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Vaginal douching increased risk of sexually transmitted infections in high-risk adolescents

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Does vaginal douching increase risk of sexually transmitted infections (STIs) in high-risk adolescents?



prospective cohort study (substudy of Reaching for Excellence in Adolescent Care and Health [REACH] Project) with median follow-up of 3 years.


16 centres in the USA.


368 females 12–19 years of age (mean age 17 y, 65% had HIV infection) who were considered to be at high risk of STIs and were STI-free at baseline or became STI-free after treatment.

Risk factor:

douching status (assessed every 6 mo): never (did not report douching at any visit), intermittent (reported douching at some, but not all, visits), or always (reported douching at all visits).


incidence of an STI (Trichomonas vaginalis, Chlamydia trachomatis, Neisseria gonorrhoeae, or herpes simplex virus type 2) assessed by laboratory testing of urine, anal, and endocervical samples every 6 months.


Douching status over the entire follow-up period was “never” in 24% of participants, “intermittent” in 63%, and “always” in 14%. Time to STI incidence was shorter in adolescents who always douched compared with those who never douched (table). A similar effect was seen when douching status was limited to behaviour reported during STI-free periods (34% “never,” 27% “always”) (table).


Regular vaginal douching increased risk of sexually transmitted infections in high-risk adolescents.


Tsai CS, Shepherd BE, Vermund SH. Does douching increase risk for sexually transmitted infections? A prospective study in high-risk adolescents. Am J Obstet Gynecol 2009;200:38.e1–8.

Incidence of sexually transmitted infections (STIs) by douching status in female adolescents

Clinical impact ratings: Family/general practice 4/7; Paediatrics 5/7; Sexual health 5/7; Women’s health 6/7


Adolescent females may believe that douching is a health-promoting activity, but results from the study by Tsai et al show that intermittent and frequent douching is a health risk behaviour. High-risk Mexican-American and African-American high school girls in Texas stated that they believed douching was necessary to keep clean, prevent STIs, and meet expectations of boyfriends or partners.1

The study by Tsai et al is one of the first to show a causal link between douching and STIs among adolescent females who are at risk. Previous studies were limited by cross-sectional designs and had equivocal results. By using a prospective design, Tsai et al were able to clearly identify an association between douching and acquiring an STI.

The findings are important for nurses working in schools, adolescent health clinics, and gynaecological, obstetrical, and public health settings. Nurses working with HIV-positive African-American adolescent females, in particular, should note that this group had the highest level of douching and, thus, may be at highest risk of future episodes of STI related to douching.

Educating young women about the increased risk of STIs from repeated douching means confronting the belief system that reinforces the need to douche to be clean. This may be no easy task, particularly when nurses, who also need to be culturally sensitive, have few encounters with vulnerable adolescents, whereas family and friends may reinforce their beliefs more frequently. Nurses in the public health arena should advocate for more media messages to promote sexual health. Nurses working with adult women can also communicate this health information because mothers, grandmothers, and aunts may model and reinforce the practice of douching to adolescents. Finally, health and sex education curricula in schools should include factual information describing how douching can upset the vaginal ecosystem and contribute to repeated STIs. This message should be initiated in early adolescence before girls develop menstrual hygiene practices and become sexually active.

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  • Source of funding: National Institute of Child Health and Human Development; National Institute of Drug Abuse; National Institute of Allergy and Infection Diseases; and National Institute of Mental Health.

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