Vaginal douching and associated factors among married women

attending a family planning clinic or a gynecology clinic

Deniz Caliskan
a,
*
, Nuket Subasi
b
, Ozlem Sarisen
a
a
Public Health Department, Ankara University School of Medicine,
Munzeviler Sokak No: 1, 06590 Akdere-Ankara, Turkey
b
Public Health Department, Hacettepe University Faculty of Medicine, Turkey
Received 17 January 2005; received in revised form 25 October 2005; accepted 3 November 2005
Abstract
Objective: The aim of this study was to determine the vaginal douching habits and associated factors of women attending two different
healthcare clinics.
Study design: This cross-sectional study was conducted between 1 and 31 May 2004. All participants were women (n = 635) who attended
either a university hospital gynecology clinic or a primary health care center family planning unit. One-way ANOVA, chi-squared test, and
binary and multiple logistic regression analyses were used for the statistical evaluation of data.
Results: The mean age of the participants was 36.90 10.72 years (range: 1875). Half of the participants believed vaginal douching had a
positive effect on health. They believed vaginal douching demonstrates cleanliness, prevents infections and pregnancy, removes sperm
following intercourse, a necessity of Islamic doctrine, and reduces symptoms like discharge, unpleasant odor, etc. Of the women, 50.2%
performed vaginal douching. Vaginal douching was associated with age, education level, type of dwelling, working outside of the home, age at
marriage, age at birth of rst child, parity, spontaneous abortion, history of pelvic inammatory disease, use of contraceptives, and attending a
healthcare clinic.
Conclusion: Douching is a common habit among Turkish women. Many women are not aware of the harmful effects of douching. Public
health and health professionals should monitor more closely this traditional habit in Turkey.
# 2005 Elsevier Ireland Ltd. All rights reserved.
Keywords: Vaginal douching; Turkish women
1. Introduction
Vaginal douching is the process of intravaginal cleansing
with a liquid solution [1,2]. Douching is a common practice
among women all over the world and is used for personal
hygiene or aesthetic reasons in many countries [16]. In
Muslim countries, vaginal douching is both a traditional and
a religious practice [7,8]. Many Muslim women douche to
perform ghusl after intercourse or during a bath. Ghusl is
described as the greater purication. According to Islam,
ghusl is obligatory following marital intercourse, childbirth,
menstruation, or when a person decides to become Muslim.
The procedure involves washing the hands and other
affected parts of the body with water to remove any impurity.
Ghusl refers not only to vaginal douching, but it is necessary
for the entire body to be washed, and water should reach all
parts of the body [9]. Many Muslim women in the study
explained that vaginal douching is a component of ghusl,
and if they do not perform vaginal douching they cannot be
puried. For these reasons, vaginal douching is common
among Muslim women worldwide [5,7].
Vaginal douching reduces the density of normal vaginal
ora [14,10,11]. It may provide a pressurized uid vehicle
for pathogen transport, enabling lower genital tract
infections to ascend above the cervix into the uterus,
fallopian tubes, or abdominal cavity.
www.elsevier.com/locate/ejogrb
European Journal of Obstetrics & Gynecology and
Reproductive Biology 127 (2006) 244251

This paper was orally presented at 5th International Reproductive

Health and Family Planning Congress, Ankara, Turkey, between 20 and
23 April 2005.
* Corresponding author. Tel.: +90 312 363 89 90; fax: +90 3123198236.
E-mail address: caliskan@medicine.ankara.edu.tr (D. Caliskan).
0301-2115/$ see front matter # 2005 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ejogrb.2005.11.024
In addition, douching is harmful and should be
discouraged because of its association with pelvic inam-
matory disease (PID) [1214], increased susceptibility to
sexually transmitted diseases, including human immunode-
ciency virus [1517], bacterial vaginosis [1821],
increased risk of recurrent vulvovaginal candidiasis [22]
and recurrent urinary tract infections [23], reduced fertility
[24], ectopic pregnancy [25,26], pretermbirth [27], lowbirth
weight [28], and cervical ectopia or carcinoma [2932].
Nonetheless, douching continues to be a common practice in
many developed and developing countries.
In this study, our aim was to determine the vaginal
douching habits and associated factors among Turkish
women who attended two different healthcare clinics.
2. Method
This cross-sectional study was conducted between 1 and
31 May 2004. Two different healthcare clinics in Ankara, the
capital of Turkey, were chosen for this study. The rst, a
family planning unit of a primary healthcare center in a
semi-urban area, serves people at the low and middle socio-
economic levels. The other, the Gynecology Clinic of
Ankara University Faculty of Medicine, Department of
Obstetrics and Gynecology, is located in an urban area and
serves people at the middle and high socio-economic levels.
As shown in Table 1, these two groups were signicantly
different from each other. The women who attended the
family planning unit (Group 1, n = 223) were less educated,
more likely to be living in shanty houses, and were less
likely to be working outside of the home, compared with the
women who were seen at the university gynecology clinic
(Group 2, n = 412). Reproductive characteristics were
different as well. The study group formed by those who
attended Group 1 were younger, married at a younger age,
had lower parity, and used modern contraceptive methods
more than the group of women from Group 2. It is expected
that Group 2 women with a high socio-economic status used
more modern contraceptive methods than Group 1. This
situation may be explained by the fact that Group 1s clinic is
mainly for contraceptive services and Group 1s women was
younger than Group 2s.
A self-administered questionnaire form was lled out by
women in the waiting rooms of both healthcare clinics. For
those who were illiterate, researchers lled out the
questionnaire with the participants. Single women were
not accepted because of the rarity of premarital intercourse
in Turkey. The enrolment rates were 85% for the applicants
from the gynecology unit (62 single women and 11
emergency applicants were not accepted into the study)
and 100% for those from the family planning unit.
The verbal consent of each woman was obtained and they
were given information about the study.
2.1. Statistical analysis
The dependent variable of this study was the use of
vaginal douching. Chi-squared test, binary logistic analysis,
and one-way ANOVA were used as descriptive univariate
D. Caliskan et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 127 (2006) 244251 245
Table 1
The cross-tabulation of socio-demographic and reproductive characteristics of participating women according to the clinic attended
Variable Group 1 Family
planning unit n = 223
Group 2 Gynecology
clinic n = 412
Total n = 635
Mean age (years)
***
32.10 7.70 39.50 11.21 36.90 10.72
Mean length of education (years)
**
6.84 3.39 7.85 4.53 7.49 4.53
Mean age at marriage (years)
**
19.03 3.06 19.85 4.03 19.56 3.73
Mean age at rst birth (years)
*
20.21 3.09 21.03 4.07 20.74 3.77
Mean of length of accommodation in Ankara (years) NS 14.4 10.8 13.6 10.5 14.1 10.7
Mean total parity
**
2.81 1.88 3.72 3.27 3.40 2.89
Mean total births
*
1.95 1.09 2.28 2.14 2.16 1.85
Mean total abortions
***
0.75 1.20 1.26 1.79 1.08 1.63
Mean induced abortions
***
0.48 0.92 0.96 1.55 0.69 1.38
Mean spontaneous abortions NS 0.27 0.74 0.30 0.71 0.29 0.72
Percentage working out of the home
***
5.4 25.9 18.7
Percentage living in an apartment
***
49.5 66.5 60.6
Percentage using contraceptive methods
***
IUD 30.1 25.6 27.2
Condom 29.7 12.4 18.6
Withdrawal 15.1 18.3 17.2
Pill 19.2 7.5 11.7
Female sterilization 0.9 8.3 5.6
Injectable contraceptive 1.4 1.3 1.3
No methods 3.6 26.6 18.4
NS: Not signicant.
*
p < 0.05.
**
p < 0.01.
***
p < 0.001.
analyses to determine an association between dependent and
independent variables (age, education level, type of dwell-
ing, working outside of the home, age at marriage, birth of
rst child, total parity, spontaneous abortions, history of
ectopic pregnancy, PID, cervical malignancy, and contra-
ceptive methods used). A p-value less than 0.05 was
considered to be signicant. Variables that were found to be
statistically signicant were incorporated into a multiple
logistic regression model.
3. Results
The number of women who participated in the study was
635. The mean age was 36.90 10.72 years (range: 1875).
3.1. Beliefs of women regarding the effects of vaginal
douching on health
Two hundred and eighty-two (44.4%) women believed
that vaginal douching has positive effects on health. They
believed that it demonstrates cleanliness, prevents infections
and pregnancy, removes sperm following intercourse, a
necessity of Islamic doctrine, and reduces symptoms
(discharge, odor etc.). Two hundred and sixty-four
(41.6%) believed that vaginal douching may have harmful
effects on health. They described these harmful effects as
infection, irritation, and symptoms.
3.2. Vaginal douching habits
Six-hundred and twenty-seven answered the question as
to whether they perform vaginal douching. Three hundred
and fteen of the 627 women (50.2%) were currently
performing vaginal douching or had in the past. The
characteristics of vaginal douching are provided in Table 2.
The mean number of women who had douched in the last
week was 2.92. The women were found to start vaginal
douching after marriage and the mean age of starting vaginal
douching was 19.52. The women in the study who were
douching did so 23 times a week, and were using water.
They learned vaginal douching from their mothers or were
self-taught, and vaginally douched after sexual intercourse,
while showering, as ghusl or after using the toilet. The main
reasons given for vaginal douching were cleanliness and
religious practice. As many as 88.1% of the study women
who were engaging in vaginal douching had not been
informed about its effects by health professionals.
3.3. Factors associated with vaginal douching habits
The independent variables associated with vaginal
douching according to which clinic the women went to
are shown in Table 3. No statistically signicant association
was found between vaginal douching and clinic attended
according to age group, history of ectopic pregnancy,
and cervical malignancy in women and contraceptive
method use. For this reason, these variables were not shown
in Table 3. There were statistical differences in both groups
according to type of dwelling; women living in shanty
houses tended to perform vaginal douching. It was found
that while there was no association between education level,
working outside the home, age at marriage, age at rst birth,
number of total parity, and number of spontaneous abortions
of the women attending the family planning unit and vaginal
douching; women who were less educated and were not
working outside the home, had marriage and rst delivery at
the age of 18 years or below, had parity of 4 or more, or had
more than one spontaneous abortion were found more likely
to perform vaginal douching within the gynecology clinic
group.
After binary logistic regression analysis, variables that
were determined to be statistically signicant were
incorporated into a multiple logistic regression model. In
this analysis, the main predictors of vaginal douching habits
were type of dwelling (OR: 2.01, 95% condence interval
(CI) 1.2893.135, p = 0.033), history of PID (OR: 1.54, 95%
CI 1.0352.295, p = 0.022), and the clinic attended (OR:
1.53, 95% CI 1.0632.227, p = 0.002). The remaining
variables were not found to be statistically signicant after
performing multivariate analysis.
4. Discussion
Among the study participants, it was found that there was
a common belief that vaginal douching has a positive effect
on health. In addition to this, 50% of the participants
frequently used vaginal douching. There are few studies on
vaginal douching in Turkey. The prevalence of vaginal
douching is reported to be slightly higher than 6364% in
Turkey [7,33]. Also, in the United States, douching is more
common among AfricanAmerican women than those of
other ethnic groups. The prevalence of douching among
American women has decreased since 1988, but still remains
a common practice among adolescents, AfricanAmericans,
and Hispanics. In 1995, 55% of non-Hispanic black women,
33% of Hispanic women, and 21% of non-Hispanic white
women reported regular douching. In the US, there have
been reports indicating that 5269% of adolescents douche
at least once a week [1,2,6], and douching behavior is
common among adolescents and young adult women who
are at high risk of sexually transmitted diseases
[3,4,16,34,35]. Furthermore, douching is prevalent in some
African countries, such as Cote dIvoire, where the douching
rate among women is reported to exceed 97% [1]. Brown
and Brown reported that in sub-Saharan Africa, researchers
from 11 countries have documented traditional intra-vaginal
practices included vaginal douching. Outside of Africa,
traditional intra-vaginal practices have been reported in
Qatar, Indonesia, Thailand, Haiti, and the Dominican
Republic [5]. Joesoef et al. reported that in Indonesia
D. Caliskan et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 127 (2006) 244251 246
82% of women had douched at least once in the preceding
month [17]. In a study by Rajamanoharan et al., reported
rates of vaginal douching in London were 2% among white
women, 9% among black Caribbean women, and 13%
among other ethnic groups [18]. In France, 24% of French
white women were found to use vaginal douching, while the
rate among black African women living in France was 71%
[36].
The characteristics of vaginal douching reported in other
studies were similar to our ndings [14,3439]. When these
common ndings of douching are summarized, the timing of
douching was the same in relation to sexual activity,
symptoms (discharge, odor, etc.), and after menstruation.
Women who were douching in these studies considered it to
be a healthy practice and often stated that hygiene was the
primary reason for douching. Most of the women in these
D. Caliskan et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 127 (2006) 244251 247
Table 2
The distribution of some characteristics of vaginal douching according to the clinic attended
Characteristics of vaginal douching (VD) Attending clinics
Family planning unit n (%)
a
Gynecology clinic n (%)
a
Total n (%)
a
F or x
2
-test p-value
VD habit
Never applied VD 129 (57.8) 183 (45.3) 312 (49.8) x
2
= 14.71, p < 0.001
Used to apply VD 13 (5.8) 59 (14.6) 72 (11.4)
Current applies VD 81 (36.3) 162 (40.1) 243 (38.8)
Mean VD application at last week 2.91 1.26 2.92 1.54 2.92 1.46 NS
Mean age at start of VD (years) 19.46 4.02 19.55 4.90 19.52 4.63 NS
Mean age at marriage (years) 18.55 2.69 18.98 3.18 18.85 3.05 NS
Frequency of VD
At least once a day 18 (20.7) 52 (26.3) 70 (24.6) x
2
= 15.31, p < 0.01
Every other day 3 (3.4) 21 (10.6) 24 (8.4)
23 times a week 47 (54.0) 61 (30.8) 108 (37.9)
Once a week 11 (12.6) 37 (18.7) 48 (16.8)
Less than once a week 8 (9.2) 27 (13.6) 35 (12.3)
How did the woman learn VD?
Self-taught 47 (52.2) 81 (38.8) 128 (42.8) NS
Mother 22 (24.4) 70 (33.5) 92 (30.8)
Friends 5 (5.6) 15 (7.2) 20 (6.7)
Health professional 5 (5.6) 14 (6.7) 19 (6.4)
Religious books or persons 7 (7.8) 12 (5.7) 19 (6.4)
Other relatives 4 (4.4) 12 (5.7) 16 (5.4)
Others 5 (2.4) 5 (1.7)
When did the woman perform VD?
b
After intercourse 59 (67.0) 137 (64.0) 196 (64.9) x
2
= 70.69, p < 0.001
During a shower 42 (47.7) 105 (49.1) 147 (48.7)
During ghusl 18 (20.5) 83 (38.8) 101 (33.4)
After using the toilet 20 (22.7) 69 (32.2) 89 (29.5)
After menstruation 11 (12.5) 71 (33.2) 82 (27.2)
When the symptoms occur 14 (15.9) 56 (26.2) 70 (23.2)
Reason for VD
b
Cleanliness 63 (69.2) 159 (75.7) 222 (73.7) NS
Religious 24 (26.4) 49 (23.3) 73 (24.2)
To prevent pregnancy 21 (23.1) 29 (13.8) 50 (16.6)
Habit 19 (20.9) 30 (14.3) 49 (16.3)
To reduce symptoms (discharge, odor, etc.) 9 (9.9) 14 (6.7) 23 (7.6)
Others 5 (5.5) 5 (2.4) 10 (3.3)
Preparation used for VD
Water 60 (69.0) 152 (71.4) 212 (70.7) NS
Water and soap 25 (28.7) 60 (28.2) 85 (28.3)
Others (shampoo, vinegar) 2 (2.2) 1 (0.5) 3 (1.0)
Information about VD from health professionals
None 80 (88.9) 180 (87.8) 260 (88.1) NS
Yes, about doing VD 9 (10.0) 14 (6.8) 23 (7.8)
Yes, about not doing VD 1 (1.1) 11 (5.4) 12 (4.1)
NS: not signicant.
a
Percentages were taken from answers given.
b
One person was able to give more than one answer.
studies stated that douching was necessary for good hygiene.
Motives for douching were many: to clean the vagina after
menses or before or after sexual intercourse, to prevent or
ameliorate an odor, to prevent or treat vaginal symptoms
such as itching and discharge, and less commonly, to prevent
pregnancy. External factors such as the inuence of mothers,
friends, and relatives contribute to a womans decision to
douche.
In Muslim Countries water or water and soap are most
commonly used for douching, whereas in western countries
[7,15,17,30] commercial products are more often used.
Commercial products were rarely (1%) used by the women
in our study. This may be explained by the fact that these
products are uncommon on the market and are more
expensive than water or soap. Joesoef et al. reported that in
Indonesia, douching with water or water and soap is a
common practice among women to clean their genitals
following urination or sexual intercourse [17]. The type of
commercial and home products that were used was
important to the effect of vaginal douching. Many of these
had antimicrobial effects. In experimental studies it was
shown that douching resulted in microoral changes [1,35].
After a saline or acetic acid douche, the microora returned
to the pre-douching level within 72 h. However, repetitive
douching with a solution containing the antibactericidal
agent povidone-iodine caused more dramatic short-term and
prolonged changes in the microora, allowing an over-
growth of pathogenic organisms that have faster growth rates
than the Lactobacillus species, the predominant normal ora
[1,35,12,14]. More than half of the women who douche in
western countries use commercial products that contain
various combinations of acidiers, bacteriostatics or
antimicrobial agents, and weak surfactants [1,35,12,14].
The use of only water in vaginal douching may have changed
vaginal pH and microora concentrations, and may have not
caused infection to ascend in women who had douched.
Vaginal douching was commonly performed after using
the toilet (defecation or urination) by the women in our
study (29.5%), so the risk infection ascending was increased.
Anal hygienic cleansing is accomplished only with water,
D. Caliskan et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 127 (2006) 244251 248
Table 3
The independent variables associated with vaginal douching according to the clinic attended.
Independent variables Clinic attended
Family planning unit Gynecology clinic
No douching n (%)
a
Douching n (%)
a
x
2
Test p value No douching n (%)
a
Douching n (%)
a
x
2
Test p value
Education level of women
Illiterate 4 (3.1) 6 (6.4) NS 16 (9.0) 37 (17.1) x
2
= 23.91, p < 0.001
Primary school 76 (59.4) 55 (58.5) 62 (34.8) 88 (40.6)
Secondary school 16 (12.5) 16 (17.0) 15 (8.4) 28 (12.9)
High school 29 (22.7) 15 (16.0) 43 (24.2) 47 (21.7)
University 3 (2.3) 2 (2.1) 42 (23.6) 17 (7.8)
Type of dwelling
Apartment 71 (55.9) 38 (40.9) x
2
= 4.86, p < 0.05 132 (72.5) 138 (63.0) x
2
= 4.09, p < 0.05
Shanty house 56 (44.1) 55 (59.1) 50 (27.5) 81 (37.0)
Working outside of the home
Housewife 121 (94.5) 89 (94.7) NS 117 (63.9) 181 (82.6) x
2
= 18.20, p < 0.001
Working 7 (5.5) 5 (5.3) 66 (36.1) 38 (17.4)
Age at marriage
18 58 (46.0) 53 (57.0) NS 64 (35.6) 119 (55.1) x
2
= 15.07, p < 0.001
19 68 (54.0) 40 (43.0) 116 (64.4) 97 (44.9)
Age at rst birth
18 38 (30.6) 36 (40.0) NS 40 (23.8) 69 (32.5) x
2
= 3.49, p < 0.05
19 86 (69.4) 54 (64.0) 128 (76.2) 143 (67.5)
Total parity
01 34 (26.4) 26 (27.7) NS 44 (24.0) 34 (15.4) x
2
= 7.70, p < 0.05
23 57 (44.2) 37 (39.4) 75 (41.0) 83 (37.6)
4+ 38 (29.5) 31 (33.0) 64 (35.0) 104 (47.1)
Number of spontaneous abortions
0 109 (84.5) 74 (78.7) NS 152 (83.1) 168 (76.0) x
2
= 3.01, p = 0.053
1+ 20 (15.5) 20 (21.3) 31 (16.9) 53 (24.0)
History of PID in women
Absent 73 (57.0) 50 (54.3) NS 90 (50.8) 80 (38.8) x
2
= 5.56, p < 0.01
Present 55 (43.0) 42 (45.7) 87 (49.2) 126 (61.2)
a
Percentages were taken from answers given.
D. Caliskan et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 127 (2006) 244251 249
Table 4
The association of some independent variables and vaginal douching
Independent variables Vaginal douching application Crude odds ratio 95% CI OR p Value
No douching n (%)
a
Douching n (%)
a
Age group
<29 (reference category) 103 (55.4) 83 (44.6) 1.000 x
2
= 7.85, p < 0.05
3039 105 (52.0) 97 (48.0) 1.146 0.7691.710
4049 76 (46.1) 89 (53.9) 1.453 0.9542.214
>49 28 (37.8) 46 (62.2) 2.039 1.1743.539
Education level of women
Illiterate 20 (31.7) 43 (68.3) 5.092 2.39510.826 x
2
= 22.0, p < 0.001
Primary school 138 (49.1) 143 (50.9) 2.454 1.3674.405
Secondary school 31 (41.3) 44 (58.7) 3.362 1.6566.812
High school 72 (53.7) 62 (46.3) 2.039 1.0813.847
University (reference category) 45 (70.3) 19 (29.7) 1.000
Type of dwelling
Apartment (reference category) 203 (53.6) 176 (46.4) 1.000 1.0702.047 x
2
= 5.62, p < 0.01
Shanty house 106 (43.8) 136 (56.2) 1.480
Working out side of the home
Housewife 238 (46.9) 270 (53.1) 1.926 1.2722.917 x
2
= 9.76, p < 0.01
Working (reference category) 73 (62.9) 43 (37.1) 1.000
Age at marriage
18 122 (41.5) 172 (58.5) 1.894 1.3752.609 x
2
= 15.37, p < 0.001
19 (reference category) 184 (57.3) 137 (42.7) 1.000
Age at rst birth
18 78 (42.6) 105 (57.4) 1.462 1.0292.077 x
2
= 4.52, p < 0.05
19 (reference category) 214 (52.1) 197 (47.9) 1.000
Number of total parity
01 (reference category) 78 (56.5) 60 (43.5) 1.000 x
2
= 7.50, p < 0.05
23 132 (52.4) 120 (47.6) 1.182 0.778-1.794
4+ 102 (43.0) 135 (57.0) 1.721 1.127-2.628
Number of spontaneous abortion
0 (reference category) 261 (51.9) 242 (48.1) 1.000 1.0372.299 x
2
= 4.60, p < 0.05
1+ 51 (41.1) 73 (58.9) 1.544
History of ectopic pregnancy in women
Absent (reference category) 278 (49.9) 279 (50.1) 1.000 NS
Present 6 (37.5) 10 (62.5) 1.661 0.5954.632
History of PID in women
Absent (reference category) 163 (55.6) 130 (44.4) 1.000 1.0762.045 x
2
= 5.81, p < 0.01
Present 142 (45.8) 168 (54.2) 1.483
History of cervical malignancy in women
Absent (reference category) 297 (51.0) 215 (49.0) 1.000 0.5203.120 NS
Present 9 (45.0) 11 (55.0) 1.274
Contraception
Intrauterine device (reference category) 97 (56.1) 76 (43.9) 1.000
Withdrawal 49 (47.1) 55 (52.9) 1.625 0.9902.666 x
2
= 19.81, p < 0.01
Pills 30 (42.3) 41 (57.7) 1.979 1.1253480
Condoms 63 (56.3) 49 (43.8) 1.126 0.6931.831
Female sterilization 11 (32.4) 23 (67.6) 3.027 1.3836.624
Injectable contraceptives 2 (25.0) 6 (75.0) 4.343 0.85122.174
No method 44 (41.1) 63 (58.9) 2.073 1.2633.401
Clinic attended
Family Planning Unit (reference category) 129 (57.8) 94 (42.2) 1.000 x
2
= 9.05, p < 0.01
Gynecology Clinic 183 (45.3) 221 (54.7) 1.657 1.1912.306
NS: not signicant.
a
Percentages were taken from answers given.
and by hand in Muslim countries [7]. Anal cleansing or
contamination leads to an increased risk of urogenital
system infections [1013,23]. When combined with vaginal
douching, this risk of infection is increased.
Differing from other studies, religious reasons and
motivation were found as secondary predictors of douching
in our study. However, the role of religious beliefs in vaginal
douching should be examined more extensively as a
controlled, community-based study in Turkey.
According to the univariate analysis, vaginal douching in
our study population was associated with age, level of
education, type of dwelling, working outside of the home,
age at marriage and birth of rst child, parity, spontaneous
abortion, history of PID, use of contraception, and the clinic
attended (Table 4). Multiple logistic regression analysis
revealed that many associations of many variables were
found to be insignicant. Women who lived in shanty
houses, had a history of PID, and attended the university
gynecology clinic used vaginal douching more than the
other women in the study. In our study, living in a shanty
house was a strong predictor of low socio-economic status.
In many studies, vaginal douching was more frequent among
women with a low socio-economic status [1,2,7,6].
Regarding the progress of PID, vaginal douching may
cause PID, but later this association becomes complicated.
Women with symptoms of pelvic inammation had
frequently performed vaginal douching. Compared with
women who had never douched, women who frequently
douched with a commercial product or homemade prepara-
tion were at substantially increased risk of both PID and of
contracting a sexually transmitted disease [1,2,1217].
It was an unusual nding of this study that women who
attended the university gynecology clinic frequently
performed vaginal douching. These women were of a
higher socio-economic status and thus we expected to nd a
lower rate of vaginal douching. In Turkey, many physicians
encourage their female patients to come for a gynecological
examination after cleaning at the end of menstruation. To
physicians, clean means the end of menstrual bleeding,
but to female patients it means vaginal douching. We suspect
that this may be the reason vaginal douching was more
frequent than expected among the women who attended the
university gynecology clinic.
There is no ofcial medical or public health advisory
policy concerning the risks or benets of douching. Most
studies linking douching to adverse reproductive effects are
retrospective case studies; thus, the causal relationship
between douching and its adverse effects remains uni-
dentied. Prospective longitudinal studies may be able to
show the effects of douching. There are a limited number of
prospective studies in the literature. Numerous studies have
shown that vaginal douching is associated with bacterial
vaginosis, PID, reduced fertility, ectopic pregnancy, preterm
birth, recurrent urinary tract infections, cervical ectopia, and
carcinoma [1232]. In contrast, both Ness et al. and
Rothman et al., in their multi-center and prospective studies,
showed that vaginal douching did not increase the risk of
PID [40,41].
Government, health, and professional organizations
should re-examine the data currently available and
determine whether there is enough information to issue
clear policy statements on douching [1]. Recently, with the
impact of studies conducted on this issue, in the US, the
Centers for Disease Control and Prevention and the Food
and Drug Administration have seriously discussed whether
to issue statements curtailing or discouraging douching [42].
In the light of this study, it can be stated that vaginal
douching is common among the women in Turkey. Many of
the women who took part in the study believed that vaginal
douching has health benets. Health professionals in Turkey
do not pay attention to this traditional habit. Due to the
evidence regarding the harmful effects of vaginal douching
on health, it should be discouraged. Intervention studies may
be the best way to gain both knowledge of the health benets
and an insight into the temporal associations of douching
and its adverse outcomes [1]. The motivation for douching is
a complicated issue imbued with psychological, social, and
religious features that need to be addressed if vaginal
douching behavior is likely to be modied on any scale
[1,37]. In order to change this behavior in the future,
community-based studies should be conducted, focusing on
changing behavior and based on the socio-cultural
characteristics of health-related behavior. Additionally,
there will be a need for education programs that take into
consideration the religious connotations of douching for
Muslim women.
References
[1] Martino JL, Vermund SH. Vaginal douching: evidence for risk or
benets to womens health. Epidemiol Rev 2002;24:10924.
[2] Zhang J, Thomas AG, Leybovich E. Vaginal douching and adverse
health effects: a meta-analysis. Am J Public Health 1997;87:120711.
[3] Merchant JS, Oh MK, Klerman LV. Douching: a problem for adoles-
cent girls and young women. Arch Pediatr Adolesc Med 1999;53:834
7.
[4] Simpson T, Merchant JS, Grimley DM, Oh MK. Vaginal douching
among adolescent and young women: more challenges than progress. J
Pediatr Adolesc Gynecol 2004;17:24958.
[5] Brown J, Brown R. Traditional intravaginal practices and the hetero-
sexual transmission of disease: a review. Sex Transm Dis
2000;27:1837.
[6] Aral SO, Mosher WD, Cates W. Vaginal douching among women of
reproductive age in the United States: 1988. Am J Public Health
1992;82(2):2104.
[7] Caliskan D, Col M, Akdur R, Yavuzdemir S, Yavuz Y. Vaginal
douching in the area of park health centre. Ankara Universitesi Tip
Fakultesi Mecmuasi 1996;49:7380 (In Turkish).
[8] Ortayli N, Bulut A, Nalbant H, CottinghamJ. Is the diaphragma viable
option for women in Turkey. Int Family Planning Persp 2000;26:
3642.
[9] http://www.diyanet.gov.tr/english/default.asp (frequently asked ques-
tions about ghusl).
[10] Newton ER, Pipet JM, Shain RN, Perdue ST, Peairs W. Predictors of
vaginal microora. Am J Obstet Gynecol 2001;184:84555.
D. Caliskan et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 127 (2006) 244251 250
[11] Schwebke JR, Richey CM, Weiss HL. Correlation of behaviors with
microbiological changes in vaginal ora. J Infect Dis 1999;180:
16326.
[12] Scholes DS, Dailing JR, Stergachis A, Weiss NS, Wang SP, Grayston
TS. Vaginal douching as a risk factor for acute pelvic inammatory
disease. Obstet Gynecol 1993;81:6016006.
[13] Ness RB, Soper DE, Holley RL, et al. Douching and endometritis. Sex
Transm Dis 2001;28:2405.
[14] Ness RB, Hillier SL, Richter HE, et al. Douching in relation to
bacterial vaginosis, lactobacilli, and facultativa bacteria in vagina.
Obstet Gynecol 2002;100:76572.
[15] Ruche GL, Messou N, Ali-Napo L, et al. Vaginal douching: associa-
tion with lower genital tract infections in African pregnant women.
Sex Transm Dis 1999;26:1916.
[16] Blythe MJ, Forteberry JD, Orr MS. Douching behaviors reported by
adolescent and young adult women at high risk for sexually
transmitted infections. J Pediatr Adolesc Gynecol 2003;16:
95100.
[17] Joesoef MR, SumampouwH, Linnan M, Schmid S, Idajadi A, St Louis
ME. Douching and sexually transmitted diseases in pregnant women
in Surabaya, Indonesia. Am J Obstet Gynecol 1996;174:1159.
[18] Rajamanoharan S, Low N, Jones SB, Pozniak L. Bacterial vaginosis,
ethnicity, and the use of genital cleaning agent: a case control study.
Sex Transm Dis 1999;26:4049.
[19] Chiaffarino F, Parazzini F, De Besi P, Lavezzari M. Risk factors for
bacterial vaginosis. Eur J Obstet Gynecol Reprod Biol 2004;117:
2226.
[20] Holzman C, Leventhal JM, Qiu H, Jones NM, Wang J. Factors linked
to bacterial vaginosis in nonpregnant women. Am J Public Health
2001;91:166470.
[21] Ness RB, Hillier SL, Kip KE, et al. Bacterial vaginosis and risk of
pelvic inammatory disease. Obstet Gynecol 2004;104:7619.
[22] Corsello S, Spinillo A, Osnengo G, et al. An epidemiological survey of
volvovaginal candidiasis in Italy. Eur J Obstet Gynecol Reprod Biol
2003;110:6672.
[23] Hooton TM. Recurrent urinary tract infection in women. Int J Anti-
microb Agents 2001;17:25968.
[24] Baird DD, Weinberg CR, Voigt LF, Dailing JR. Vaginal douching and
reduced fertility. Am J Public Health 1996;86:84450.
[25] Kendrick JS, Atrash HK, Strauss LT, Gargiullo PM, Ahn YW. Vaginal
douching and risk of ectopic pregnancy among black women. Am J
Obstet Gynecol 1997;176:9917.
[26] Chow WH, Dailing JR, Weiss NS, Moore DE, Soderstrom R. Vaginal
douching as a potential risk factor for tubal ectopic pregnancy. Am J
Obstet Gynecol 1985;153:7279.
[27] Fiscella K, Franks P, Kendrick JS, Meldrum S, Kieke BA. Risk of
preterm birth that is associated with vaginal douching. Am J Obstet
Gynecol 2002;196:134550.
[28] Fiscella K, Franks P, Kendrick JS, Bruce FC. The risk of low birth
weight associated with vaginal douching. Obstet Gynecol
1998;92:9137.
[29] Critchlow CW, Wolner-Hanssen P, Eschenbach DA, et al. Determi-
nants of cervical ectopia and of cervitis: age, oral contraception,
specic cervical infection, smoking and douching. Am J Obstet
Gynecol 1995;173:53443.
[30] Gardner JW, Schuman KL, Slattery ML, Sanborn JS, Abboth TM,
Overall JC. Is vaginal douching related to cervical carcinoma? Am J
Epidemiol 1991;133:36875.
[31] Brinton JA, Nasca PC, Mallin K, et al. Case-control study of in situ and
invasive carcinoma of the vagina. Gynecol Oncol 1990;38:4954.
[32] Bayo S, Bosch FX, Sanjose S, et al. Risk factors of invasive cervical
cancer in Mali. Int J Epidemiol 2002;31:2029.
[33] Hodoglugil NNS, Aslan D, Bertan M. Intrauterine device use and
some issues related to sexually transmitted disease screening and
occurrence. Contraception 2000;61:35964.
[34] 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;15:838.
[35] Forch BJ, McDaniel ND, Chacko MR. Racial differences in vaginal
douching knowledge, attitude and practices among sexually active
women. Pediatr Adolesc Gynecol 2001;14:2933.
[36] Meyer L, Brouselle C, Soulat C, Gros I. Vaginal douching and ectopic
pregnancy [letter]. JAMA 1991;265:26701.
[37] Lichtenstein B, Nansel TR. Womens douching practices and related
attitudes ndings from four focus groups. Women Health 2000;31(2/
3):11731.
[38] Iannacchione MA. The vagina dialogues: do you douche?: douching is
associated with signicant risks. Nurses are in a position to suggest
alternatives. Am J Nurs 2004;104:405.
[39] 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;30:68993.
[40] Ness R, Hiller SH, Kip KE, et al. Douching, pelvic inammatory
disease, and incident gonococcal and chlamydial genital infection in a
cohort of high-risk women. Am J Epidemiol 2005;161:18695.
[41] Rothman KJ, Funch DP, Alfredson T, Brady J, Dreyer NA. Rando-
mized eld trial of vaginal douching, pelvic inammatory disease and
pregnancy. Epidemiology 2003;14:3408.
[42] Baird DD. The great douching debate: to douche, or not to douche.
Obstet Gynecol 2000;95(3):473.
D. Caliskan et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 127 (2006) 244251 251