#1: Douching
COMMUNITY VOICE: Brad Loekle | HEALTHCARE EXPERTS: Jon Baker PA-C, Jordan Axelrad, MD Mitchell Lunn, MD
SHOW NOTES
Definitions
Douching: technically refers to cleansing the vaginal canal with liquid
Enema: delivers water or a solution directly into the rectum to loosen fecal matter and stimulate a bowel movement (i.e. pooping). Can be done as a way of relieving constipation or as a way to “clean house” before anoreceptive sex
Ways to douche
Bulb enema
A common “over the counter” option you can find at drugstores
Includes a bulb (filled with fluid) attached to a nozzle which can be inserted into the rectum
Can buy reusable rubber enemas that you fill with tap water, or can buy brand names (such as Fleet enemas) that come pre-filled with solutions designed to help stimulate a bowel movement - more on these solutions later.
A rubber bag with a small tube attached. You fill the bag with water, lock the tube shut with a small plastic piece and insert the other end of the tubing into the anus
A great option for folks who need to be in certain positions while douching or have mobility differences
Shower nozzle:
What it sounds like.
Beware of the high velocity and large volumes that come with shower nozzle douching. These can be damaging to the rectum!
Best practices – or, how to ace your douching exam
Dietary fiber
What to buy: something with psyllium husk or high soluble fiber as the active ingredient. No need to buy brand names (all you’re paying for is the muscular torsos on the labels, which...fair)
The dose: scale up slowly (every other day) to avoid bloating, cramping and other side effects. Increase gradually, and goes best with water
The actual gymnastics – er, mechanics
Positioning: bent at the waist (this straightens the rectum, making it easier to get liquid where it needs to go)
Place lube on the tip of the device to prevent local trauma to the area
Insert the device into the rectum but not too far (otherwise water goes too far in and you pull down unformed stool into the very area you want to cleanse)
Hold a Coke can-volume of water for about a minute
Expel into the toilet
Myth-busting
“The harder and faster I douche, the better”
Douching at high volumes/speeds (e.g. with shower nozzles) can can physically damage the rectum
Water can travel too far and risk pulling extra feces into the rectum
“I can douche as often as I’d like”
Aim to douche no more than 1x/day and 3x/week
When we say once a day, we mean the entire process of clearing the rectum, knowing that you may need more than one rinse per sitting, so to speak
Some experts have pointed out that douching runs the risk of stripping the colon of its mucosal layer – which plays an important protective role
“Douching with ~fancy~ commercial solutions is better than douching with plain water”
Douching with water - tap water - is preferable over other solutions (such as those found in brand-name enemas)
No need to look for “pH balanced” solutions – the anus is a neutral pH with the rest of the body
Moreover, some of these solutions are designed to irritate the colon/rectum to help you poop, which – while useful for constipation – should be avoided if you plan on inserting something else into your rectum shortly thereafter
“Using warmer water helps cleanse more effectively”
Remember: the tips of our fingers can handle water temperatures a lot higher than than what our insides can
Lukewarm water is the way to go (since cold water, while safe, is not terribly pleasant)
“Douching after sex will help me avoid sexually transmitted infections”
In fact, the opposite may be true, as further local mucosal injury and introduction of pathogens may increase the risk of injury and/or acquiring an infection.
Overall, douching after sex does not decrease the risk of getting a sexually transmitted ifnection and has no proven health benefit.
Douching and sexually transmitted infections
There’s very little scientific literature on this subject. However, the few studies we’ve found suggest that those who douche > 1x per week may have an increased association with getting an STI, such as chlamydia, gonorrhea, or HIV
The reasoning behind this: in those who douche, the outer protective layer of cells in the rectum can sometimes be removed. This means that bugs that cause STIs have increased access to their port of entry, so to speak.
For people who have sex without condoms, remember that part of being a responsible sex partner is getting screened for STIs in the sites you use for sex (including your butt and throat)
Is there anyone who should think carefully about douching?
Patients with high-inflammatory states affecting their rectum:
Particularly underlying colitis, active rectal or anal infections, active HPV.
In these cases, douching may exacerbate the underlying condition by further irritating the rectum.
Patients whose immune systems aren’t running at 100% (such as those with HIV and low CD4 counts):
These folks can be susceptible to a greater number of infections.
Important to make sure filtered or bottled water is being used
Patients with chronic kidney disease:
Folks with chronic kidney disease have a hard time clearing phosphate from their systems.
Here, the pro-tip is to avoid using phosphate solutions (such as those found in Fleet enemas) since this introduces extra phosphate to your retum which can then be absorbed into your body.
TRANSCRIPT
Brad: I am a bottom and I am an avid doucher. I'm a big fan of it. I've got probably 20+ years of experience with it under my belt - literally.
Sam: Welcome to Queer Health Podcast - a podcast that talks about health for sexual and gender minorities. I'm Sam. I use he/him pronouns and I’m an Internal Medicine/Primary Care resident in New York City.
Gaby: I'm Gaby. My pronouns are she/her, and I have the same job title.
Sam: If you're interested in knowing why we started this podcast and what to expect from this season, we encourage you to check out our five minute intro episode that you should be able to find on whatever streaming service you're using.
Gaby: ...and who is it that just told us they bottom?
Sam: That was Brad Loekle.
Brad: I am a standup comedian and television writer. People might recognize me from my years on a show called World’s Dumbest on truTV. I was one of Joan River's’ writers for Fashion Police for many, many, many years. A semifinalist on Last Comic Standing, and the author of the book My Big Gay Life.
Sam: what doesn't appear on Brad's resume is actually the reason we asked to talk with him, the skill he has cultivated for over two decades. And that is today's topic: douching.
Gaby: And by that, we mean: putting water in your butthole to get any uninvited poop out of your anus and rectum before sex.
Sam: So – if you have a butthole and it's in your cast of sexual body part characters, or that's an aspiration of yours, this episode is for you.
Gaby: Okay. So we do have one more person to introduce before we can get things rolling.
Richard: I'm Richard Greene, a primary care doctor in New York city and the medical director of the Pride Health Center at Bellevue Hospital. And my pronouns are he and him.
Gaby: Richard is going to give us some perspective on why douching is even a queer health topic in the first place.
Richard: Douching is pretty common among gay, bisexual, and queer men who have anal sex. And also it's widely discussed in the community, but no one ever brings it up with their healthcare provider. And most of the healthcare providers I know have absolutely no information about it – and some feel so uncomfortable that they will actually just tell patients not even to do it without even much information. So are you ready to take a deep dive into the data on douching?
Sam: We're going to cover a few things that you need to know about understanding the risks and benefits of douching.
Gaby: we're going to cover the relevant anatomy and the role of fiber supplements.
Sam: ...and also what kind of liquid is safe to use and some associated risk with douching, like sexually transmitted infections.
Richard: And while Brad is a gay cisgender bottom – and the studies we'll discuss often focused on men who have sex with men and include a small number of trans women, too – it's also really important to note that a 2018 study showed us that about a third of cisgender women who have anal sex also use rectal enemas.
Sam: Alright. So basically, like I said: if you have a butthole and it's part of your sex life – or maybe you want it to be part of your sex life – this information is for you.
[QHP THEME MUSIC + TOILET FLUSH]
Brad: the first time a guy I hooked up with told me, you should probably do I didn't even think he meant enema. So I went to CVS and got a women's old school – I don't even know if they make these anymore – but like a Summer’s Eve. Thinking that was the gay protocol. Quickly learned that it wasn't, I didn't make that product.
Richard: In my early days, there were ads on TV where a mother and a daughter wearing flowy gossamer dresses would walk down the beach and one would say to the other, “you know, sometimes I just don't feel fresh.” And then there would be an ad for vaginal douching.
Sam: Would it say the words “vaginal douche”?
Richard: No, it would be called Summer’s Eve. No one actually knew what it was, but the phrase “sometimes I just don't feel fresh” became canonized into gay parlance.
Sam: So Brad too, had probably heard about what it means to have a Summer's Eve, “not so fresh” kind of moment.
Brad: I only did that once - and then I talked to other gay men and friends. Who were like, “Oh no, honey. When we say douching, we mean clean out your rear.”
Sam: So this brings up questions. Number one – and pardon the pun – number two. Let's define douching. And by douching, we mean enema. And by enema, we mean tap water enema.
Gaby: Amidst all those puns you've actually made a really important point, which is that douching specifically refers to flushing the vaginal canal with water, with the intention to clean it. As an aside - these vaginal douches are not recommended for a handful of health reasons but the big takeaway is: technically speaking, douching refers to vaginal cleansing.
Sam: Okay, so let's bear down on some more definitions. So if douching isn't the term for – well, douching – then what is? That answer is enemas. Enemas are meant for relieving constipation. They're designed to deliver water or a solution directly into the rectum to loosen poop and stimulate the act of pooping
Gaby: Even when we take out vaginal douche from the picture, there are still a lot of different ways to douche your rectum. For starters, some people use shower nozzles if they have them handy. And the idea here is pretty straightforward. You turn the nozzle on, point it at the rectum and let the water pressure do the work. Other folks might prefer a lower-velocity option such as a bulb enema. And this is one of the most common types of douching tools out there you can buy these empty and fill them with tap water or in the case of a brand called Fleet enema, they'll come prefilled with some sort of solution already inside of them
Sam: Let's talk about the potential side effects of using fleet enema solutions rather than just a vessel filled with tap water.
Richard: Fleet is a type of saltwater solution, a ~sodium phosphate~.
Gaby: The product is meant to help with constipation. Not douching – constipation. There's actually a difference here.
Richard: the reason we're making this distinction is because the liquid that comes at a Fleet enema to help with constipation actually irritates the colon, causing it to contract. Which is why it's not a great thing to use. If you're preparing for sex; you don't want your colon to be irritated, cause it might pull more things forward.
Gaby: All right. So now we've talked about shower nozzles, we’ve talked about enemas, we've gone through the pros and cons of using fleet enemas but there's one more kind of enema or douching product that I want to mention.
Sam: This is a bag that you can hang with tubing that has a shutoff clam meaning you can insert the nozzle into your rectum but not allow the water to enter until you're somewhere where you feel you can expel the water the way you want to.
Gaby: And accessibility plug: this option is great for folks who aren't sure if they can make it from where they're douching over to the toilet fast enough. The shutoff clamp is key for that. All right, let's move on. I want to talk about what evidence is out there for each of these cleansing options and get a sense of what we know and what we don't know.
Sam: Emphasis on the “don't know.”
Jon: There is an absolute dearth of information. We know almost nothing about douching.
Sam: That's Jon Baker
Jon: I am a PA or physician assistant. I focus on sexual health, especially for, gay men, and other people engaging in anal intercourse.
Gaby: When Jon says we know almost nothing about douching, what he means is that there are no published guidelines or strong scientific studies done that asked douching-specific questions.
Richard: There isn't nothing. We'll touch upon some of the studies later, but it's not so well-studied. And so recommendations often rely on expert opinion.
Gaby: Speaking of our experts, I want to go back to Jon to get to the very bottom of what drives douching. Which, to put it plainly, is butt anatomy.
Jon: The - the anus and rectum itself ranges from about eight inches to 12 inches. depending on a person's anatomy. And in a totally healthy rectum and anus, there actually should be no stool there. There's a muscle that's called the puborectalis that holds stool above the anus and rectum. And then when you defecate that muscle relaxes and allows us to all the past.
Sam: So a muscle that holds the poop above the rectum until you're over the toilet bowl, ideally, and keeps it out of the rectum.
Gaby: Yes, your rectum is cinched in. As long as she’s cinched tight, the poo is off the rectal runway.
Sam: This week's challenge, rectal realness.
Jon: So in a very happy, healthy working GI system, the anus and rectum is clear. That gives you an eight, eight to 12 inch landing space, which for the majority of, of encounters is going to be fine. every once in a while we have that great encounter where maybe it's not – and that may bring us to a different place.
Sam: So, unless you're putting something bigger than a foot into your rear for most folks, you're in rectal territory
Gaby: So I guess the big takeaway for me is that for most people, the rectum is going to be what you want to focus on for cleanliness before intercourse. Or, to put it another way, the rectum is going to be the floor that you want to sweep before you have guests over. This is where I want to introduce another one of our experts, Dr. Jordan Axelrad. He's a gastroenterologist or a digestive tract doctor at NYU where he primarily works with folks who have diseases like colitis and inflammatory bowel disease. And he had some basic housekeeping tips when it comes to douching.
Jordan: I have generally recommended that patients who just want to maintain on a diet that's high in soluble fibers, you know, so basically bulk laxative things like psyllium and so forth can be really useful.
Gaby: So fiber is what both Jon and Jordan brought up for keeping the rectum clean.
Sam: the cinched rectum.
Richard: cinched, but not clenched.
Sam: Very important.
Gaby: Say more. Richard, what do you mean by that?
Richard: So some people hold a lot of tone in their rectum, particularly in their anus. And it can cause some problems with, hemorrhoids – but that's a - that's an issue for another day.
Gaby: Getting back to douching, it sounds like both of our experts feel like the key to douching is fiber. Fiber through your mouth in a pill form or through your diet.
Jordan: There's not like one particular brand or anything like that. Of course, there's like a lot of marketing towards men who have sex with men of that, different fiber supplements. We all know them. I think basically any brand of like psyllium or something like that, or even Metamucil will do it.
Sam: Things like Metamucil or psyllium husk work as bulking agents. That means they basically sweep everything hanging around in the digestive tract along and then delivering it all bulked up to the rectum for easy removal.
Gaby: Okay. So the experts have all recommended fiber, but does Brad in the field have any experience with it?
Brad: It doesn't help me. I tried those – some of those pills and some of those formulas that they say are specifically for bottoms and that, you know, a lot of gay men in particular will see other gay men on Instagram and Twitter kind of promoting. They have in no way produced a better response, and a few of them actually really my body had a negative response to.
Sam: Jon actually spoke to this phenomenon of folks taking fiber supplements and feeling discomfort.
Jon: People definitely will get some, some side effects if they just start with a huge amount of fiber or when their body isn't, isn't used to that.
Gaby: And so here, we're talking about side effects, like bloating, diarrhea, cramping, all of which Brad was alluding to earlier.
Sam: Richard, what exactly do we know about the role of water and fiber supplements and feeling constipated and bloated?
Richard: It's hard to make generalizations, but there's some data out there – given that the colon pulls water in when there's fiber there – to make sure that people stay well hydrated. Because if you get dehydrated, it can be thicker and maybe not pass as easily as we want. And drinking plenty of water and scaling it up slowly. if you're someone who's thinking about taking fiber supplements is the way to help minimize some of the cramping and feeling bloated.
Sam: How would you sum up the dosing recommendations for folks who would start a fiber supplement that our experts gave us?
Richard: It's hard to make a recommendation on a starting dose cause it hasn't really been studied. But if you've tried fiber and it made you crampy, then try taking half the dose you took initially - or spread out how often you take it when you start – maybe every other day, just to get things moving.
Gaby: Dosing stuff aside, we should note that both experts have said that generic brands are totally fine. Though, to Brad's point, there will be fewer torsos and the advertising which is plus or minus depending on what you're into. But long story short the active ingredient not the brand is what you should be focusing on
Sam: Ultimately, you're looking for something with ingredients that say “psyllium husk” or with “high soluble fiber content”. It is worth mentioning that fiber has benefits beyond douching.
Jordan: It's also good for health. You know, generally because high fiber diets have been associated with reductions in cholesterol, reductions in your risk of diabetes and cardiovascular health. And, um, you know, I think that that's something else to keep in mind.
Gaby: In summary fiber is good for your health and good for your douching goals.
Sam: Alright, so fiber or no fiber, many folks are still going to do. Let's talk about the physical mechanics of it. Brad was telling us about using an enema bulb where he had had a bit of a mechanical mishap.
Brad: I did one time clench too soon and separated – cause on most enema bulbs, It's not...the little tube is not fused to the bulb to make it easy to clean – and I clenched too soon. And so they separated. That only happened. once You learn from that experience.
Sam: We decided Brad can call his douching autobiography Clenched Too Soon.
Gaby: We touched base with Jon for his more mechanics oriented instructions that unfortunately came too late for a younger, more naive Brad.
Sam: Was it stand, sit, squat, turn, work?
Gaby: No, not exactly Sam. Just…listen to the experts.
Jon: I think if you have the space in your bathroom to lie on know side, that's probably the most comfortable and easiest to control. some patients will spot over the enema. Some patients will bend over a surface, like a counter. That bending motion actually helps to relax the rectum, and straighten things out so that that enema can go straight in. So you do actually want to be bent at the waist, during enema use.
Sam: A little bathroom floor lay down sounds nice.
Gaby: Yes. (laughs) And unlike Brad, we'll spare using your roommate's nice towels to clean up the butt fountain that you accidentally made.
Sam: Okay. So just like Seder, we’re reclining and we start to feel the urge to escape to the bathroom.
Gaby: Not exactly at my Seder, Sam.
Sam: Okay. Fair enough.
Gaby: So what about how to put the enema device where it needs to go? Did we have any mechanical advice there?
Richard: Jon - and I - advise putting some lube on the tip of whatever device you're using and inserting it into the rectum. And once the lube is on, Jon recommends this.
Jon: Insert it all the way until the widening part of either that bottle or the ridge is against the outside of the anus, and then squeeze it to expel the liquid into the anus and rectum. Hold it there for no more than a minute. And then you'll expel to the toilet.
Gaby: And if you can't hold it that long, that's okay.
Sam: Exactly. Everyone's body will react a little bit differently. All right. So that's how to get water inside the rectum. But once it's there we wanted to know from Jon if there's anything else someone should be thinking about
Jon: You really actually kind of want the water to stay in the rectum. You want it at the very end. If that goes past the rectum, It's going to mix with stuff that's not necessarily stool yet. that's in the rest of the colon, and then it may actually drag that into the rectum. So you may actually bring a store into the place that you're trying to get out of.
Sam: Lying on your side or a little bent at the waist, some lube on the tip of your enema device, a gentle insertion and voia.
Gaby: Just make sure you're near a toilet in case voila happens fast.
[QHP THEME MUSIC + TOILET FLUSH]
Sam: Alright. So let's talk about some more nuances. Like the volume of water folks should be using.
Gaby: So some use a store-bought enema that they feel with tap water and use others have a rubber reusable bulb, which they fill a few times and then others have a shower nozzle attachment, which would presumably be a lot more water in terms of volume.
Brad: I know a lot of gay men, gay men are men, and we get oddly competitive, so they're using a shower attachment so that now technically an endless flow of water is kind of like, well, ready, fill myself up as much as I can, take because that'll somehow clean me out better, the other person might be able to go deeper and penetrate me further sexually. I have heard that that is the douche you should not be using for a myriad of reasons, like controlling water pressure, controlling temperature, overloading your anal cavity doing damage that way.
Richard: We brought up the question of volume and damage to our experts. In short, Brad was right. The nozzle predisposes folks to the most risk because of the high volume of water. It can deliver so rapidly
Sam: So if the shower nozzle delivers too much water what is the right or safe volume for douching?
Jordan: so definitely, you know, I wouldn't do more than like eight ounces or so, or, or a can of diet Coke, for example. Just a couple of ounces is usually, you know, sufficient to really clear the rectum if that’s the issue.
(Can of soda being opened)
Sam: Hey Gaby, can I borrow that can of Coke for a second?
Gaby Um, you can keep it.
Sam: So somewhere between a well drink and a can of Coke is a safe volume.
Gaby: Yeah. So which brings us back to the safety concerns about shower nozzles. And here's Jon again, on some advice for people who do use the shower nozzle to douche.
Jon: The, the two problems with the shower attachment one is the pressure. And so I think probably my best advice there, if you want to use a shower attachment, is to watch the water until it's shooting up about maybe an inch or two. but no more than that. Cause again, you don't want to shoot that directly into the rest of the colon. You want to keep it in the rectum. So really get the pressure set before you insert it.
Gaby: because remember, if it gets into the colon, you have unformed poop there that once brought into the rectum takes more time to clean out. So you're not doing yourself any favors.
Jon: And then the other part is the timing of it. So once you put that in there and there's water going in, you really don't know how much water. And so the goal would be to use a really similar amount to what would be in the two vehicles that were recommended – so probably about a cup of water. And that's going to be really hard to judge when you're using the shower attachment. But I will tell you, if you've used enough water that you're getting this sort of unformed stool, which is often very fibrous looking and it doesn't look like what you would expect to be in the toilet, then you're probably going too far or putting too much liquid in there.
Richard: Let's be clear about the safety aspect here. Putting large volumes of water into the rectum can cause problems by either stretching the tissue and putting in small tears or worse, large ones. And using volumes the size of a water bottle – one at a time – can prevent that.
Gaby: So if you're using small volumes, then how do you know when enough is enough? Brad actually had some thoughts on this.
Brad: When Catholics are waiting for a new Pope, they're waiting for the smoke to go white. And when I’m douching, I'm waiting for the water to go clear.
Sam: Ah. A truly religious experience.
Brad: So if that happens after one bulb, then great. That's where my, you know my anus was that day. If it takes a couple of times, it takes a couple times.
Sam: But what about the safety and risks of how often you douche?
Gaby: So not how much water in a given bulb or how many bulbs to use each time, but how many times you're douching throughout, saym a week?
Richard: And to answer that, let me introduce my friend and colleague, Dr. Mitchell Lunn.
Mitchell: I'm an assistant professor of medicine at Stanford University School of Medicine. I am a nephrologist by training, and I spend about 75% of my time conducting LGBTQ+ health research.
Gaby: So we asked Mitchell how often folks do and the associated health risks that can come with more frequent douching..
Mitchell: When I think of the kind of the words “aggressive douching,” I think of folks who do more than, more than once a day and, more than three times a week.
Richard: Like we were saying, the frequency that you douche has its own set of risks. Where too much volume is about fissuring or physical trauma, too often can lead to inflammation.
Mitchell: And the reason for that is that, with every douching you're getting rid of some of that, mucus layer, and that, is really a protective layer. It's what protects your colon from getting infected from the billions and billions of bacteria that are in your large intestine.
Richard: So here's where we are now. Start with fiber, not too fast. If you're going to douche, tap water, use a dash of lube to avoid fissures and tears and keep the volume of water low in your rectum. So it's not to invite anything from above in your colon, down to the party.
Gaby: Or onto the bedsheets,
Sam: Nozzle gals, low flow, low volume. (starts singing) dooooon't go chasing –
Richard: Are we allowed to do that?
Sam: No.
[QHP THEME MUSIC + TOILET FLUSH]
Brad: There's legitimate concerns to be had about Rite aid or health, if you're over-douching – doing multiple douches a day all the time. Um, I also think like people are now like, I don't want you to put like matcha and chai tea and like, you know, rose quartz and grind it up and put it in my anus. Like, I don't want artisinal farm-to-table.
Sam: According to a review of enema use in men who have sex with men, roughly two thirds used water to douche. And about a quarter of the folks who do she added salt soap and/or an antibacterial product to the water. And overall about a third of the folks who were douching just used a commercially available product.
Gaby: So we didn't ask Jon about his farm to table preferences, but he actually did weigh in on water types.
Jon: The anus is a neutral pH with the rest of the body, so you don't need to use either anything acidic or basic. And as long as you're, you're using water, that's probably about as safe as we can get with the, the current state of knowledge.
Sam: So solutions that are sold as pH balance? Well, that shouldn't really matter according to our experts, because if you're using water, the pH is going to be just fine for your rectum.
Gaby: Right. And tap water or bottled water. Is that a pH that is totally fine for your rectum.
Sam: Mitchell also noted that temperature really matters –
Mitchell: But I would want to emphasize not to have hot water, people. We always are taught that hot water is what you're supposed to, you know, wash your hands with and all these other things. I tend to remind people that our tips of our fingers can handle water temperatures a lot higher than than what our insides can. lukewarm water. Is, is the way to go cold is also not pleasant. Right? So somewhere in between.
Gaby: Okay. so warm water.
Richard: What about adding soaps, extra salts or rubbing alcohol?
Sam: Warm. Water.
Richard: Are we sure?
Mitchell: don’t douche with bleach. Don't douche with isopropyl or rubbing alcohol.
Sam: Okay. So that was clear. No bleach, no alcohol water. Just use tap water.
[QHP THEME MUSIC + TOILET FLUSH]
Sam: Now that we have covered the 101 level for douching, we're going to pivot. We've talked about how to maximize safety and try to convey what we do know.
Gaby: …and part of the reason we wanted to start with douching is because we hear so many rumors about it.
Sam: Yeah. Like it's the worst thing you could do.
Gaby: But somehow so many queer people are expected to do it.
Richard: We asked Brad about what it actually looks like when folks have the information about potential harm and could discuss this with their healthcare providers.
Brad: It seems to me that conversation is happening more and more if you have an LGBTQ+ doctor. A more focused doctor. But I can, but I can also see the pushback where people are like, I'm just gonna like continue to do that in a way that I've always done. Cause I would rather not have a fecal moment.
Richard: It's important to remember that there's a balance between knowing the health risks and knowing that you don't want poo around during sex. And so when I talk to patients, I mostly ask people what they know about the health risks of douching. And then I fill in the gaps for them. I list some of the potential complications and what they should know about them.
Sam: The fact that we're talking about the health risks of douching doesn't necessarily imply that it's something that's unsafe. What we're trying to do is just make sure folks know the facts so they can decide if it's something that they're comfortable doing. And it's something that they're comfortable doing with their body.
Gaby: Right. So let's get into what some of those risks are. So some of them we've already talked about, we're talking mechanical terrors from the insertion of the enema device or showering your bathroom floor with anus water.
Sam: Yeah, how could I forget? But something else Brad shared was what he's heard within his network about the relationship between douching and sexually transmitted infections.
Brad: I do hear some concern about STI and even just general kind of bacterial infections. Because if the person is going to choose to not use a condom, I think there's then also a feeling of like, I'm going to get some kind of, I've got a urinary tract infection, I'll get some things through, you know, my dick if the other person's anus is and you know, clean enough to eat off of.
Gaby: We took that standard to our experts and asked about douching and its possible impact or relationship with STS or sexually transmitted infections.
Jordan: Yeah. So this is the one thing that's actually been studied. There have been studies showing an increased risk of acquisition of STIs – sexually transmitted infections – with douching and enema use especially more frequent douching and enema use.
Gaby: The biology of what drives the connection between douching and increased numbers of STIs isn’t quite known, but some people suggest that increased levels of douching is going to damage the outer protective layer of cells in the rectum. And that makes that area of the body a little more vulnerable to the kinds of things that cause STIs – the actual bugs themselves.
Sam: So there is one specific study that we want to mention that speaks to what Jordan is talking about
Gaby: The study reviews a few other studies - and it showed that folks who reported douching more were also more likely to have STIs – including gonorrhea, chlamydia, and HIV.
Jordan: That’s obviously confounded by patients who may do frequent douching or enemas that they may be engaging in more risky or increased number of sexual partners and so forth that would otherwise increase their risk of sexually transmitted infections. So there's obviously overlap there
Sam: Jordan called the relationship between how often someone douches and the amount of STIs they may have as confounding. We want to explain what that means here. When the relationship between two things is confounded, it means it's hard to tease apart cause and effect. And this case, this means that maybe the folks who douche more are just having sex more. And that means they're more likely to get these types of infections from having sex and not necessarily doing itself.
Sam: if you want to check out the information, you can see a link to the study in our show notes. But we're going to move on for now with the understanding that folks who do share two to three times more likely to get a sexually transmitted infection, including chlamydia gonorrhea, and HIV.
Richard: So the verdict on sexually transmitted infections is you can be clean enough to have your ass eaten – whatever that means for you – and also maybe have a higher chance of getting some sexually transmitted infections.
Sam: Yes, but we should emphasize again that this is really understudied. So at best, this is guidance, not gospel.
Gaby: And it's about knowing what the risks are and then making an informed douching and/or ass-eating decision.
Richard: Okay. I've got a bit of a curve ball here, according to one study that did a survey about douching, about a quarter of folks who do so do it after they bottom.
Gaby: So it's not just preparation for the party –it's also a little cleanup, too?
Richard: So we reached out to Jordan to ask a little bit about this post party cleanup and what could happen with sexually transmitted infections. And here's what he told us: he said that many folks feel like douching after sex might reduce their risk of getting infections. In fact, the opposite could be true. You could create further damage to the local tissue and increase the risk of having an infection take hold. So overall douching after sex is not necessary and we would recommend minimizing it if possible.
Gaby: Okay. So the whole line of logic that we had about douching before sex and the way that that might impact STIs – the same thinking goes for reducing after sex.
Sam: Right. Water irritation, breaking down the protective layer that keeps the door closed to infectious bugs – that's all going to get washed away after sex too.
Richard: And this is a great reminder that our bodies are often pretty good at protecting themselves from common things if we let them. And for people who have sex without condoms, remember the part of being a responsible sex partner is getting screened for sexually transmitted infections in the sites that you use for sex. If that includes your throat and your butt, then you gotta get those screen too.
So now with our questions about these sexually transmitted infections answered, I want to know if there are any special medical conditions that can be impacted by douching.
Jordan: for patients who have specific issues, particularly patients with underlying colitis, you know, recent or active rectal or anal infections, patients with, you know, knowing active anal HPV, these sorts of things they may want to think about avoiding, get it just for fear of exacerbating their underlying condition.
Gaby: So Jordan mentioned HPV or human papilloma virus. And that's a virus that belongs to a family of viruses that replicates in skin. It can sometimes cause warts around the anus and other parts of the body.
Sam: It's the same family of viruses that can cause certain types of cervical cancer, as well as rectal cancers.
Gaby: You might know it from the Gardasil vaccine, which is the brand name for a specific vaccine against specific HPV virus types. The ones that cause cancer.
Sam: Right. And the whole reason we're talking about HPV is that that's a common reason folks might have irritation or inflammation in their butt area. So if you feel like you have something else going on, throwing water on that fire may make that fire worse.
Richard: Right. The introduction of water against the tissue and the rectum can cause some irritation. And if it's already damaged, then it might damage it even further. And when you have a virus like HPV there, that can cause even for their problems,
Gaby: So, what you're saying is a sign that something is wrong is just pain when you douche.
Sam: Jordan said it well:
Jordan: There should never be pain in any of these situations.
Richard: wanted to follow up with Jordan because he sees a lot of people who have HIV. Some people with HIV who have lower immune function can also be susceptible to certain infections that other people aren't like cryptosporidium or isosporidium. The names aren't so important, but we wanted to find out if douching reduced or worse in their risk of getting these infections.
Jordan: if we have patients who are undergoing transplant or on a ton of immunosuppression for a variety of medical conditions, you know, patients who have well water for example, they necessarily shouldn't be drinking that. They should drink bottled water and so forth.
Richard: If your T cells are low, either from HIV or you're taking medicines to lower your immune system for a transplant or something, and make sure that the water you're using is filtered or bottled. I also want to make the point that if you have HIV and you have an active viral load, I would encourage you to, engage with healthcare and try to get the virus under control because the great news is if your virus is undetectable, then there's no way to transmit HIV to your partners during sex.
Gaby: And a pause to say that we acknowledge that getting in touch with health care can be tricky, and we will be talking more about that in future episodes. So let's put a pin in that for now.
Sam: We've covered most of our agenda, but Brad had some points about style.
Brad: I took them upstairs to my room and you know, he started moving towards my nether regions in that way, and I said, well, okay, babe, if we're going to do this, you've got to get me like five or 10 minutes to go in the bathroom. So just stay here and listen to music or put on some porn or live your best life. I don't care. Journal, I don't give a shit. I'll be back in 10 minutes when I can actually, you know, kind of hygienically and comfortably have your penis inside of me.
Richard: So for grownups, you don't have to kill the moment if you have to run off to prepare.
Gaby: No, you can just make that moment look a little different.
Richard: So why don't you bring us home? What have we learned so far?
Gaby: We've talked about the importance of fiber, the mechanics of dishing and how much volume to douche with.
Sam: Emphasis on tap water that is room temperature or lukewarm with no salt added
Gaby: And if you're a shower nozzle kind of lady, shower nozzles can overpower. So make sure to have them at a low water stream before gassing up the tank.
Sam: And for a moment of clarity mean it's this understudied issue: there seems to be an increased risk of sexually transmitted infections (like chlamydia and gonorrhea) for folks who do douche.
Richard: the most important thing always is to have an honest conversation about your values. So if you're someone who's planning to douche, no matter what your healthcare provider says, then have an open and honest conversation with them so you can understand the risks for you with your own health. There is no sense in hiding it if this is what you're going to do, Better, to be able to be informed than to leave it out of the conversation entirely. And if you don't like the answer and you think that they're wrong, get a second opinion.
Gaby: Or a third one.
Sam: Ultimately, Brad spoke to the reality that even the best laid plans, can't always protect your new bedsheets.
Brad: You're putting a penis in an anus. And anuses, for a reasonable percentage of the day in their lifetime, have feces in them. So this is merely an occupational hazard.
Sam: Brad also spoke to cultural notions around douching and the gay community and how this may cause some pressure for folks to feel like they have to.
Brad: I always wanted to be in my twenties that like ready-made bottom, that bottoms can just show up and be ready at any moment, anytime of the day. And be a perfectly clean bottom for a top. And I have long about that false, you know, dialogue and mythology. Because the fact of the matter is, an anus is an anus. And if you start sticking things up there in a back and forth motion, something might happen
Richard: And just because there might be some poop in the rectum doesn't mean someone needs to seek medical intervention. We talked about douching today so folks know the risks and realities. And in doing what we want to state again, just like Brad said, something might happen and that's okay.
Gaby: And we chose this topic, not to tell you to douche, but to let you douche, if you choose to, with a better understanding of what it means for your health.
Richard: And like Brad said, keep realistic expectations in mind.
Sam: Keep your shower nozzles low
Gaby: Use a water bottles worth or three-ish douching bulbs.
Sam: And keep your fiber supplements handy.
[QHP THEME MUSIC]
Sam: QHP is a power sharing project that puts community stories in conversation with health expertise to expand autonomy for sexual and gender minorities
Richard: We would like to thank Brad Loekle for taking his time and encourage you to check out his social media and links in our show notes. Thank you again to Jordan Axelrad at NYU, Mitchell Lunn at Stanford and Jonathan Baker in New York.
Gaby: if you have questions comments or feedback, please let us know. You can find us through social media @QueerHealthPod or you can just come to our website www.queerhealthpod.com.
Sam: And thank you to Lonny Ginsburg for composing our theme music.
Richard: Opinions in this podcast are our own and do not represent the opinions of any of our affiliated institutions. And even though we're doctors, please don't use this podcast as medical advice, but instead consult with your own healthcare provider.