included a grandmother (n = 1) or a friend’s mother (n = 1). The context in which the first discussion occurred is listed in Table 3. During this discussion, 24% of participants encouraged douching and 73% were neutral; one person discouraged it. Many participants endorsed douching to help with cleanliness (50%), treat vaginal odor (25%), prevent vaginal infection (7%), or prevent pregnancy (4%). Only 4% said that douching could cause vaginal irritation, damage the vagina, or that a woman’s body should clean itself.

Of individuals who reported having had a discussion about douching, 51% reported also having a second discussion between 12 and 27 years of age (m = 19.6, sd = 3.98). These conversations occurred with a friend (56%), girlfriend or spouse (29%), mother (6%), or sister (6%). The content of the second discussion and reasons for recommending douching were similar to the first discussion. Context for the first and second discussions are outlined in Table 3.

Of individuals that received a discussion on douching, ratings for the first and second discussions were similar. For both discussions, over 85% rated the discussion as “excellent”, “good”, or “fair”. The remaining 13% were unsure or rated the discussion as “poor.” Additionally, 38% of these men asked questions after their discussion. These questions mostly related to logistical practices (why, how often, and how it is done, and who taught her)

Discussions subjects will give to others

Participants also were asked questions about their willingness to discuss douching with others, what they would say about douching, whether douching is of relevance to their lives. Eighty-three percent (n = 74) participants stated that they would be willing to discuss douching in the future, but only 14% of them would discourage it. The remaining 86% would either encourage douching (n = 33) or remain neutral (n = 30). Additionally, men who were willing to discuss douching also were more likely to encourage it (44%) than men who were not willing to discuss douching (29%), χ2( =8.616, p = .035. For those who said that they would discuss douching, most would say that it helps with cleanliness (57%) and treats odor (39%). Others would say that douching is not birth control (24%), prevents infections (23%), is unnecessary (23%), can cause vaginal infection (17%), can treat vaginal infection (14%), or that the body should clean itself (13%). Sixty-three percent of men also gave reasons why they would not discuss douching, such as they would not know what to say (46%), it is not their place (45%), she does not want to hear about douching from them (36%), they would not be comfortable with the subject (34%), and she would not be comfortable with the subject (21%). Other responses regarding what men plan to say during a douching discussion and reasons not to discuss douching are located in Table 4

Although most men would be willing to discuss douching, only 44% (n = 39) felt that douching is relevant to them. Overall, most did not find it relevant because they were not in a relationship with a female (29%) or it was not important in their lives (22%). Only 26% found it relevant because douching impacts women in their lives, another 11% were concerned with protecting themselves from STDs. Five percent said their partner’s cleanliness and odor is relevant and 1% felt that it is relevant because they may have a daughter in the future. Respondents stated that their partner’s health, cleanliness, and hygiene would have an effect (33%), douching could affect their significant other or spouse (22%), it is relevant because they are sexually active (15%), they are concerned with protecting themselves from STDs or pregnancy (15%), and it is relevant to them because they are single (4%). Forty-four percent of the sample said they would be interested in learning more about douching and 56% added that they would find information on douching useful.

This study found that many college males have been exposed to female douching and several have had discussions about douching, often with their spouse or significant other (61%). As such, for many of the men that participated in this study, douching was not a completely novel topic. However, men who reported knowing a current doucher were more likely to think women should douche than men who did not know a doucher. Further, men who were willing to discuss douching were more likely to encourage it than men who were not willing to discuss douching. Therefore, men may be a point of intervention to decrease douching in women, as current knowledge and attitudes of men may actually serve to increase and promote douching 

Similar to research with females, males in this study reported many benefits to douching. Men tended to endorse douching for cleanliness, to remove menstrual blood, alleviate vaginal itching or odor, it feels good, and to treat infections, all of which have been endorsed by women participating in previous douching research [1,27,32,39-42,52]. Few men endorsed items regarding douching being an unnecessary practice, causing irritation, or that a woman’s body should clean itself. Therefore, similar to the challenge with women, of men that are familiar with douching, their knowledge is primarily positive and view douching as a beneficial form of feminine hygiene [1,27,37-39,41,42,52,53].

Several men in the study reported wanting their specific partner to douche, and over half of the participants want women in general to douche. Just over one third of the sample has had a discussion about douching, many with a significant other or a friend; however, the impact of these discussions typically serves to promote douching rather than discourage it, with only a few men discouraging its use and a majority expressing either positive or neutral attitudes. Previous research shows that women who douche are more likely to discuss douching with younger females and are likely to encourage its use [4252]. Likewise, men who have had a discussion about douching may also be more apt to encourage its use, perpetuating the practice of douching among females.

Overall, a majority of men (83%) also seemed willing to discuss douching with women, but only a small number of them (14%) would discourage its use. Additionally, less than half of the sample (44%) felt that douching was relevant to them and felt that it was not their place to discuss douching or that either they or their spouse would be uncomfortable with the subject material. It is possible that if men do not feel that douching is a topic that is relevant to them, then they may lack motivation to discuss the topic with a significant other. However, for those that are willing to discuss it, interventions may be needed, considering that men who know doucher or have had a discussion about douching were more likely to encourage or support its use. Thus, this has several implications for clinical practice and future interventions.

Implications for practice

This study suggests that men lack knowledge regarding the negative consequences of douching, and may even perpetuate its practice. However, many men expressed a willingness to discuss douching in the future. Education is needed to ensure that men have accurate information regarding the harms of vaginal douching, not only to their female partner, but potential effects on their own sexual health and activity. This may encourage men to discourage douching with the females in their lives. Though a logical leap, in addition to primary care physicians, men may be able to play a role in breaking the intergenerational cycle [42,52] that perpetuates douching; but they must first be educated so that they can provide accurate information to women in their life. Such education should not only include the negative health consequences associated with vaginal douching as specific to their partner, but also how their partner’s sexual health can be related to their own sexual health. Thus, educational interventions that may have the greatest impact are those that teach males about douching in ways that make it relevant to them and show how it can have a negative impact on them

Study limitations

Limitations of this study may include a sample bias towards men of a higher educational background. Since participants were undergraduate and graduate students, their additional education may have resulted in more information about douching than men with less education. This would suggest that the knowledge level projected in this sample may be not be average. Additionally, these results may not be generalized to non-college educated men, or older men who have greater long-standing relationships, and may subsequently have greater knowledge about douching, its practice, and risks. Also, this study also did not assess for sexual orientation; thus, it is not known to what extent the results of this study generalize to a homosexual or bisexual versus heterosexual population. Also, these results pertain only to the transmission of information in heterosexual or bi-sexual (i.e. male to female) relationships, and may not be indicative of douching knowledge and discussions that take place in women who have sex with women. Also, the use of a self-administered questionnaire limited the amount of detail obtained about douching related knowledge and attitudes. Future studies should examine different ways to educate men about douching and female hygiene, and whether or not women are likely to consider information from their significant others when making decisions about hygiene and sexual hygiene behaviors.

Little research has been done regarding men’s knowledge of female hygiene and sexual hygiene behaviors. Some literature has suggested that male preference and attitudes affect female sexual health practices, such as topical microbicide use [57,58], condom use [60,61], and HIV-prevention methods [62]. However, research also is sparse on the potential impact of men’s attitudes and opinions on such behaviors in women. This study suggests that if men are to be thought of change agent to reduce douching, they must first be educated about the accuracies of douching. For motivational purposes, it would also be beneficial to teach them ways in which the topic of douching and other female hygiene may impact them (e.g., STI infection, spread of bacterial infections, causing infections and irritation for their partner). The results from this study encourage future research and efforts to reduce douching and suggests a need to account for and improve men’s knowledge of douching. Additional work is needed on the potential role and impact of their opinion on partner sexual hygiene behaviors.

The authors wish to thank Angela Burgess, Lora Black, William Devine, and David Roach for their support in data collection and data management, and all of the men for their participation in this research study

Declarations and Conflict of Interest

This study received ethics approval from the University of Houston – Clear Lake institutional review board. This manuscript contains no personal details or information, and does not require consent for publication. Data used in the analyses for this publication can be obtained by contacting the corresponding author. There are no competing interests to report, declarable funding. Dr. Black assisted in data collection, analysis, manuscript preparation, and submission. Dr. Short was engaged in study design and conceptualization, data analysis, and manuscript preparation

1. Blythe MJ, Fortenberry JD, Orr DP. Douching behaviors reported by adolescent and young adult women at high risk for sexually transmitted infections. J Pediatr Adolesc Gynecol. 2003; 16: 95-100.

2. Scholes D, Stergachis A, Ichikawa LE, Heidrich FE, Holmes KK, Stamm WE. Vaginal douching as a risk factor for cervical Chlamydia trachomatis infection. Obstet Gynecol. 1998; 91: 993-997.

3. Ness RB, Soper DE, Holley RL, Peipert J, Randall H, Sweet RL, et al. Douching and endometritis: results from the PID evaluation and clinical health (PEACH) study. Sex Transm Dis. 2001; 28: 240-245.

4. Chow JM, Yonekura ML, Richwald GA, Greenland S, Sweet RL, Schachter J. The association between Chlamydia trachomatis and ectopic pregnancy. A matched-pair, case-control study. JAMA. 1990; 263: 3164-3167.

5. Daling JR, Weiss NS, Schwartz SM, Stergachis A, Wang SP, Foy H, et al. Vaginal douching and the risk of tubal pregnancy. Epidemiology. 1991; 2: 40-48.

6. Kendrick JS, Atrash HK, Strauss LT, Gargiullo PM, Ahn YW. Vaginal douching and the risk of ectopic pregnancy among black women. Am J Obstet Gynecol. 1997; 176: 991-997.

7. Wølner-Hanssen P, Eschenbach DA, Paavonen J, Stevens CE, Kiviat NB, Critchlow C, et al. Association between vaginal douching and acute pelvic inflammatory disease. JAMA. 1990; 263: 1936-1941. 

8. Zhang J, Thomas AG, Leybovich E. Vaginal douching and adverse health  effects: a meta-analysis. Am J Public Health. 1997; 87: 1207-1211.

9. Fiscella K, Franks P, Kendrick JS, Bruce FC. The risk of low birth weight associated with vaginal douching. Obstet Gynecol. 1998; 92: 913-917.

10. Iannacchione MA. The Vagina Dialogues: Do You Douche?: Douching is associated with significant risks. Nurses are in a position to suggest alternatives. AJN The American Journal of Nursing. 2004; 104: 40-45.

11. Shaaban OM, Youssef AE, Khodry MM, Mostafa SA. Vaginal douching by women with vulvovaginitis and relation to reproductive health hazards. BMC Womens Health. 2013; 13: 23.

12. Baird DD, Weinberg CR, Voigt LF, Daling JR. Vaginal douching and reduced fertility. Am J Public Health. 1996; 86: 844-850.

13. Mueller BA, Luz-Jimenez M, Daling JR, Moore DE, McKnight B, Weiss NS. Risk factors for tubal infertility. Influence of history of prior pelvic inflammatory disease. Sex Transm Dis. 1992; 19: 28-34.

14. Luo L, Xu JJ, Wang GX, Ding GW, Wang N, Wang HB. Vaginal douching and association with sexually transmitted infections among female sex workers in a prefecture of Yunnan Province, China. Int J STD AIDS. 2016; 27: 560-567.

15. Foxman B, Aral SO, Holmes KK. Interrelationships among Douching Practices, Risky Sexual Practices, and History of Self-Reported Sexually Transmitted Diseases in an Urban Population. Sex Trans Dis. 1998; 25: 90-99.

16. Gresenguet G, Kreiss JK, Chapko MK, Hillier SL, Weiss NS. HIV infection and vaginal douching in central Africa. AIDS. 1997; 11: 101-106.

17. La Ruche G, Messou N, Ali-Napo L, Noba V, Faye-Ketté H, Combe P, et al. Vaginal douching: association with lower genital tract infections in African pregnant women. Sex Transm Dis. 1999; 26: 191-196.

18. Low N, Chersich MF, Schmidlin K, Egger M, Francis SC, van de Wijgert JH, et al. Intravaginal practices, bacterial vaginosis, and HIV infection in women: individual participant data meta-analysis. PLoS Med. 2011; 8: e1000416.

19. Bui TC, Thai TN, Tran LT-H, Shete SS, Ramondetta LM, Basen-Engquist KM. Association Between Vaginal Douching and Genital Human Papillomavirus Infection Among Women in the United States. J Infect Dis. 2016; 214: 1370-1375.

20. Gonzalez NL, O’Brien KM, D’Aloisio AA, Sandler DP, Weinberg CR. Douching, Talc Use, and Risk of Ovarian Cancer. Epidemiology. 2016; 27: 797-802.

21. Aral SO, Mosher WD, Cates W Jr. Vaginal douching among women of reproductive age in the United States: 1988. Am J Public Health. 1992; 82: 210-214.

22. Forrest KA, Washington AE, Daling JR, Sweet RL. Vaginal douching as a possible risk factor for pelvic inflammatory disease. J Natl Med Assoc. 1989; 81: 159-165.

23. Rosenberg MJ, Phillips RS. Does douching promote ascending infection? J Reprod Med. 1992; 37: 930-938.

24. Scholes D, Daling JR, Stergachis A, Weiss NS, Wang SP, Grayston JT. Vaginal douching as a risk factor for acute pelvic inflammatory disease. Obstet Gynecol. 1993; 81: 601-606.

25. Chacko MR, Kozinetz CA, Regard M, Smith PB. The relationship between vaginal douching and lower genital tract infection in young women: A Search for Risk Modulating Factors. Adolescent Pediat G. 1992; 5: 171-176.

26. Cottrell BH. Vaginal douching. J Obstet Gynecol Neonatal Nurs. 2003; 32: 12-18.

27. Cottrell BH. Vaginal douching practices of women in eight Florida panhandle counties. J Obstet Gynecol Neonatal Nurs. 2006; 35: 24-33.

28. Holzman C, Leventhal JM, Qiu H, Jones NM, Wang J; BV Study Group. Factors linked to bacterial vaginosis in nonpregnant women. Am J Public Health. 2001; 91: 1664-1670.

29. Ness RB, Hillier SL, Richter HE, Soper DE, Stamm C, McGregor J, et al. Douching in relation to bacterial vaginosis, lactobacilli, and facultative bacteria in the vagina. Obstet Gynecol. 2002; 100: 765.

30. Onderdonk AB, Delaney ML, Hinkson PL, DuBois AM. Quantitative and qualitative effects of douche preparations on vaginal microflora. Obstet Gynecol. 1992; 80: 333-338.

31. Zhang J, Hatch M, Zhang D, Shulman J, Harville E, Thomas AG. Frequency of douching and risk of bacterial vaginosis in AfricanAmerican women. Obstet Gynecol. 2004; 104: 756-760.

32. Cottrell BH. An updated review of of evidence to discourage douching. MCN Am J Matern Child Nurs. 2010; 35: 102-107.

33. Rezk M, Sayyed T, Masood A, Dawood R. Risk of bacterial vaginosis, Trichomonas vaginalis and Candida albicans infection among new users of combined hormonal contraception vs LNG-IUS. The European journal of contraception & reproductive health care: the official journal of the European Society of Contraception. 2017:1-5.

34. Chandra A, Martinez GM, Mosher WD, Abma JC, Jones J. Fertility, family planning, and reproductive health of US women: data from the 2002 National Survey of Family Growth. Vital Health Stat. 2005; 25: 1-160.

35. Merchant JS, Oh K, Klerman LV. Douching: a problem for adolescent girls and young women. Arch Pediatr Adolesc Med. 1999; 153: 834- 837.

36. Oh MK, Merchant JS, Brown P. Douching behavior in high-risk adolescents. What do they use, when and why do they douche? J Pediatr Adolesc Gynecol. 2002; 15: 83-88.

37. Oh MK, Funkhouser E, Simpson T, Brown P, Merchant J. Early onset of vaginal douching is associated with false beliefs and high-risk behavior. Sex Transm Dis. 2003; 30: 689-693.

38. Alcaide ML, Mumbi M, Chitalu N, Jones D. Vaginal cleansing practices in HIV infected Zambian women. AIDS Behav. 2013; 17: 872-878.

39. Annang L, Grimley DM, Hook EW 3rd. Vaginal douche practices among black women at risk: Exploring douching prevalence, reasons for douching, and sexually transmitted disease infection. Sex Trans Dis. 2006; 33: 215-219.

40. Gazmararian JA, Bruce FC, Kendrick JS, Grace CC, Wynn S. Why do women douche? Results from a qualitative study. Matern Child Health J. 2001; 5: 153-160.

41. Ness RB, Hillier SL, Richter HE, Soper DE, Stamm C, Bass DC, et al. Why women douche and why they may or may not stop. Sex Transm Dis. 2003; 30: 71-4.

42. Rupp R, Short MB, Head-Carroll Y, Rosenthal SL. Intergenerational transfer of douching information. J Pediatr Adolesc Gynecol. 2006; 19: 69-73.

43. Bui TC, Tran LT, Hor LB, Scheurer ME, Vidrine DJ, Markham CM. Intravaginal Practices in Female Sex Workers in Cambodia: A Qualitative Study. Arch Sex Behav. 2016; 45: 935-943.

44. Brotman RM, Klebanoff MA, Nansel T, Zhang J, Schwebke JR, Yu KF, et al. Why do women douche? A longitudinal study with two analytic approaches. Ann Epidemiol. 2008; 18: 65-73.

45. Cottrell BH, Close FT. Vaginal douching among university women in the southeastern United States. J Am Coll Health. 2008; 56: 415-421.

46. Foch B, McDaniel N, Chacko M. Racial differences in vaginal douching knowledge, attitude, and practices among sexually active adolescents. J Pediatr Adol Gynec. 2001; 14: 29-33 

47. Czerwinski BS. Variation in feminine hygiene practices as a function of age. J Obstet Gynecol Neonatal Nurs. 2000; 29: 625-633.

48. Lichtenstein B, Nansel TR. Women’s douching practices and related attitudes: findings from four focus groups. Women Health. 2000; 31: 117-131.

49. Caliskan D, Subasi N, Sarisen O. Vaginal douching and associated factors among married women attending a family planning clinic or a gynecology clinic. Eur J Obstet Gynecol Reprod Biol. 2006; 127: 244- 251.

50. Chacko MR, McGill L, Johnson TC, Smith PB, Nenney SW. Vaginal douching in teenagers attending a family planning clinic. J Adolesc Health Care. 1989; 10: 217-219.

51. Funkhouser E, Pulley L, Lueschen G, Costello C, Hook E 3rd, Vermund SH. Douching beliefs and practices among black and white women. J Womens Health Gend Based Med. 2002; 11: 29-37.

52. Short MB, Black WR, Flynn K. Discussions of vaginal douching with family members. J Pediatr Adolesc Gynecol. 2010; 23: 39-44.

53. Alcaide ML, Cook R, Chisembele M, Malupande E, Jones DL. Determinants of intravaginal practices among HIV-infected women in Zambia using conjoint analysis. Int J STD AIDS. 2016; 27: 453-461.

54. McKee D, Baquero M, Anderson M, Karasz A. Vaginal hygiene and douching: perspectives of Hispanic men. Cult Health Sex. 2009; 11: 159-171.

55. Morar NS, Ramjee G, Gouws E, Wilkinson D. Vaginal douching and vaginal substance use among sex workers in KwaZulu-Natal, South Africa: research letter. S Afr J Sci. 2003; 99: 371-374.

56. Bisika T, Ntata P, Konyani S. Gender-violence and education in Malawi: a study of violence against girls as an obstruction to universal primary school education. J Gender Stud. 2009; 18: 287-294.

57. Montgomery CM, Lees S, Stadler J, Morar NS, Ssali A, Mwanza B, et al. The role of partnership dynamics in determining the acceptability of condoms and microbicides. AIDS Care. 2008; 20: 733-740.

58. Salter ML, Go VF, Celentano DD, Diener-West M, Nkhoma CM, Kumwenda N, et al. The role of men in women’s acceptance of an intravaginal gel in a randomized clinical trial in Blantyre, Malawi: a qualitative and quantitative analysis. AIDS Care. 2008; 20: 853-862.

59. Catallozzi M, Williams CY, Zimet GD, Hargreaves KM, Gelber SE, Ratner AJ, et al. Attitudes towards microbicide use for bacterial vaginosis in pregnancy. Sex Health. 2014; 11: 305-312.

60. Hood KB, Shook NJ. Who Cares What Others Think? the Indirect Effect of Others’ Attitudes on Condom Use Intentions. Int J Sex Health. 2014; 26: 282-294.

61. Vasilenko SA, Kreager DA, Lefkowitz ES. Gender, Contraceptive Attitudes, and Condom Use in Adolescent Romantic Relationships: A Dyadic Approach. J Res Adolesc. 2015; 25: 51-62.

62. Montgomery ET, van der Straten A, Chidanyika A, Chipato T, Jaffar S, Padian N. The importance of male partner involvement for women’s acceptability and adherence to female-initiated HIV prevention methods in Zimbabwe. AIDS Behav. 2011; 15: 959-969