Vaginal Hygiene and Douching: Perspectives of Hispanic Men

Abstract

Vaginal douching is widely practiced by women in the USA, particularly among minority ethnic groups, and is associated with increased risk of pelvic and vaginal infections. Douching practices are shaped by social and cultural norms regarding female hygiene, reproduction, and sexuality. Little previous research has addressed the beliefs and practices of Latina women, and none has included the perspective of men, though limited data suggests that women may douche to please male partners. The present study seeks to identify the socially and culturally shaped beliefs and attitudes that influence douching practices from the perspective of Latino men. We conducted in-depth qualitative interviews in English or Spanish with adult Latino men seeking primary care at a community health centre in New York City (USA). Results indicate that these Latino men (mostly of Caribbean descent) are emphatic about the role of cleanliness in vaginal health, reporting that it substantially influences their choice of partner. Most are very supportive of douching, which they consider a necessary hygiene activity. Vaginal health is perceived as a state that must be attained and maintained through proactive hygiene measures that remove seminal residue, menstrual blood, sweat and bacteria that contaminate the vagina. The implications of these findings for interventions with Latina women are discussed.

Introduction

Vaginal douching, the process of intravaginal cleansing with a liquid solution, has been described for at least 3000 years (Martino & Vermund, 2002, Farage & Lennon, 2006). While the prevalence of douching has decreased among women in the US in the last two decades, douching remains a widespread practice and is more frequent is and more common among minority ethnic women and among women of lower socioeconomic status (Cherpes et al 2003). The behaviour is associated with increased risk of pelvic inflammatory disease, (Scholes et al 1993, Wolner-Hanssen et al 1990) a major cause of infertility, chronic pelvic pain, and ectopic pregnancy (Zhang et al 1997, Scholes et al 1993, Kendrick et al 1997); Chlamydia Trachomatis infection (Peters et al 2000, Foch et al 2001); decreased fecundity (Baird et al 1996); preterm delivery (Bruce et al 2002); Herpes Simplex type 2 (Cherpes et al 2003); and bacterial vaginosis (Schwebke et al 2004, Holzman et al 2001). Although debate continues, the preponderance of evidence suggests that douching is neither necessary nor beneficial, and is very likely to be harmful (Cherpes et al 2003, Martino et al 2002).

Douching practices are shaped by social and cultural norms regarding female hygiene, reproduction, and sexuality; thus, messages about the potential risks of douching must be grounded in an understanding of the social context of douching. Research with both African American (Grimley et al 2006, Oh et al 2002) and Latina women (McKee et al 2008) suggests that douching is part of a comprehensive set of hygiene practices. Research conducted primarily with African American and white women has found the most cited reasons for douching include a desire to feel clean and fresh, prevention or treatment of infection,(Crosby et al 2000) and less commonly to prevent pregnancy (Oh et al 2002, Oh et al 2003, Lichtenstein & Nansel 2000, Gazmararian et al 2001). Research conducted in Botanicas - shops that sell religious or spiritual items and medicinal plants - (Anderson et al 2008) and with Latina women (McKee et al 2008) in New York City finds parallels in the strong motivation to feel clean, and the belief that douching promotes vaginal health, but also highlights that douching may perform multiple reproductive, sexual and romantic functions, including enhancement of male sexual pleasure by vaginal ‘tightening.’

Limited data on the role of male partners in women’s decision to douche suggests that some women may douche because they want to be more attractive to their partners (Oh et al 2003). Some women believe that vaginal odour and wetness are repellent to men (Karasz & Anderson 2003). One study to date has addressed men’s attitudes toward douching. Markham et al (2007) conducted a survey of primarily minority, male and female alternative school youth. They found that two thirds of young men in that setting had heard of douching, 81% thought it decreases odour, and 75% prefered that their partner douche.

While health care professionals generally discourage douching, effective interventions for reducing douching are rare (Grimley et al 2005). This report is part of a larger study investigating vaginal hygiene practices, and the meaning associated with them, to guide development of an intervention to decrease douching among Latinas. Here we sought to identify the socially and culturally shaped beliefs and attitudes that influence douching practices from the perspective of Latino men. Investigation in this little explored area is essential to fully understand the context of douching and to identify barriers to reducing douching behaviour.

Method

Participants and procedures

The Institutional Review Board of the authors’ institution reviewed and approved all procedures. Men participating in this study were patients attending a family medicine-staffed community health centre in the Bronx, New York. This health centre serves a multiethnic working class population. We approached a convenience sample of men who were present at the health centre for medical care, identified themselves as Latinos and as being sexually active with women, and who were fluent in either English or Spanish. Of 18 eligible men approached, 5 declined participation (three ‘not interested’ and two ‘had no time available’). For this exploratory study, we included men between the ages of 18 and 60, on the grounds that we were interested in describing views of sexually active adult men of Latino backgrounds, and were not interested in generating hypotheses related to age. Men were provided a US $30 incentive for participating.

Each participant provided informed written consent before being interviewed privately at the health centre. The research associate (a woman in her mid-forties, of Puerto Rican descent) conducted interviews in English or Spanish as preferred by the participant. We considered that there were advantages and disadvantages to either a male or female interviewer in exploring this sensitive subject matter. Studies have found that responses vary based on interviewer gender (Padfield & Proctor, 1996) but that it cannot be assumed that responses are more accurate in same gender dyads (Williams & Heikes 1993). We chose a female interviewer who had been extensively trained and had experience interviewing Latina women about vaginal hygiene and douching. The interviews were audio taped and transcribed verbatim. Interviews ranged in length from 12 to 46 minutes. Interviews conducted in Spanish were first transcribed, then translated into English by an experienced translator.

The interview guide employed open-ended questions to focus on men’s familiarity with douching or other feminine hygiene practices; their concepts of vaginal health, disease, and attractiveness; preferences related to douching; and men’s role in promoting their partners’ vaginal health.

Analytic approach

The analysis team included the principal investigator (a family physician), a master’s level analyst (a bilingual Latina), and a psychologist co-investigator. Whenever questions arose, we returned to the tape to re-check the transcription and translation. The analysis used an editing approach (Miller & Crabtree 1994, Polit & Beck 2008) to identify important themes related to the context and meaning of douching. Core codes were anticipated before the data were collected, based on findings of interviews conducted with Latina women (McKee et al 2008) and proprietors of Botanicas (Anderson et al 2008). Core codes related to models of vaginal health and douching and included the social and personal contexts of douching, learning and communication around douching, importance attributed to douching, and preference for douching or non-douching women.

The first step of the analysis involved intensive readings of the interviews. Two 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. Two analysts coded each interview, then met to discuss and resolve any discrepancies in coding judgments. This process was repeated until the team judged that the coding list was conceptually adequate, concise and usable, with few discrepancies between the coders. The finalized coding scheme was applied using Nvivo^tm software to facilitate the retrieval of text passages. We then prepared summary matrices of the coded data. Following a group process similar to that described by Miles and Huberman (1994) we subjected the data to a series of reductions to group similar responses and facilitate description and analysis. The final step of the analysis process involved explicit comparison of themes identified with Latina women for convergence or divergence in the men’s data. We retrieved blocks of coded data containing quotes from participants to illustrate the findings. We present the quotes identifying each individual by an assigned alias.

Results

Sample

Of 13 Latino male participants, six completed the interview in Spanish. Participants ranged in age from 24–56 (mean age 39). Most (11/13) were currently married or living with a partner. Most (10/13) were born outside the mainland USA. Most respondents were of Dominican or Puerto Rican ancestry.

Beliefs about vaginal health and odour

All men in our sample indicated that cleanliness is essential to maintain vaginal health. They uniformly described a healthy vagina as free of discharge or at least free of ‘abnormal’ discharge, and without a ‘strong’ or ‘repulsive’ odour. Men’s narratives suggest that the vagina is viewed as an inherently dirty part of the body for several reasons. First, the vagina is a repository for sperm and menstrual blood, which are viewed as important sources of contamination and odour. Thus men indicate that good hygiene is necessary for sexually active women to remove sperm or menstrual blood:

Apart from bathing with water and soap, the woman should use an antibacterial product or something that is sure to eliminate the foul odour that a man’s semen can produce. After a while, semen can rot in less than three hours. A man’s semen decomposes and it has an awful smell, very funny and strange odour. (José, all names changed, age 40)

I mean from my experience a woman should douche. Because you know… you need to clean all that backed up stuff that you have inside, you need to release that. You know I mean it could come from, you know… menstruation, or stuff like that, or you know you have some situation… like sexual intercourse with like multiple partners. That could be very yucky, so I mean from my personal experience, I’ve witnessed situations like that. That's why to me personal hygiene is really, really important. (Manuel, 29)

Many men also believe that pubic hair increases sweating, which is associated with an increase in bacteria and odour. Thus, the shaving of pubic hair is described as a desired practice:

Her vagina should be shaved because just like a man a woman can sweat and cause a foul odour when there is too much pubic hair. (Ramon, 44)

Perhaps most importantly, men view the vagina as particularly prone to infection, requiring special cleansing to remove bacteria in order to avoid symptomatic infections for women and the spread of infection to male partners:

When my partner douches it benefits me a lot because in that way we protect ourselves from not catching any diseases or any disease we can catch during sex… Some sort of bacteria or something. (Juan, 24)

Thus men suggest that an unclean vagina is both unattractive and unhealthy. Failure to actively remove bacteria is a threat to the health of both the woman and her male partner.

Assessing vaginal health

Despite its importance, men acknowledged difficulty in assessing the vaginal health of potential sexual partners, but identified particular signs that they relied upon for evaluation. Odour, a frequent theme in men’s narratives, is mentioned as a readily perceptible vaginal trait considered an unequivocal indicator of disease:

Any time any one has even odour in the mouth or anywhere else, it’s infection. So [vaginal odour] can’t be normal… there’s gotta be something going on. So if everything is clean, everything is normal it has a normal smell…And you don’t have to see certain things visually to realize that something’s not wrong because, I mean, there’s no way that a woman has certain diseases, and be completely normal, smells very nice and not have anything, you know, it’s almost impossible. (Enrique, 36)

Because odour is believed to be an important sign of potential infection, men emphasize relying primarily on odour to evaluate the likelihood that a woman is clean and ‘takes care of herself’:

First of all you can tell by the smell, that's the main thing… you know she's not taking care of herself. I mean it's hard to ask her ‘Hey, so when is your last GYN checkup’. It's not something that just comes out in conversation. (Hector, 40)

Most men describe odour as often the only way to evaluate the state of vaginal health. Some go so far as to describe how odour can be used to determine whether sexual activity should occur:

I do what is called the finger test… Like I would insert my finger into her…[before] intercourse. [If there is odour] you can tell that she’s dirty… and pass… just not feeling it right now. Most of the experiences that I’ve had with women they’ve usually been clean, thank God. They’ve always douched. They’ve never given me an STD. (Alberto, 28)

In addition to odour, men mention more outward signs that they perceive indicate how well women care for themselves externally, and by extension, internally. The most common of these traits are care for hair or nails:

Although looks can be deceiving but I say that when you see a woman’s clean hands, well groomed, her feet looking good and clean, you can tell that that woman is clean, you can see it… (Fernando, 39)

It depends on the clothes she wears, how she maintains her hair, how she maintains her finger nails because nails and makeup contribute to a woman’s hygiene. (Ramon, 44)

A few of the men interviewed recognize that these signs are not entirely infallible. Some reported (not without distress) experiences in which the external aspect of the vagina did not necessarily reflect its inner state.

Sometimes one judges the vagina from the outside and things seem alright, but after having sexual relations and introducing the male organ to the vagina and when it is time to bathe and the stench has stuck to you; you say, well it was decent on the outside but on the inside of the vagina it was rotten. (Fernando, 39)

Some men acknowledge a potential paradox in hygiene. While it is considered an important means to prevent infection, it is also possible to temporarily remove odour without removing infection.

Because, you know, how the hell do I know whether she douches or not or maybe she has an infection and she still douches to cover it but it’s still going to smell two days later and then I’m like oh, she douches but why do I want to be with her… As long as she’s clean. (Enrique, 36)

Knowledge and attitudes related to hygiene practises

Men unanimously agreed that cleanliness is fundamental to their partners’ vaginal health. However, the interviews reflected different attitudes about how to practice vaginal hygiene. Men were aware of specific practices, including but not limited to douching products. They also indicated a variety of sources for learning about feminine hygiene, which included their personal experience with female partners, and less commonly, female family members or the media. Most denied that specific practices were discussed among men.

Beliefs about non-douching hygiene practises

Most men emphasized the role of pre-coital hygiene activities, including shaving of pubic hair and for the majority (n=9) vaginal cleansing before sexual encounters was considered vital. Of these, four men stressed its importance, even as a prerequisite, for oral sex:

What I’m saying is that if I go to a hotel with a girl friend, even if I met the woman on the same day which is not recommended but if… we go to a hotel and I notice that she doesn’t bathe then I won’t have oral sex with her… although I won’t have oral sex with the woman I can still have intercourse with her because I will use a condom to protect myself. (Bernardo, 56)

Men also discussed the importance of post-coital hygiene, primarily because of the perceived need to remove sperm. This participant describes the consequences of not washing after intercourse:

We had sexual relations and I ejaculated sperm in her and she didn’t wash her vagina. In the morning we had sexual relations again and her vagina had a horrible stench. I suppose that the sperm in her vagina decomposed or something… She didn’t wash herself she continued to sleep and the next day I never wanted to be with that woman again. (Fernando, 39)

Three participants also specifically endorsed the use of ovulos as a means to cleanse residue from the vagina. Ovulos are vaginal suppositories, imported from the Dominican Republic, which contain metronidazole and nystatin. While available over-the-counter in the Dominican Republic, the same medications require a medical prescription in the USA.

Beliefs about douching practices

The primary function of douching was described as a means to regularly remove residual sperm or blood. The majority (9 of 13) endorsed douching in particular as a necessary practice to accomplish this. About half (n=6) believe they can tell whether a woman douches or not based on odour. The remainder of the sample believes that douching is not required as long as women engage in other hygiene activities.

About half (n=6) indicate some awareness of adverse effects of douching, mostly focused on ‘over drying’ the vagina, or the role douching plays in contributing to infections for their partners. This participant indicates an awareness of the idea of disturbing normal flora:

[To have a healthy vagina women should] take a bath every day, probably not overdo it because from what I understand a lot of the times you can kill the good bacteria by washing too much or douching too much. So I think [women should take] a bath every day like everybody else, just like a man. (Ruben, 47)

Another indicates that while initially he thought douching was beneficial, he has since learned it can be problematic:

Well at first, at first I thought [douching] was great. I thought that was a great way [for women] to clean up their insides or whatever, and I thought that was great. But from what I've been hearing too much douching or frequent douching takes out the natural enzymes from the women. (Hector, 40)

Perceived male role in vaginal health

When asked about how they felt they could contribute to the vaginal health of their partners, men indicated three main approaches. The first was to provide information or encouragement about the importance of hygiene. In some cases, this involves directly providing advice about practices:

My responsibility as a husband would be for example if I make love to her, I would have enough confidence to tell her that she has to bathe and she has to use antibacterial products. Not only water and soap because sometimes water and soap … It doesn’t eliminate germs; you have to use antibacterial soap like the Dominican product called Lemisol. (Jose, 40)

Rather than providing direct information, this participant believes that the way in which he treats a partner influences her desire to take care of herself:

My responsibility as a man towards a woman, because a woman is to me like a delicate flower, you know what I'm saying. So you gotta compliment and you got to treat them good, you got to take them out. You know a woman’s got to feel confident about themselves… So if a woman is confident, a woman nine times out of ten is going to take care of themselves properly, they're going to feel pretty, they want to put perfume on, they want to look good for their man and stuff like that. (Manuel, 29)

Others see themselves as promoting good hygiene for partners by serving as role models themselves:

I will bathe at home but if I am going to a hotel with a friend, I immediately get undressed and jump in the shower to bathe. Once she sees me bathing then she should automatically know that I expect her to do the same thing. (Jose, 40)

Most men indicated that an important way to contribute to their partner’s vaginal health was to take good care of their own personal hygiene, emphasizing bidirectional transmission of bacteria between partners:

I always have to check myself that the penis is clean because that is how the diseases can arrive. Certain things can come without anyone knowing and you can have an infection and transmit it to your partner because … there could be bacteria under the foreskin. That is how diseases begin, the man doesn’t take care of himself, the woman doesn’t take care of herself. (Bernardo, 56)

Well I try to take care of myself as well…by trying to clean myself and well by consulting with a doctor as well about what I could do to keep good hygiene. It doesn’t count if she is clean while I’m dirty like if she is bacteria free and I’m not…I can get her infected as well. (Juan, 24)

Almost all men indicated that they had a responsibility to protect the primary partner’s vaginal health, by avoiding exposures to sexually transmitted infection. This could be accomplished by monogamy, or at least by engaging in protected intercourse when outside the primary relationship.

Well, I could take care of myself by avoiding sexual relations out of my marriage because if you’re going to cheat there will be consequences. (Bernardo, 56)

Yes, and sometimes as a man, men can be promiscuous, and they should protect themselves if they are going to have sexual relations apart from their official partner. You should use a condom and you shouldn’t kiss the woman, simply just have sex and that is all. (Fernando, 39)

This participant describes his effort to avoid bringing an infection home to his wife after having sex with a casual partner:

So you do it and then that’s it, you take care of yourself… I washed my penis with water and Clorox right after the incident, right after it happened…From what I know, Clorox kills AIDS or it kills some sicknesses…the germs and bacteria and all of that…I was so scared putting Clorox straight on my penis, but more than anything I did it for my wife’s safety, you understand? I didn’t want to transmit anything to her. (Fernando, 39)

Implications of perceived cleanliness

Interviews revealed that women’s vaginal hygiene had multiple meanings for men. Cleanliness was valued for its health-related consequences, but was also closely linked to perceptions of social status and desirability of partners. First and foremost, men indicated that vaginal cleanliness contributed significantly to a woman’s sexual attractiveness, in part related specifically to absence of odour:

If there is a repugnant odour it's going to turn you off, so you're not going to want to… you're not going to want to have sex or be intimate with somebody… I'm sure if the women smell the men and he smells repugnant too it's not going to turn her on, so smell is very important. (Hector, 40)

Notions of cleanliness had considerable influence on men’s decisions about choice of sexual partners, again often linked to odour as a sign of poor hygiene or infection:

It was a very strong smell…It was a sick… fishy-type smell. So right then and there, me I'm the type, I mean I don't want to put a person on the spot. So I just… never said anything. I never called the person back…at the end of the date. (Manuel, 29)

The perception that women have good vaginal hygiene influences not only the choice of partner, but the quality of the sexual experience for both partners:

If the man realizes that the woman maintains good vaginal hygiene then the man will do a good job while performing oral sex… because my theory is that if a man does not perform oral sex on a woman he won’t do a good job with any woman he has sexual relations with. A man that just penetrates a woman won’t satisfy her. (Ramon, 44)

Men’s narratives provide several reasons why they believe that cleaner women are more desirable. First, women who regularly douche are believed to rid the vagina of impurities and thus are thought to prevent infection:

A woman should douche because she should clean her vagina. Sometimes after intercourse a woman can catch an infection from filth or something the man may carry. Douching can benefit her a lot. (Juan, 24)

Men go further, however, to suggest that cleanliness is a sign of good character. A clean person is one who ‘takes good care of herself’ and purposefully engages in vaginal hygiene practices. Men perceive this type of behaviour as a marker of self-esteem:

[A woman’s] personal hygiene…basically nails, toes, that area, bathing, how many times a day you bathe, what [products] you use, lotions… smell and the aroma, and also the way the person dresses…That lets me know about her self-esteem, so to speak… But in general it tells me about the person’s outlook… how they value themselves… I mean the first impression might not be the best impression but after you get to know the person I, I find out that they’re really clean, their self-esteem, those things mean a lot to me. (Mario, 45)

Conversely, men also cite examples of undesirable partners, emphasizing the issue of character. Women who do not ‘take care’ of their personal or household hygiene are viewed negatively:

I can go to [a woman’s] house to sit and converse with her and you can tell that she doesn’t care and doesn’t take care of anything.… It means she is lazy … because sometimes if the woman does not like to clean her room… her clothes and underwear are all over the place then what are people suppose to think; that she is unclean, she doesn’t wash herself or bathe… Well in that case I would avoid getting to the point of having sexual relations or something. (Juan, 24)

The social desirability of cleanliness is further emphasized as this participant explains how a partner’s cleanliness reflects on the male:

You know I was at a movie theatre with a female. I mean I never had no sexual encounter or anything like that. But I'm sitting down and all of a sudden I smell a certain odour, smell like an odour of fish… I mean I didn't want to be rude… So then the odour got stronger. And that was a smell that I smelled previously…It was a very strong smell… She had an infection… I mean I don't want to put a person on the spot. So I just…Never said anything, never said anything. I never called the person back. But that experience it was kind of embarrassing because there were people sitting right next to me. And you know they were also witnessing the smell, so I didn't want to sit there. But then at the end of the date…I decided to part ways. (Manuel, 29)

Men suggest that women who ‘take care of themselves’ may be less likely to engage in risky sexual activity. As this participant explains, cleanliness extends to the moral realm:

I’m very happy, with, with my sex life, you know, just the fact that we’re both clean individuals, both physically and spiritually, morally, that we don’t go out here and get dirty, so to speak and then come back home. (Mario, 45)

Thus men describe cleanliness as an important indicator of self-care, reflecting not only physical health but moral character.

Discussion

Current understanding of the beliefs and values that promote douching among Latina women is based on very limited data. In a sample of Latina women who douche (McKee et al 2008), most respondents were firmly committed to douching. While women emphasized the importance of vaginal cleanliness and believed men preferred a clean partner, they did not indicate that hygiene practices including douching were primarily intended to please partners, nor did they report ever receiving direct input from their partners regarding feminine hygiene. Women indicated that their partners were for the most part unaware of or uninterested in feminine hygiene practices. In contrast, men in this study are emphatic about the importance of cleanliness, reporting not only that it substantially influences their choice of partner, but that it even determines the type of sexual activities in which they will choose to engage. Our findings are consistent with the responses of adolescent males in a survey conducted by Markham et al (2007). They found that most men were familiar with douching and reported a preference for their partners to douche. Our qualitative data adds to these quantitative findings by providing insight into why men strongly prefer that their partners’ douche.

In our sample of Latino men of mostly Caribbean descent, most perceive douching to be a necessary and highly beneficial part of a range of hygiene activities. This perception is related to deeply held beliefs about the importance of cleanliness. Almost unanimously, the men interviewed expressed the view that the vagina is an inherently flawed organ, that if left in its natural, untouched state, is unclean. Vaginal health is perceived as a state that must be attained and maintained through proactive hygiene measures, such as washing, douching or shaving which can purify the vagina not only of its inherent dirt but also of seminal residue, menstrual blood, sweat and bacteria which ‘contaminate’ it. Men often noted the inherent difficulties of assessing vaginal hygiene, given the internal or ‘hidden’ nature of the vagina. Some suggested that certain clues, such as clean nails or well-applied makeup, or the appearance of a woman’s apartment, could provide evidence of vaginal health. Others emphasized that such external signs could be deceiving. Almost all agreed that the odour of the vagina was the most reliable sign of hidden uncleanliness. Douching practices aimed at controlling vaginal odour thus functioned as acts of purification, and for some men, though not all, douching was viewed as preventing disease.

Our data reflect the local cultural context shared among immigrants living in poverty in the urban Northeast USA. Living in the Bronx, an epicentre of HIV infection (New York State Dept. of Health 2008) fear of sexually transmitted disease is relatively widespread. In the broader context, the emphasis on purity emphasized in men’s narratives reflects the well-known cultural ideal of Marianismo (Stevens 1973). Considered to be applicable across a variety of Latino subcultures, Marianismo refers to the embodiment of femininity, in which the ideal woman is virtuous, modest and sexually pure.(Gill & Vasquez 1996) Gil and Vasquez suggest that Latino men view women as ‘good’ or ‘bad’ in reference to these ideals. The conflation of concepts of ritual or moral purity with germ theory imbedded in our data has been described as a common theme in modern concepts of hygiene (Douglas 1966). The woman who risks disease through her failure to engage in hygienic practices reveals a failure of moral character. The fact that most men did not explicitly acknowledge this moral dimension of genital hygiene is also a characteristic of health discourse in modern life. Health discourse has been described as ‘moralizing’, though rarely explicitly moral: it conveys its moral message through nuance and metaphor rather than explicit moral precepts (Brandt 1997).

These findings have important implications for clinical practice and development of interventions to discourage douching among Latinas. Counselling messages must acknowledge that feminine hygiene practices, as with other behaviours related to sexuality, are practices grounded in social context and not simply individual behaviours. In deciding to douche, women may be responding to cues from their partners about the health, social and even moral significance of cleanliness and the desirability of women who are perceived to take good care of themselves. Messages about douching are unlikely to be successful among Caribbean Latinas unless this context is acknowledged and alternatives to douching are promoted that in particular address the importance of odour control. Additionally, our data suggest that intervening directly with male partners may be helpful, as some are already aware of potential negative consequences of douching.

Some limitations should be acknowledged. Our sample is limited to Latino men of primarily Caribbean background who sought care in a community health centre at the time of the interview. These respondents reflect a convenience sample in which female partners’ douching status was not known at the time of the interview. Our results may not be generalizable to Latinos of other ethnic backgrounds, of other socioeconomic strata, or in non-urban areas. We suggest that additional research is needed to identify similarities or differences in other Latino subgroups. A female interviewer conducted the interviews; it is likely that this had some effect on the narrative. Despite these limitations, the data presented here represent the previously unreported perspective of Latino men and shed light on women’s choice to douche.