Vaginal practices

Globally, there is a wide variety of vaginal practices and products used by women to tighten, dry, warm and clean the vagina. Women’s efforts to change their genital environment can undermine the body’s innate defences against pathogens. In particular, vaginal practices have been linked to loss of lactobacilli and disruption of the vaginal epithelium.

A number of vaginal practices have been described:¹

• External washing: Cleaning of the external area around the vagina and genitalia using a product or substance with or without water, normally using the hand. Products used vary from soap and water to traditional and chemical detergent-like substances.
• External application: Placing or rubbing various substances or products on to the external genitalia (the labia, clitoris, and vulva). Included is the 'steaming' or 'smoking' of the vagina, by sitting above a source of heat (fire, coals, hot rocks) on which water, herbs or oils are placed to create steam or smoke.
• Intravaginal cleansing ('washing'): Internal cleansing or washing inside the vagina include wiping the internal genitalia with fingers and other substances (e.g., cotton, cloths, paper) for the purpose of removing fluids. It also includes douching, which is the pressurised shooting or pumping of water or solution (including douching gel) into the vagina.
• Intravaginal insertion: Pushing or placing something inside the vagina (including powders, creams, herbs, tablets, sticks, stones, leaves, cotton, paper, tampons, tissue, etc.) regardless of the duration it is left inside.
• Oral ingestion: Drinking or swallowing of substances perceived to affect the vagina and uterus, for example to dry or lubricate the vagina. Substances may be dissolved in water or other liquids.

Research interest in these vaginal practices has been accelerated by efforts to develop vaginal microbicides. In cultures where vaginal dryness is valued, a microbicide in the form of a lubricant is unlikely to be acceptable to couples. Moreover, a microbicide’s chemical properties may be altered by being used at the same time as other substances.

Social research in African settings has also shed light on women’s motivations for these practices. Particularly in resource-limited settings with strong imbalances in power between men and women, sex may be a means to achieve economic security, either directly through sex work or by maintaining economically essential relations with husbands or other sexual partners. Adopting practices which aim to increase men’s sexual pleasure may help women meet basic needs. Other reasons to engage in these practices include genital hygiene, self-treatment of vaginal discharge, and pregnancy prevention.^{1 2}

A number of studies from a variety of settings have suggested that vaginal practices, especially douching, are associated with bacterial vaginosis.² As described above, bacterial vaginosis is itself linked to an increased risk of HIV infection.

It is also possible that vaginal practices, especially those involving foreign substances, disrupt the vaginal and cervical mucosa, either through physical trauma or chemical irritation. The review identified two small studies that found visible mucosal changes after use of substances; a third found that lesions were not associated with vaginal practices.²

A number of cross-sectional studies have found associations between vaginal practices and HIV infection, but these studies cannot demonstrate which comes first - that is, whether intravaginal practices increase susceptibility to HIV infection or whether HIV infection leads to increased intravaginal practices. The latter is a possibility, because vaginal infections such as trichomoniasis, bacterial vaginosis and thrush are common in some groups of HIV-positive women. It is plausible that intravaginal practices may be used to help relieve the symptoms of vaginal infection, including discharge and itching. Vaginal practices are also correlated with behavioural risk factors for HIV.

A ten-year study of 1270 Kenyan sex workers found that washing inside the vagina with soap was associated with an almost four times greater risk of HIV infection (risk ratio 3.84) and washing inside with water with a nearly three times greater risk (risk ratio 2.64), after adjustment for demographic factors, sexual behaviour, and sexually transmitted infections. Frequent washing was common in this population.³

A two-year study of over 4000 South African women found that, in multi-variate analysis, there was no association between new HIV infections and vaginal practices. These practices were rarely carried out immediately before sex, and were primarily cleaning of the vagina with a cloth or water. Dry sex was rarely reported.⁴

A two-year study of 4500 Zimbabwean and Ugandan women found that vaginal drying/tightening was associated with HIV acquisition in univariate analysis (hazard) but not multivariate models. Vaginal cleansing was not associated with HIV acquisition.⁵

Nonetheless the authors of the last study commented that it is likely that the relationships between less abrasive practices (e.g., washing with water) and more abrasive practices (e.g., douching/use of antiseptic solutions, household or laundry soaps, use of traditional drying/tightening substances) and vaginal flora are substantially different and that the frequency of the practices would also play a role. They found that vaginal drying and tightening practices showed stronger associations with altered vaginal flora than vaginal cleansing practices. They suggested that future studies or interventions need to take the diversity of vaginal practices into account.

Indeed, a meta-analysis of data on vaginal practices and HIV infection from ten African cohorts, including over 16,000 women, found that vaginal washing with soap was associated with an increase in the risk of infection, as compared to washing with water alone or no vaginal practices (hazard ratio 1.22, 95% confidence interval 1.00-1.49, in multivariate analysis). The researchers noted that while the increased risk was modest, the widespread nature of the practice means that it could make a substantial contribution to the African epidemic.

Use of cloths, tissues or paper was also associated with an increased risk (hazard ratio 1.41, 95% confidence interval 1.03-1.77, in multivariate analysis), possibly due to abrasion. However the association between dry sex practices and HIV infection was not statistically significant.⁶