Vaginal Douching Among Latinas: Practices and Meaning

Abstract

Objectives

Vaginal douching is widely practiced by American women, particularly among minority groups, and is associated with increased risk of pelvic and vaginal infections. This research sought to investigate vaginal hygiene practices and meaning associated with them among Latina women and adolescents. Study results would guide development of an intervention to decrease douching among Latinas.

Methods

In depth qualitative interviews conducted with English- and Spanish-speaking women aged 16–40, seeking care for any reason who reported douching within the last year (n = 34). Interviews were audiotaped, transcribed and analyzed using qualitative methods. One-third of interviews were conducted in Spanish.

Results

Two explanatory models for douching motives emerged: one stressed cosmetic benefits; the other, infection prevention and control. Most women reported douching to eliminate menstrual residue; a small number reported douching in context of sexual intercourse or vaginal symptoms. Many were unaware of associated health risks. Respondents typically learned about douching from female family members and friends. Male partners were described as having little to no involvement in the decision to douche. Women varied in their willingness to stop douching. Two-thirds reported receiving harm reduction messages about “overdouching”. About half indicated previous discussion about douching with health care providers; some had reduced frequency in response to counseling. A number of previously unreported vaginal hygiene practices and products were described, including use of a range of traditional hygiene practices, and products imported from outside the US.

Conclusions

Respondents expressed a range of commitment to douching. Counseling messages acknowledging benefits women perceive as well as health risks should be developed and delivered tailored to individual beliefs. Further research is needed to assess prevalence and safety of previously unreported practices.

Introduction

Vaginal douching is widely practiced by American women and is more frequent and more common among minority women and among women of lower socioeconomic status [1–3]. Between 1988 and 1995, rates of douching declined overall among women in the United States but dropped least among minority groups to 55% of Black women, 34% of Latinas, and 53% of lower SES women engaging in vaginal douching [2]. As in adults, the practice is more common among ethnic minority teens [2, 4–6]. Use of vaginal douche products has been associated with adverse obstetric and gynecologic consequences, though evidence of a causal link between douching and these health concerns is missing due to lack of randomized studies. The preponderance of evidence suggests that frequent douching is associated with increased risk of pelvic inflammatory disease (the most frequent serious infection experienced by US women) [7, 8]; ectopic pregnancy [7, 9, 10]; Chlamydia Trachomatis infection [4, 11]; decreased fecundity [12]; preterm delivery [13]; Herpes Simplex type 2 [14]; and bacterial vaginosis [15, 16]. Overall, evidence suggests that douching is neither necessary nor beneficial, and is very likely to be harmful [17].

Douching practices are shaped by social and cultural norms regarding female hygiene, reproduction, and sexuality; thus, messages to patients about the potential risks of douching must be grounded in an understanding of the social context of douching. The belief that the vagina is unclean, particularly during and after menstruation, has been documented around the world [18]. A consistent finding in the US is that most women who douche do so for reasons of hygiene, that is, to “feel clean” after sex or menses, and 25% douche to self-treat infection [6]. Adolescents report douching to feel good and fresh (60%), to get rid of odor (47%), to get rid of blood, (47%) [19] and to protect against STDs [20]. Focus group studies conducted with African American and white women in the southern U.S. [21, 22] reported that women douche after menstruation and after sex, commonly citing concern about odor and cleanliness.

While health care professionals generally discourage douching, effective interventions for reducing douching are rare [23]. Many women view douching as a necessary part of their feminine hygiene routine and may be reluctant to stop [4, 6, 21, 22]. Gazmararian et al. [22] conclude that simplistic interventions that only provide risk information are unlikely to be successful in changing what could be a deeply entrenched behavior rooted in cultural constructs. Studies exploring the beliefs, attitudes, and social norms related to douching have been conducted primarily with African American and white women. Because similar studies have not been conducted with Latinas, we sought to investigate vaginal hygiene practices and the meaning associated with them, to guide development of an intervention to decrease douching among Latinas.

Methods

Procedures were approved by the Institutional Review Board of the authors’ institution.

Setting

Women and adolescents participating in this study were patients attending one of two family medicine-staffed health centers or a school-based health center between December 2005 and May 2006. These practices serve a multiethnic, low-income community in the Bronx. A large percentage of patients served by these health centers are originally from the Caribbean islands, primarily Puerto Rico and the Dominican Republic (DR).

Recruitment

Women were eligible if they were present for care, self identified as Latina, were between the ages of 16 and 40, and were fluent in either English or Spanish. Permission to be approached to complete screening questions was obtained by health center staff. No women refused at this point. The research assistant then conducted an interviewer-directed screening interview of douching practices in the privacy of exam rooms. Women who reported they had douched in the past year were offered the opportunity to take part in a qualitative interview. Of all women approached (n = 91), 39 (43%) indicated douching at least once in the last year. Four adult women declined to be interviewed; no adolescents declined the interview.

Data Collection

Each participant provided informed written consent before being interviewed privately, in English or Spanish. The interviews were audiotaped and transcribed verbatim. Interviews ranged in length from 9 to 27 min. Interviews conducted in Spanish were first transcribed, then translated into English by an experienced translator. Interviewing continued until data saturation was reached.

The Interviews

An interview guide was developed to focus on the social and cultural context of douching, beginning with an investigation of perceptions of vaginal health, cleanliness, and disease or symptoms. For both douching and non-douching hygiene practices, we explored products and contexts for use as well as potential alternatives to douching. Questions addressed the goals of douching, and the social and emotional context of douching. Prompts examined communication related to douching, with family, friends, partners and health care providers. Finally, we asked women how they would feel if they could not douche.

Analysis

The analysis team included the principal investigator (a family physician) a master’s level analyst, and the interviewer, who provided clarification of the intent and subtle meanings implicit in the narrative for key passages. Whenever questions arose, we returned to the tape to re-check the transcription and translation. We used a basic analytic approach common in health research. It had elements of grounded theory in that we searched for new themes and categories in our data, and focused on the comparison of individuals and categories in building a theoretical model of our findings [24, 25]. The analysis used a combination of template and editing approaches [26, 27] to organize data and identify important themes related to the context and meaning of douching. In the template approach, key theoretical categories are established a-priori and applied to data through a structured coding process. The editing approach, by contrast, involves a more detailed textual analysis with the goal of generating new categories and ultimately, a new theoretical model. In the present study, we began with a set of core codes. These included: conceptual models of vaginal health and douching; the social and personal contexts of douching; learning and communication around douching; and ideas about reducing or stopping douching and douching substitutions. An editing approach was then used to establish subcategories and to identify unanticipated, novel themes and categories. All analysts read the transcripts independently and made notes of themes, including unanticipated themes, thus creating a tentative coding scheme. Analysts assigned provisional codes, then met to resolve differences and fine tune the coding scheme. The finalized coding scheme was applied using Nvivo^tm software to facilitate the retrieval of text passages.

We sought to understand women’s motivations for douching and willingness to change douching behavior. We searched for explanatory models employed by participants to justify the importance of hygiene in general and specific practices. Two conceptual models emerged from the narratives. In the “cosmetic model”, douching was motivated by the need to be clean, odor free or attractive. In the “infection control model”, douching was thought to serve a substantive role in prevention or treatment of infections. Two analysts independently assessed whether one or both models were present in each narrative and reviewed the four interviews where analysts initially differed. We followed a similar process to categorize the level of commitment to douching expressed by women, primarily by evaluating women’s responses to the question “How would you feel if you could not douche?” We categorized women as possibly willing to change versus firmly committed/unlikely to change. We systematically searched for patterns relating attributes (e.g. country of birth and age) to level of commitment to douching and conceptual model by review of coded text and explicit searching for disconfirming cases. Finally, we searched for differences between adolescents and adults in products used, context of hygiene practices, conceptual models, or commitment to douching.

Results

Sample

Table 1 describes the sample characteristics. Among the 10 adolescents (age 16–19) interviewed, six completed the interview in Spanish. Among the entire sample, 14 of 35 women chose to be interviewed in Spanish. Most respondents were of Dominican or Puerto Rican ancestry.

Table 1.

Participant characteristics n = 35

	N	%
Age of respondents
Mean for total sample (years)	25.8	n/a
Range	16–40	n/a
Respondents under age 20	10	28.6
Language of interview
English	21	60
Spanish	14	40
Place of origin of respondent
United States	16	45.7
Puerto Rico	5	14.3
Dominican Republic	13	37.1
Other (Latin American country)	1	2.9
Place of origin of mother
United States	10	28.6
Puerto Rico	10	28.6
Dominican Republic	13	37.1
Other (Latin American country)	2	5.7

Vaginal Hygiene Practices

A normal vagina was described as free of discharge or at least without “abnormal” discharge and without odor. Reported signs of an unhealthy vagina included odor, thick or colored discharge, irritation, and itching. Most women described regular gynecologic exams, protected intercourse, and especially, good hygiene as strategies to maintain health. All women in our sample described using hygiene practices including but not limited to douching. Non-douching practices include bathing (often multiple times per day), use of feminine wash products, wipes, sprays and deodorant suppositories, and use of óvulos (described as suppositories which aid removal of residue from the vagina). Feminine cleansing products included well-known commercial products (e.g. Summer’s Eve) and imported products, mostly from the Dominican Republic (see Table 2 for descriptions of commonly used products and their ingredients). The range of practices and special products utilized reflects the belief that the vagina is an especially sensitive part of the body, vulnerable to irritation and infection if not properly cared for.

Table 2.

Vaginal hygiene products and practices identified by respondents, classified by use

	Description and use	Ingredients
Non-douching products and practices
Lemisol	External feminine wash for daily use. Valued for “minty fresh” feeling. Manufactured in Dominican Republic. Other brands sold as “intimate washes” are La Fresca, Lufragen, Higienex and IntiMiss and contain similar ingredients	Water, isopropyl alcohol, sodium ether sulphate, sodium chloride, cocamide DEA, crystalized menthol, citric acid
Feminine wipes	Various U.S. commercial brands	Purified water, octoxynol-9, lactic acid, disodium EDTA, fragrance, potassium sorbate, cetylpyridinium chloride; sodium bicarbonate
Cuava soap	Preferred for washing vaginal area due to perceived risk of infections posed by fragrances in “regular” soaps	Sodium tallowate, water, sodium cocoate, sodium hydroxide, glycerine, color, fragrance, preservatives
Óvulos	According to respondents, these vaginal suppositories are used to clean out post menstrual residue	Active ingredients: metronidazole and nystatin
Norform	Vaginal deodorant suppositories used to control odor. Some women claim that it helps rid of post menstrual residue	PEG stereate (emulsifier) Benzethonium chloride (antibacterial), lactic acid. Label reads: “no additives that can dry out the vagina”
Shaving vaginal area	Controls sweat/moisture, thus believed to decrease bacteria that lead to odor	–
Douching products
U.S. commercial douching products	Summer’s Eve or Massengil vinegar and water solution are the products most commonly mentioned by respondents	May include: octoxynol-9 (spermicide), citric acid vinegar, polysorbate 80 (detergent and emulsifier)
Lufragen	Wash for internal or external use. Manufactured in Dominican Republic	Aluminum potassium sulfate (alum), eucalyptus, menthol, thymol, hydrogenduodecyl sodium
Homemade vinegar and water solution	Generally considered mild; many respondents note anti- bacterial properties
Alum	Sold in crystalline form and dissolved in water for douching. Valued for “tightening” properties	Alum (alumbre): aluminum potassium sulfate
Borisol	Sold as a powder and dissolved in water for douching. Valued for “tightening” properties and for treating infections, but sparse use is recommended by respondents since it is considered harsh on the body	Boric acid: mild acid with various medicinal, insecticidal and industrial uses
Camphor	Sold in crystalline form and dissolved in water for douching. Valued for “tightening” properties	Aromatic substance derived from camphor laurel tree. Produces cool feeling similar to menthol

“A woman’s personal hygiene is most delicate. Us women can get an infection from anything.”

Many women describe the need to avoid chemicals, fragrances and dyes that may be present in regular soaps.

“Any type of fabric can cause an infection due to detergent used to wash clothes… Clorox is a disinfectant, but it is not good because it is too strong for the vagina.”

Reasons for Vaginal Hygiene Practices

For all but two respondents, douching as part of feminine hygiene began after sexual debut. One respondent explains the timing of initiation:

“I think the whole concept of having sex for the first time… You have sex, you douche. Before that you’re young, a little girl, you don’t know better, there’s no reason any other thing should be going up there.”

Women varied in the primary source of information about douching. For some, learning from family is central.

“There are eight of us and we all use the same thing [douching product]. The entire family [douches], which is important to maintain good hygiene and vaginal health.”

In cases where mothers do not talk about such things, other female family members teach about vaginal hygiene. The family transfer of information often emphasizes the virtue of cleanliness in general, with extension to self-care practices:

“I guess the way I was raised up…you know the house, the environment, clean house, clean bathroom, hygiene, the body, you know your hygiene come first, and it’s the same way now with my children…”

The value placed on cleanliness and self care is evident in this respondent’s description of her grandmother as role model:

“(My grandmother) is a very clean woman. Her pee is clear, like no color whatsoever, because she is anal about health and cleanliness, it’s amazing… I know that my grandmother’s super duper clean.”

In a few cases (n = 5), women learned about douching and other forms of vaginal hygiene from friends rather than family, either because these topics were not discussed, or because the respondent’s mother did not believe in douching.

Women stressed the inherent importance of vaginal cleanliness, describing the need to be clean as almost innate and the vagina an inherently dirty part of the body:

“If I don’t douche I feel like the smell of the menstrual cycle lingers…Disgusting, even babies cry when they are dirty, like anybody feels disgusting when you don’t feel fresh and clean.”

“It’s reality to think the vagina is dirty…because imagine urine, menstruation, and every time you have sexual relations.”

Because the vagina is seen as an unclean repository, many women consider douching a routine and necessary component of vaginal hygiene and believe they should clean inside the vagina as well as external areas. A key benefit of douching is the clean and fresh feeling it yields:

“Although the reason why doctors don’t recommend it is because there are certain bacterias that we need in the vagina, to help us fight off any diseases. But I guess it’s more comforting to me to douche because then I have like an extra clean feeling.”

Women indicated that feminine hygiene practices are basic, indispensable daily rituals:

“I use Lemisol. It’s like antiseptic for the vagina. It’s like Listerine is for the mouth. But for the vagina.”

“You feel fresh and clean like when you wash your hair… that fresh clean feeling, that’s what its like in the vagina.”

Some acknowledged that the benefits were in part “a mental thing”, possibly the security from knowing that you are “really” clean:

“Sometimes I think it is like a mental thing because you put it in and you are supposed to hold on, you tighten up or whatever, and then release. So you figure, the longer you hold maybe the cleaner you are going to be. But it is probably just a mind thing, a comfort zone.”

Contexts for Vaginal Hygiene Practices

The most common context for douching, reported by half the sample, is post-menstrual. Less commonly, women reported douching before or after sexual intercourse, and occasionally in response to vaginal symptoms. Regular douching after menses is described as necessary to rid the body of any blood residue, which is considered dirty and unattractive:

“People want to clean themselves after the period…just these blood clots, dirt up there…if you are going to have sex with your husband… and blood clots comes out or something.”

It is implied that failure to eliminate this fluid is not good for the body:

“My aunts explained that if you don’t douche that [blood] stays backed up in there and that’s why you wash it out.”

Participants explained that sexually active women also need to take steps to remove sperm:

“Of course because when you have relations continually, all of the semen accumulates in the vagina because it does not secrete from the vagina entirely… So I say it is a must for women to take good care of themselves and douche and use an óvulo when they have sexual relations…An óvulo will remove everything, the residue that remains in the vagina.”

Conceptual Models Underlying Beliefs about Hygiene

While all women agreed that cleanliness is essential, they differed in the underlying conceptual models that explain the importance of cleanliness. Two frameworks emerged from the narratives. In what we termed the cosmetic model, women attribute the importance of douching to attractiveness to self or partner. Another group expressed beliefs about the role of hygiene in infection control, often in addition to cosmetic benefits of douching.

In the cosmetic model, endorsed by most women, douching fills the need to be clean and odor free, which is considered vital for attractiveness. Blood and sperm residue are viewed as a source of odor or unpleasant discharge, which is managed by post menstrual or post coital douching.

“You should douche well because at times you wash yourself and think you are clean but you should smell yourself after you bathe… if you still have a foul odor you need more cleansing.”

The fear that others can smell vaginal odor is a strong motivation:

“It’s very important. I want to feel clean not just for my partner but just like for me.

I work with children…and they want to be next to you…it would be embarrassing, you know, that they smell something.”

Many indicated that douching contributes to sexual attractiveness, either because women perceive that men desire a clean partner, or to enhance sexual experience through what women referred to as “tightening” the vagina, through the use of astringents such as alum:

“I used [sulfur and alum] many times. It will clean the infection as well as tighten the vagina. Very tight. The sulfur and alum is said to be used for infections…but I used it to tighten the vagina and it really worked.”

For some women with a cosmetic model, goals of preventing infection are specifically not endorsed:

(So you feel that if you douche you are healthier?) “No, I just feel if you douche you are cleaner.”

In the infection control model, douching is thought to serve a substantive role in prevention or treatment of infections, by removing bacteria that can cause irritation or infection.

“When you have sex you leave all the residue inside the vagina…Sometimes people don’t have sufficient hygiene and instead of cleaning yourself you could get an infection.”

Women commonly refer to the prevention of “minor” infections in the vagina (such as yeast, or nonspecific vaginal itching) and urinary tract infections.

“My cousins would always tell me that it was good to douche…that it prevents certain minor infections and irritation.”

“I had a bad experience. I had a urinary tract infection…After that happened to me I’ve become more conscious of my vaginal cleanliness…I make sure that I bathe with the Lemisol three times per day.”

Many women state that the preventive effects do not extend to sexually transmitted infections:

(Do you think that douching protects you from infections?) “Not from HIV or none of those other [sexually transmitted diseases].”

An extension of the infection control model, women used douching to treat symptoms as well as prevent them. One woman describes responding to “a stronger odor than usual”. She was advised by a Dominican health care provider that she should douche, “because the vinegar kills any germs or anything that I may be feeling.” Others also link douching to managing infections:

“I douche because sometimes I get a low pain here and when I douche the pain seems to go away. Sometime when I urinate it can be bothersome and I think it could be an infection but then I douche and it goes away.”

Partners’ Role

Most women described their partners as having little if any awareness of vaginal hygiene practices. They are most commonly described as not expressing any opinion:

“Well at first he didn’t know what it was…I would tell him that if I felt well you are going to feel well but if I feel uncomfortable… then I can’t make you feel good.”

Some are described as being vaguely accepting of it:

“He tells me that if it is for my own good that it is ok to douche.”

A few indicate that they feel they should be clean for the partner. One respondent stated, “Now it matters, now for my husband I have to be clean as well.” Another reported that she only douched before extramarital sexual encounters, “to be nice and clean”. Though such explicit comments about douching for the partner are rare, there is frequent reference to a pride in self-care that they believe partners appreciate:

“It’s always nice to know that their partner is on top of their cleanliness. You know you wouldn’t want to be with someone that isn’t clean.”

Reasons to Avoid Douching

Women noted a variety of potential consequences of douching, learned from friends, family or health care providers. Most commonly, women understood in very general terms that harm may come from overdouching. Somewhat concrete mechanisms were described such as “overdrying”, which would cause irritation, and removal of secretions, which would interfere with clinicians’ ability to diagnosis problems. Concerns about the sensitivity of the reproductive system also lead to cautions about douching. Women note that some may be unable to douche because of irritation from the douching itself, or that too much douching risks “messing up your insides.” Some refer to the potential of vinegar to cook “the skin of your uterus or [vaginal] walls”, while another referred to douching everyday like “taking a piece of steak and seasoning it.” Notions of disturbing normal flora were much less common. One respondent referred to ideas that douching can remove “certain needed bacteria,” and another to “outburst in bacteria” that might result. Another referred to “natural protections” that might be diminished.

“If your private is too clean, you can get an infection…because you have no natural fluids I guess…so if it’s too clean [the fluids] can’t function.”

Women explained that certain contexts were inappropriate for douching. Almost all volunteered that douching should be avoided during pregnancy. Many were unable to articulate a clear reason; others indicated that the fluid comes into contact with the baby (“could get into the baby’s eyes”), that vinegar or chemicals might be harmful, or just that the packaging indicated a warning. Many indicated that douching should be avoided with undiagnosed vaginal illness because it may interfere with diagnosis. A few expressed that douching could make gynecologic problems worse, though only one respondent discusses making infection “go higher”, suggesting an understanding of ascending pelvic infection.

Interactions with Health Care Providers

About half of the women indicated no previous discussion about douching with a health care provider. A few had been advised about potential risks and reported harm reduction messages about limiting the frequency or avoiding douching in certain circumstances, such as to prevent conception. Two women reported pro-douching messages from U.S. physicians. Several of the Dominican respondents emphasized differences between doctors in the Dominican Republic and doctors in the US Physicians in the former recommend douching and the use of óvulos, while US physicians do not:

“…the Americans think different. Now there’s a bit of disagreement…the doctors from my country (Dominican Republic), they always recommend douching.”

“I am Dominican and in my country, we use óvulos…No physician has ever recommended douching…The [American] doctors say it isn’t …advisable, that you are not supposed to touch your vagina too excessively.”

Commitment to Douching

Most women indicated that they would feel unclean and uncomfortable if they were unable to douche.

“I’m so used to doing it for so many years that I wouldn’t feel right.”

(How do you feel after you douche?) “Clean, absolutely clean.” (And if you couldn’t douche?) “I would feel real dirty.”

However, reactions to the idea of discontinuing were quite varied. Some women, already aware of potential risks of douching, have reduced the frequency, especially those that indicate conversations with health care providers who specifically communicated harm reduction messages. About a third of the women in the entire sample stated they would need a very good reason to change: “I demand an explanation.” Women say they would ask for specific health consequences, or would need to know if “something [was] wrong with the product”, as reasons to justify stopping. Several had been told that douching is unhealthy and chose to ignore the advice. Some weighed potential risks and decided to douche, explaining that “we do a lot of things we know aren’t good for us.” One expressed the belief that messages to stop made no sense because no alternative for vaginal cleaning is proposed when douching is discouraged:

(If you can’t douche how do you feel?) “Strange. What I have to do I do, I have to douche.” (And if the doctor told you shouldn’t?) “The doctor tells me so, but I don’t pay them any mind sometimes. I wouldn’t stop douching. Because they don’t recommend anything to cleanse the vagina with instead.”

Some discount providers’ concerns because they had experienced no problems themselves with repeated douching, which serves to reinforce the belief that douching is not harmful. A few state they have no intent to change, even with strong messages in reference to providers:

“I say that women should douche, and no one can change my mind about that concept.”

We saw a range of commitment to douching regardless of whether the participant reported beliefs consistent with the cosmetic, infection control or both models. The only group difference noted was that all adolescents were open to giving up douching if recommended by a physician, whereas some adult women were not.

Discussion

Our study is the first to explore beliefs and practices related to douching among Latina women. We found many similarities, and some important differences, in comparison to previous studies of African American and white women. Consistent with previous reports conducted with non-Latina samples [4, 6], douching knowledge is handed down from one generation to another, generally by mothers and female family members around the time of sexual maturity. Information about douching is discussed in the context of other feminine hygiene practices, emphasizing the importance of cleanliness. Similar to findings with African American women [28], Latina women who choose to douche also use a variety of other feminine hygiene products to feel clean and attractive, in part due to the perception that special care must be provided to a particularly delicate part of the body.

While there are many parallels with ideas expressed by African American women, there are several interesting findings that may be unique to Caribbean Latinas. As in other studies [19, 28], vinegar and water was the most common solution used. However, women report using a variety of Dominican products including cleansers for external and internal areas of the vagina, as well as alum and camphor purchased in botánicas—small shops selling traditional and herbal remedies from Latin America [29]. The use of óvulos by women in the US is previously unreported. Of note, óvulos—whose active ingredients Metronizadole and Nystatin are available only by prescription in the US—are imported and sold in the botánicas and bodegas (corner stores) of New York City. The influence of Dominican health care providers is apparent, whom women describe as recommending routine use of óvulos and douching for vaginal health.

Our interviews explored the conceptual models that underlie the importance women ascribe to cleanliness. Women differed, with some stressing only the cosmetic benefits of cleanliness, while others stressed hygiene as a means to prevent or treat infection as well. These perceived benefits are clearly paramount to many women who choose to douche. The Latina women in our sample consider the practice to be a highly desirable component of routine hygiene, stressing the importance of odor control and the desire to rid menstrual and semen residue. Sexual benefits relate to being clean for one’s partner and to enhanced pleasure via vaginal “tightening”, previously discussed primarily in reports of traditional practices in Africa [30]. Perceived benefits extend to positive feelings associated with cleanliness, both the physical comfort associated with douching, and feelings of pride and self worth associated with being a clean person.

As in African American samples [23, 31], many Latina women in our sample found the idea of stopping to be troubling at best, though participants did express a range of willingness to change. As noted in studies of other populations [4, 5, 21, 32], awareness of specific health risks associated with douching was very low for our Latina participants. Women cite the lack of adverse consequences as evidence that the practice is safe and advisable. Many have had little or no interaction about douching with health care providers. For relatively uninformed women, access to information may lead some to stop douching. Others have responded to messages to limit douching provided by either family or health care providers, suggesting there is a group who may be responsive to counseling messages. Ness and colleagues found that physician advice influenced perceptions and behavior for some women. For other more entrenched women, douching is considered mandatory [33].

Because douching may be difficult to change for some women, counseling messages that acknowledge the perceived benefits as well as potential risks of douching need to be developed, and delivered in ways tailored to individual beliefs and motivations. For some Latina women, the influence of health messages learned from family, friends, or health care providers in the Dominican Republic must be acknowledged. Early interventions targeting adolescents before douching is established may be more useful for reducing risks. Further research to assess the prevalence of practices in the Latina community should be conducted. Nothing is known about the safety of traditional practices, such as alum, or about the prevalence or consequences of the use of óvulos.

Some limitations should be acknowledged. Our sample is limited to Latinas of primarily Caribbean background who douche and who were seeking primary care at the time of the interview. Beliefs of Latina women who choose not to douche or who are not linked to the primary care system were not explored. These results cannot necessarily be generalized to Hispanic women of different backgrounds.