Sexual Enrichment Aids: A Mixed Methods Study Evaluating Use, Hygiene, and Risk Perception Among Women

Abstract

Sexual Enrichment Aids (SEAs), or “sex toys” like dildos or vibrators, are used to enrich sexual experiences, either alone or with sexual partners. Although SEA use has become increasingly prevalent in recent decades, there remain significant gaps in knowledge regarding sexual behaviors and hygiene surrounding their use. In this study, we use mixed methods approaches (cross-sectional survey and qualitative semi-structured interviews) to better understand sexual behavior, potential risks, and hygiene practices of women who self-identify as having sex with men, with women, or with women and men when using SEAs. We found SEA use is common, with 79.9% of women using an SEA. Among these women, 31.8% of women indicated that they share SEAs with sexual partners. Further, condom use is rare while sharing SEAs, with only 14% of women utilizing condoms regularly. The majority (81.8%) of women wash their SEAs, primarily with soap and water. Yet, there is no consensus among women interviewed regarding the perceived risk associated with SEA use. Together, our findings support the need for increased evidence-based education for women to increase safety and hygiene of SEA use.

Introduction

Sexual Enrichment Aids (SEAs or “sex toys”) like dildos and vibrators can be used to enrich sexual experiences alone or with sexual partners. SEA use among women has become increasingly prevalent over the last 70 years. Indeed, studies between the 1950’s and 1970’s designated SEA or vibrator use as rare and unappreciable among women (Hite, 1973; Kinsey et al., 1953). By the 1980’s, a survey found that still only 26% of women used vibrators during solo masturbation (Wolfe, 1981). A 2005 study of women who have had sex with women found that one-third had used a penetrative SEA (Marrazzo, 2021). However, more recent studies, including two large cross-sectional studies of women completed in 2008 and 2012–2014, found that approximately half of women had used a vibrator or SEA within their lifetime (Herbenick et al., 2009; Wood et al., 2017). Additionally, the prevalence of SEA use among women who have sex with women (WSW) and women who have sex with women and men (WSWM) was 70.6% and 79.7%, respectively, suggesting differences in use based on sexual partner preference (Herbenick et al., 2010).

Sexual behaviors of SEA use among women, including use of lubricant, use of barrier protection (i.e. condoms), and cleaning practices, are important to understand because these behaviors could be associated with positive or negative health outcomes (e.g infection or increased sexual pleasure). Previous studies have found that 41% of women use lubricants with their vibrators (Herbenick et al., 2009). Additionally, among WSW and WSWM, lubricant use is common, with 60.1% and 77.1%, respectively, ever utilizing lubricant, which is most often used during partnered sexual contact and when SEAs are used (Hensel et al., 2015). Further, reported barrier protection (i.e., condoms) use while using vibrators or SEAs is rare among women and there exists incongruent literature on this topic. The majority of women (87.7–92.6%) do not use barrier protection (Herbenick et al., 2009; Wood et al., 2017). Among WSW, barrier protection is more prevalent while using SEAs, compared to other sexual activities like digital or oral sex (Rowen et al., 2013). Yet, even with barrier use being most prevalent with SEAs use, approximately 60% of WSW surveyed never use barrier protection with SEAs (Rowen et al., 2013). Other studies suggest that this may be even lower, with only 14% of WSW utilizing male condoms on SEAs (Marrazzo et al., 2002). Indeed, some WSW have expressed that condoms are most appropriate for sex with men, using a condom on an SEA can interrupt the sexual encounter, and condom use makes the encounter less personal, more technical, or clinical (Marrazzo, 2021). Likewise, others have found that 92.9% of WSWM do not utilize barrier protection during genital contact with a partner if there is no penile-vaginal or penile-anal intercourse (Schick et al., 2015). Finally, up to 96% of women report cleaning their SEAs regularly (Herbenick et al., 2009; Wood et al., 2017). However, this study had limited close-ended survey options that may not fully capture the nuances of cleaning behaviors among women. Further, there is a lack of consensus regarding cleaning behaviors of SEAs. Marrazzo, et al. found that one-third of WSW never or only sometimes clean their SEAs between uses with other women (Marrazzo et al., 2002). Indeed, WSW have discussed obstacles to using washed SEAs (particularly while sharing a SEA during a sexual encounter), including use of alcohol and drugs, perceptions of their partner being safe or appearing clean, and cleaning between partners could “take away from the moment” (Marrazzo, 2021).

Together, these and other behaviors while using SEAs need to be more fully understood due to the potential for negative or positive health outcomes for women. SEA use among women is associated with positive sexual function, including in the domains of desire, arousal, lubrication, orgasms, and decreased pain (Herbenick et al., 2009, 2011). Additionally, SEA use is associated with certain health-promoting activities, including gynecological visits and genital self-exams within the past year (Herbenick et al., 2009). However, there are some studies that suggest SEAs may also play a role in negative health outcomes. Women who share their SEAs are more likely to report a past diagnosis of candida infection and bacterial vaginosis (Wood et al., 2017). Bacterial vaginosis is also associated with a failure to always clean SEAs before use (Marrazzo et al., 2002). Bacterial vaginosis, a condition in which the vaginal flora becomes imbalanced, can infer significant risk to women, including an increased risk of preterm birth, low birth weight, and endometritis (both postpartum and post-abortal), pelvic inflammatory disease, and increased risk of human immunodeficiency virus acquisition (Gravett et al., 1986; Hillier et al., 1995; Peipert et al., 1997; Taha et al., 1998, 1998). Finally, SEAs may be able to harbor infectious diseases. Although infectious disease transmission by SEAs has not been well studied, one study did show that Human Papillomavirus (HPV) could be detected on certain SEAs after use, in some cases even 24 hours after cleaning (Davis et al., 1996).

Previous studies have not extensively investigated preferences in SEA material, detailed cleaning methods, sharing behaviors among women across sexual practice groups, and perceived risk associated with SEA use. Yet these aspects of SEA behaviors among women are important to understand in order to provide appropriate information to women so they can assess risk and benefits accurately; since SEAs are not regulated by the U.S. Food and Drug Administration, there are few current medical guidelines to direct cleaning behaviors of SEAs, and SEAs have the potential to transmit pathogens or otherwise impact vulvovaginal health in women (Anderson et al., 2014; Biesanz, n.d.; Billups et al., 2001; Wood et al., 2017). Further, most studies only utilize cross-sectional survey methods, limiting our understanding of the complexity of SEA use and sexual behaviors of women. Mixed methods are increasingly being utilized to investigate health-related topics due to the ability to more comprehensively understand health issues (Guetterman et al., 2015; Halcomb & Hickman, n.d.). Indeed, the sexual behaviors and decision making of women may be more nuanced than can be adequately captured using cross-sectional methods alone. Instead, by using mixed methodology and integrating both quantitative cross-sectional data with qualitative interviews of women, we can better discern the complexities of SEA use among women (Guetterman et al., 2015; Halcomb & Hickman, n.d.).

In this mixed methods study, our aim was to better understand sexual behaviors of young women regarding SEA use, hygiene, and risk perception. In contrast to other studies that include women a wide age range (18–60 years old), we focus on young women aged 18–35 years old because the prevalence and risk of many sexually transmitted infections are highest among this age group. Specifically, we were interested in characterizing how prevalent SEA use is among young women, including the types of SEAs used and if lubricant is commonly used, the materials of SEAs that are common, if and how women share SEAs with sexual partners, including if they utilize barrier protection while sharing, how and when women clean their SEAs, and how women perceive risk associated with SEA use. To understand these research questions, we conducted a cross-sectional survey and semi-structured interviews of women self-identifying as having sex with men (WSM), having sex with women (WSW), or having sex with women and men (WSWM).

Materials and Methods

Participants

These data were collected under the Sexual Enrichment Aids: Research for Chlamydia and Hygiene (SEARCH) protocol, approved by the University of New Mexico Institutional Review Board (#19–227). Participant inclusion criteria included self-identifying as a woman, between the ages of 18 and 35, and sexually active. Women did not have to be cisgender to participate. We had one woman self-describe as a transgender woman, thirty-five women self-describe as gender-variant/non-conforming, and two women self-describe as non-binary.

Cross-sectional survey data collection

Women were recruited via social media postings on Twitter, Facebook, and Instagram and email listservs, targeting women of diverse backgrounds, including race, ethnicity, and sexual orientation. We did not limit participation to geographic location, but the survey and the interview were completed in English. Women completed a confidential online survey that would take less than 20 minutes and gathered information about demographics, sexual behaviors, SEA use and hygiene, and sexually transmitted infection (STI) history. For example, we asked “How often do you use a sex toy like a vibrator or a dildo? Never, A few times a year, Monthly, A few times a month, Weekly, A few times a week, Daily”, “Do you ever share or use sex toys with other people or partners? Yes, No”, (if participant answers yes to previous question) “How often do you share or use sex toys with others? A few times a year, Monthly, A few times a month, Weekly, A few times a week, Daily, When you share or use sex toys with others, do you use condoms on the sex toys? Yes, Sometimes, No”, and “How often do you clean your sex toys? Before every use, After every use, Before and after every use, Neither before or after every use, Whenever I think about it, Never”. Participants completed the survey in April 2020 and received a $10 Amazon merchandise card for their participation. Survey data was securely stored using REDCap, hosted at the University of New Mexico (Harris et al., 2009). Full survey format and questions are available upon request from corresponding author.

Cross-sectional survey data analysis

Statistics and research design were completed with the assistance of the University of New Mexico Clinical and Translational Science Center Biostatistics Core. Descriptive statistics such as frequencies were used to characterize all included participants or participants by demographic variables, such as sexual practice group. As the cross-sectional surveys measured the prevalence of several outcomes, prevalence relative risks with 95% confidence intervals (CI) were estimated. All statistical tests used a two-sided alpha = 0.05. All analyses were conducted using Statistical Analysis Systems (SAS) software, v. 9.4 (SAS Institute Inc 2013. SAS/ACCESS® 9.4 Interface to ADABAS: Reference. Cary, NC: SAS Institute Inc., n.d.).

Semi-structured interview data collection

To recruit women for the semi-structured qualitative interviews, we used convenience sampling, in which women who completed the survey were invited to participate in the interview. In an effort to conduct an equal number of interviews among each sexual practice group, we recruited additional women via social media postings in partnership with local sexual health resource centers, sex shops, and research groups, to increase participation of WSW and WSWM. These women did not complete the survey because we had already reached our target enrollment. Our original target n was 18 (n=6 per sexual practice group). However, we had not reached data saturation among groups of women at this point and the number of interviews was increased until we reached data saturation, at 24 participants (Saunders et al., 2018). Here we utilize methods of data saturation, in which saturation is determined by the amount of data needed until no new information is gained (informational redundancy) (Saunders et al., 2018).

Interested participants were randomized by sexual practice group and invited to complete a confidential interview. One team member (Team Member 1) had access to the interested participant information, only included those who endorsed SEA use, verified interest, and scheduled interviews with another team member (Team Member 2, or Team Member 3) who did not have access to participant identifiers. From June 2020 to February 2021, we conducted semi-structured interviews virtually through the Zoom platform (Zoom Video Communications, Inc. (2021) Https://Zoom.Us/, n.d.) with the video feature disabled and audio only recording to increase participant comfort talking about SEA use and to help ensure anonymity. Prior to recording, the interviewer obtained informed consent and asked participants to not use any identifiable information.

Interviews lasted between 30 and 60 minutes and were guided by a semi-structured interview guide, which included questions about their sexual behaviors, SEA use, sharing SEAs, materials of SEAs, SEA hygiene, and impact of SEAs on sexual risk. The interview guide was re-evaluated after the first and fifth interviews and modified to make questions clearer and ensure we were obtaining rich data to address the research questions. Examples of interview questions within the semi-structured interview guide include: “Please tell me about your sex toy use”, “How often do you use sex toys?”, “What does sharing a sex toy look like to you?”, “What kind of toys do you use?”, “Tell me more about when you decide to use a condom with your sex toys?”, “How do you choose what type of toy to buy?”, “Do you know what material your sex toys are made out of?”, “Do you clean your sex toys? How often and How do you clean them?”, and “Do you think that sex toys make sex more risky, less risky, or have no impact on risk?”. After completion of each interview, a professional transcription company transcribed all audio files for use in data analysis. Participants received a $20 Amazon merchandise card upon completion of the interview.

Semi-structured interview data analysis

We analyzed transcripts of the interviews using an inductive content analysis approach that was team-based, iterative, and descriptive using NVivo qualitative analysis software (QSR International Pty Ltd. (2020) NVivo (Released in March 2020), Https://Www.Qsrinternational.Com/Nvivo-Qualitative-Data-Analysis-Software/Home, n.d.; Vaismoradi et al., 2013). The primary coder (Team Member 2) created a preliminary coding structure and coded one transcript, after which the coding team (Team Members 1, 2, & 3) met to discuss. After agreeing on the preliminary structure, two analysts (Team Members 2 & 3) independently coded three more transcripts, until an inter-rater reliability reached at least 80% agreement. Then one analyst (Team Member 2) coded the remaining transcripts. Two coding team members (Team Members 1 & 2) reviewed all transcripts and coding and summarized the most relevant categories, while meeting frequently with the senior qualitative analyst (Team Member 3).

At 14 interviews, we paused to complete preliminary coding and determine if we had met saturation (cite saturation paper). We decided that additional interviews needed to be completed, primarily within the WSM and WSWM groups to ensure more equal representation. We did not create new categories from the new interviews and saw a similar distribution across groups of women and codes, and therefore determined that we reached data saturation (see Table 1).

Table 1:

Qualitative codes related to SEA use, hygiene, and potentially risky behaviors with representation of participants who discussed each topic.

Code	Definition	N (%) Representation
		All Groups (n=24)	WSM (n=8)	WSW (n=6)	WSWM (n=10)
Sex Toy Usage	Includes talking about how often they use their sex toy, with who, when they use sex toys	24 (100)	8 (100)	6 (100)	10 (100)
a. Type	What kind of sex toys they use	21 (88)	7 (88)	5 (83)	9 (90)
b. Material	What it is made out of	21 (88)	8 (100)	6 (100)	7 (70)
c. Sharing	Includes details about what the phrase “sharing a sex toy” look like to them. Clarifications around who it is used on, how it is being used on them, and if there is an order of preference.	18 (75)	6 (75)	5 (83)	7 (70)
d. Condoms	Anything regarding using condoms with their sex toys. If yes, more about thought process of when to use condoms. If not, still recorded.	22 (92)	8 (100)	5 (83)	9 (90)
Safety	Includes general discussion around safety including STIs, risk, hygiene, privacy	8 (33)	3 (38)	3 (50)	2 (20)
a. Hygiene	More focused on participant’s cleanliness and hygiene. Includes if they clean their toy, how often, when they decide to, how they clean them, etc.	23 (96)	8 (100)	6 (100)	9 (90)

Presentation of data in manuscript

In this manuscript, we discuss categories of SEA use, hygiene, and behaviors that may contribute to negative sexual health outcomes, such as sharing SEAs between partners and lack of barrier protection. We present results from the cross-sectional survey and interviews in tandem for each category to more comprehensively describe each finding, as the goal of a mixed methods approach was to gain a deeper understanding of what women reported in the cross-sectional survey through semi-structured interviews.

Results

Participant Characteristics

Eight-hundred sexually active women aged 18 to 35 completed the cross-sectional survey, answering primarily close-ended questions regarding their sexual behaviors regarding SEAs. We excluded four participants based on inclusion criteria, in which participants were not within our target age range or sex. An additional four participants were excluded from sexual practice stratification analyses based on self-described sexual practices being neither WSM, WSW, nor WSWM. Participants primarily resided in the United States, but recruitment was not limited to geographic location (Table 2). Participant characteristics are found in Table 3. The average age of participants, across sexual practice groups, was 27 years old.

Table 2:

Geographic location of cross-sectional survey participants

Geographic Location	n=796
North America (Excluding USA)	n=25 (3.1%)
Canada	24
Chile	1
United States of America	n=734 (92.2%)
Alabama	10
Alaska	2
Arizona	11
Arkansas	3
California	32
Colorado	26
Connecticut	2
Delaware	0
Florida	18
Georgia	13
Hawaii	0
Idaho	7
Illinois	12
Indiana	10
Iowa	4
Kansas	7
Kentucky	5
Louisiana	5
Maine	3
Maryland	4
Massachusetts	10
Michigan	16
Minnesota	14
Mississippi	3
Missouri	4
Montana	3
Nebraska	8
Nevada	3
New Hampshire	3
New Jersey	6
New Mexico	297
New York	27
North Carolina	5
North Dakota	3
Ohio	15
Oklahoma	10
Oregon	8
Pennsylvania	22
Rhode Island	2
South Carolina	2
South Dakota	0
Tennessee	7
Texas	27
Utah	6
Vermont	2
Virginia	8
Washington	17
West Virginia	3
Wisconsin	28
Wyoming	1
Europe	n=24 (3.0%)
Belgium	1
Denmark	1
Germany	1
Italy	1
Netherlands	1
Norway	1
Poland	1
United Kingdom (England, Northern Ireland, Scotland, Wales)	17
Australasia	n=9 (1.1%)
Australia	7
New Zealand	2
South America	n=1 (0.1%)
Brazil	1
Unknown	n=3 (0.4%)

Table 3:

Participant characteristics

	WSM (n=586) n (%)	WSW (n=27) n (%)	WSWM (n=179) n (%)
Age
18–22	86 (14.7)	9 (33.3)	64 (35.8)
23–26	152 (25.9)	4 (14.8)	42 (23.5)
27–30	178 (30.4)	5 (18.5)	47 (26.3)
31–35	170 (29.0)	9 (33.3)	26 (14.5)
Education Level
Some high school, high school diploma, GED, Trade school	67 (11.4)	3 (11.1)	41 (22.9)
Some college, Associate’s degree, Bachelor’s degree	346 (59.0)	13 (48.1)	114 (63.7)
Some graduate education, Master’s degree, Doctoral degree	173 (29.5)	11 (40.7)	24 (13.4)
Household Income
Less than $20,000	121 (20.6)	4 (14.8)	55 (30.7)
$20,000–34,999	115 (19.6)	9 (33.3)	53 (29.6)
$35,000–49,999	100 (17.1)	3 (11.1)	30 (16.8)
$50,000–74,999	110 (18.8)	7 (25.9)	19 (10.6)
$75,000–99,999	70 (11.9)	2 (7.4)	11 (6.1)
Over $100,000	70 (11.9)	2 (7.4)	11 (6.1)
Relationship Status
Single (Never married)	245 (41.8)	17 (63.0)	103 (57.5)
Married or domestic partnership	308 (52.6)	9 (33.3)	62 (34.6)
Widowed	0 (0.0)	0 (0.0)	0 (0.0)
Divorced	20 (3.4)	1 (3.7)	3 (1.7)
Separated	3 (0.5)	0 (0.0)	2 (1.1)
Other	10 (1.7)	0 (0.0)	9 (5.0)

Women who expressed interest in participating in the qualitative interview (n=193) were stratified based on self-identified sexual practices and randomized for invitation to participate. Interviews were conducted until data saturation was reached (n=24), with efforts made to include approximately equal numbers of women in each sexual practice group (WSM=8, WSW=6, WSWM=10). Because demographics reported in the survey were separated from interview contact information to maximize participant confidentiality, the only demographic information collected was sexual practice group and participant location (United States location=17, International location=7).

SEA Use Among Women is Common

In order to investigate SEA use among women, we determined the prevalence and frequency of SEA use among women, percent of participants who utilize lubricants with SEAs, and the types of SEAs that women utilize. The proportion of women who have used a SEA in our study was 79.9%. Additionally, we found the relative risk of ever using a SEA was 1.21 times greater among WSWM compared to WSM (Table 4). We also found that the frequency of SEA use was higher among WSWM, with the relative risk of using a SEA at least weekly was 1.55 times greater among WSWM compared to WSM (Table 5). We found similar trends for WSW, but did not reach statistical significance, likely due to low survey participation among this group (Table 4, 5). Similar to previously reported findings, we found that of the women who use SEAs, 39.2% also use lubricant (Herbenick et al., 2009). In semi-structured interviews, when asked what types of SEAs they used, most women referenced dildos (20/24), vibrators (16/24), combination SEAs like vibrating dildos (7/24), magic wands (8/24), and clitoral stimulation SEAs (6/24).

Table 4:

Relative risk of SEA use

	Yes (n, %)	No (n, %)	Relative Risk	95% CI
WSM	444 (70.4)	143 (89.4)	1.0
WSW	26 (4.1)	3 (1.9)	1.19	0.80–1.76
WSWM	161 (25.5)	14 (8.7)	1.21	1.01–1.46

Table 5:

Relative risk of frequency of SEA use

	Never (n, %)	Less Than Weekly (n, %)	Relative Risk	95% CI	At Least Weekly (n, %)	Relative Risk	95% CI
WSM	143 (89.4)	272 (75.3)	1.0		172 (62.7)	1.0
WSW	3 (1.9)	16 (4.4)	1.25	0.76–2.08	10 (3.7)	1.39	0.73–2.64
WSWM	14 (8.7)	70 (19.3)	1.25	0.96–1.64	92 (33.6)	1.55	1.20–2.02

Silicone is the most commonly used SEA material

We next wanted to investigate the types of SEA materials that women utilize, as materials have differing porosities and unique challenges to cleaning that could influence hygiene. During semi-structured interviews, women referenced using a variety of different SEA materials including glass, rubber, silicone, plastic, leather, thermoplastic rubber, aluminum, and metal. Silicone was the most referenced material (20/24). However, the variation and knowledge of SEA material varied by sexual orientation group. WSM and WSW were more likely to state that they utilized SEAs produced from silicone, plastic, and rubber-like materials, whereas WSWM were more likely to additionally cite materials like metal, leather, TPR, and glass. WSWM were also more likely to state that material type was an important factor when selecting SEAs. Reasons cited varied from certain materials providing enhanced pleasure, “…with glass dildos, they’re amazing because of the temperature play aspect…”, to hygiene considerations, “…it is something that I look for when I purchase [SEAs]. So oftentimes it is of easy-to-clean materials, so things that aren’t porous…”. Yet, many women were unsure what material their SEA was produced from. Indeed, one participant stated, “I don’t really know what they’re made of, but if you want to know what I think they’re made of, I think it’s silicone and plastic” (WSM). One woman was unsure if recommendations existed surrounding SEA durability, stating, “I don’t know if there’s a recommendation [to] throw out your dildo after three months like a toothbrush or something, but there might be and I don’t know about it and I haven’t looked into that or taken heed of that advice” (WSM).

Sharing SEAs is a common sexual behavior among a subset of women

Since SEA use is common among women, we next investigated how women utilize SEAs with partners in greater depth. We examined the prevalence of sharing SEAs with intimate sexual partners and, via semi-structured interviews, were able to better understand what sharing a SEA means to different women. Sharing SEAs is common among women of all sexual practice groups, with 31.8% of women surveyed stating they share SEAs with other people or partners. However, the relative risk of sharing a sex toy was 2.42 and 1.49 times greater among WSW and WSWM, as compared to WSM, respectively (Table 6). Further, we found in the interviews that the term “sharing” had multiple meanings and could indicate both penetrative and non-penetrative uses. A WSWM explained the difference between definitions used within the community and her personal definition of sharing, “…as far as sharing, I’ve come to learn through researching it heavily…to a lot of people, it means sharing with non-monogamous partners and/or random hook-ups, or sharing the toy at some kind of sexual gathering. Whereas in the context in which I would use that word, it might be that I have a small enough toy that he and I both might use it to penetrate either of us…” Similarly, a WSW participant described her sharing behaviors as “…I would use one [SEA] on them. They would use one [SEA] on me. There’s one [SEA] that we could use together. And so all of that felt like sharing sex toys”. Another participant describes non-penetrative sharing, in which she spoke about a SEA that “…looks like a bicycle seat…We put it in between us, put our genitalia up on it and it would vibrate. That was something that was only fun with another partner. It didn’t really work for solo play.” Alternatively, one WSM described her experience of sharing as “…he’s the one often using it, and I’m just on the receiving end.”

Table 6:

Relative risk of sharing SEAs with a sexual partner

	Yes (n, %)	No (n, %)	Relative Risk	95% CI
WSM	120 (59.7)	324 (75.1)	1.0
WSW	17 (8.5)	9 (2.1)	2.42	1.45–4.03
WSWM	64 (31.8)	98 (22.8)	1.49	1.09–2.03

Condom use while using a SEA is uncommon

Finding that nearly one-third of women share SEAs with sexual partners, we next investigated if barrier protection was common among women while sharing SEAs and the potential obstacles to doing so. We found that condom use while using or sharing a SEA was uncommon among women. Indeed, of the 200 women surveyed who shared SEAs, only 28 used condoms regularly. We found the relative risk of using a condom on SEAs was 4.03 and 4.62 times greater among WSW and WSWM, respectively, compared to WSM (Table 7). Indeed, during our semi-structured interviews, all WSM said they do not use condoms with their SEAs. Further, most women interviewed seemed to be surprised to even be asked about condom use with SEAs, as this is not something that they had previously considered. Among WSW and WSWM, there was a spectrum of condom use, which may depend on certain contexts. One WSWM stated, “I do sometimes [use condoms]. I do have a few toys that I don’t fully trust the material, so I’ll use a condom with them just in case.” Alternatively, one WSW explains her decision to not use condoms as, “…none of the sex toys I use are dildo shaped. I feel like a condom wouldn’t fit on them right.”

Table 7:

Relative risk of condom use while sharing a SEA

	Yes (n, %)	Sometimes/No (n,%)	Relative Risk	95% CI
WSM	7 (25.0)	113 (65.7)	1.0
WSW	4 (14.3)	13 (7.6)	4.03	1.18–13.77
WSWM	17 (60.7)	46 (26.7)	4.62	1.92–11.15

Most women endorse cleaning SEAs regularly, primarily with soap and water

Since many women share SEAs with sexual partners without barrier protection and there could be potential for autoinoculation of different sexually transmitted infections via an un-cleaned SEA, we next investigated the prevalence of cleaning SEAs among women. Further, we investigated specific practices that women use for cleaning SEAs and motivation to do so. Most women endorse cleaning their SEAs regularly (81.8%)—defined as before use, after use, or before and after use. The remaining women (18.2%) reported they clean their SEAs never, neither before nor after every use, or whenever they think about it. There was no significant difference in relative risk of cleaning frequency between sexual practice groups (Table 8). The majority of women interviewed (22/24) and surveyed (73.2%) stated they use soap and water to clean their SEAs. Other cleaning methods included using commercially available SEA products (14.1%), water alone (9.7%), boiling them (in interview and open-ended survey response), baby wipes, or hand sanitizer (open-ended survey response). Regarding her motivation for cleaning SEAs one WSWM said, “…One time I did forget to clean it, and it was crusty, and that kind of grossed me out.” Although the majority of women endorse cleaning their SEAs, the reason for choosing a cleaning method was unclear. One WSW stated, “…the only things that I used are kitchen cleaners on it or the Lysol wipes…I don’t know what else to use. If you know how I should clean this, let a girl know!” Another participant shared, “…I just never did any research on how you’re supposed to clean your sex toy” (WSWM). Likewise, 25.9% of surveyed women stated they have never received any information regarding how to clean their SEAs. Others stated they get their information from the product instructions, local shops, or the Internet. Women also stated they were unsure how to clean certain SEAs due to electric components: “It looks like a tube of lipstick, but it’s actually a vibrator and you twist it and it buzzes. But because there is a battery right there, I don’t really know how to clean it” (WSW).

Table 8:

Relative risk of SEA cleaning

	Regular (n, %)	Irregular (n, %)	Relative Risk	95% CI
WSM	364 (70.4)	223 (80.8)	1.0
WSW	22 (4.3)	7 (2.5)	0.85	0.31–2.32
WSWM	130 (25.3)	46 (16.7)	1.14	0.75–1.74

Women are uncertain of the risks associated with SEA use

Finally, using semi-structured interviews alone, we aimed to understand how women perceived the risk associated with SEA use. Women interviewed varied on their responses regarding the impact SEAs may have on the risk level of sexual activity. Some were uncertain how SEAs may impact risk level, with one WSM stating, “Well, I don’t know much about that. I don’t feel educated about that at all.” Others said SEA use does not have an impact on risk. Indeed, half of WSW and some of the WSWM stated such. One WSWM believed that, “They shouldn’t have any impact at all. I mean, from what I was always told is that you can only get an STI through transmission…” Yet another participant stated, “…It does make sex less risky because the worst you can get from an unclean dildo…if it’s mildly clean, maybe a UTI, but the risk of having condomless sex with a live penis is a lot worse” (WSWM). However, the participant does not specify if the consequences she is referring to are unintended pregnancy or STI transmission. Many postulated the risk associated with SEA use may depend on how they are used and with whom. A WSWM said, “…it definitely depends on whether you’re sharing it and how you’re sharing it. And I think sharing a sex toy would make sex more risky, increasing the risk of STIs.” Several participants, particularly among WSM, discussed how this topic was not a consideration before completing the interview. One woman shared, “Before our interview, I would say probably no risk [associated with SEA use], but now that we’ve discussed cleaning and safe use and things like that, I’d say there’s probably more risk than I thought, maybe not STIs, but as a woman, yeast infections or bacterial vaginosis.” Another WSM said, “I guess it’s something I hadn’t really thought of, but it makes sense because it’s a tool…I’m sure that there can be transmission, especially if one person uses it who has an infection, and then another person uses the same one without cleaning…You’ve got my wheels turning.”

Discussion

Using a mixed methods approach, we were able to build upon previous knowledge regarding the sexual and hygiene behaviors of women across sexual practice groups regarding SEA use. We found the prevalence of SEA use among women is higher than previously reported, with nearly 80% of women reporting their use (Herbenick et al., 2009; Wood et al., 2017). Similar to other studies, we found SEA use prevalence and frequency of use is higher among WSWM, and likely WSW, though our study was insufficiently powered to draw such conclusions (Herbenick et al., 2010; Wood et al., 2017).

SEAs are manufactured from a variety of materials (food-grade and medical-grade silicone, thermoplastic elastomer and thermoplastic rubber, metals, glass, etc.) with differing porosities. Further, aside from a small number of SEAs marketed as medical devices to treat sexual dysfunction, the U.S. Food and Drug Administration does not regulate the manufacturing of SEAs, as they are considered to be novelty items (Biesanz, n.d.; Billups et al., 2001). In our study, most women used SEAs manufactured from silicone, though few specified if the silicone was food-grade or medical-grade. Additionally, many women were unsure of the materials utilized in their SEAs. Many SEAs are used via insertion into body cavities (vagina, anus, and mouth) and, particularly those manufactured from more porous materials, could potentially harbor bacteria and STIs (Anderson et al., 2014). It may, therefore, be important to thoroughly investigate SEA materials in a research setting to understand transmission of STIs via SEAs. This could assist in the development of evidence-based guidelines to educate women regarding SEA material options and best-practice cleaning behaviors.

Women across sexual practice groups indicated that they share SEAs with sexual partners, though the term “sharing” differed among participants. In agreement with other studies, WSW and WSWM were more likely to report sharing SEAs than WSM (Wood et al., 2017). Though sharing was common, we found condom use was uncommon, reflective of other studies demonstrating similar findings (Herbenick et al., 2009; Schick et al., 2015; Wood et al., 2017). The use of condoms while sharing SEAs was higher among WSW and WSWM than WSM. Although this was statistically significant, it is unclear if this is clinically relevant, as the overall number of women who utilize condoms regularly is relatively low. With only 28 of 200 (14%) women across sexual practices stating they regularly use condoms while sharing SEAs, there is still substantial risk for negative health outcomes among women, despite the aforementioned statistically significant difference. This is further complicated by the fact that some women describe sharing as one partner using the SEA on the other, which may not necessitate condom use, if bodily fluids are not shared also. Others also describe the limitations of condoms, in that they are only appropriately shaped for SEAs that resemble a male penis. Further, in interviews, most women expressed surprise at being asked about condom use. It may be unsurprising that many women do not utilize condoms while sharing SEAs, as condom use during vaginal intercourse is also low among young women, where the consequences, like unintended pregnancy or STI transmission, are more apparent (Fairfortune et al., 2020; National Health Statistics Reports, Number 105, August 10, 2017, 2017).Indeed, a 2011–2015 National Health Statistics Report found that among women aged 15–44, the overall prevalence of condom use during their last sexual encounter was only 23.8% (National Health Statistics Reports, Number 105, August 10, 2017, 2017). The survey additionally found that 47.2% of women in the study had not used condoms in the past month of sexual intercourse with more casual sexual partners (defined as going out once in a while, just friends, or had just met him) (National Health Statistics Reports, Number 105, August 10, 2017, 2017).

In our survey, 18.2% of women endorsed infrequent cleaning of their SEAs. This may be higher than previously reported (Herbenick et al., 2009; Wood et al., 2017). We also found the majority of women stated they clean their SEAs with soap and water, oftentimes hand soap. This finding was confirmed both in the quantitative survey and qualitative interviews. Yet, a large percent of women have not received specific guidance on how to clean SEAs and most women interviewed did not cite specific reasons for utilizing their given cleaning method. Further, there is little evidence-based guidance for women regarding cleaning techniques. There are few professional medical society guidelines for medical practitioners to utilize when counselling patients (Addressing Health Risks of Noncoital Sexual Activity, n.d.; Bacterial Vaginosis: Treatment - UpToDate, n.d.; Health Care for Lesbians and Bisexual Women, n.d.; Lesbian, Gay, Bisexual, Transgender, and Other Sexual Minority Women: Medical and Reproductive Care - UpToDate, n.d.; Butterfield, n.d.; Knight & Jarrett, 2017; LeFevre, 2014; Mravcak, 2006). Namely, recommendations discourage sharing SEAs and suggest use of condoms or cleaning SEAs between each use, when shared. Only one recommendation, to our knowledge, particularly states a cleaning method to be used, in which hot soapy water is recommended (Lesbian, Gay, Bisexual, Transgender, and Other Sexual Minority Women: Medical and Reproductive Care - UpToDate, n.d.). Many guidelines are aimed at only WSW and WSWM, which may not be inclusive of all patients in need of counseling. Further, little evidence is cited within these professional guidelines and it is unclear if such recommendations are appropriate or patient-centered. There is no scientific evidence, to our knowledge, that hot soapy water will eliminate vaginal secretions, bacteria, yeast, and/or STIs from different SEA materials, particularly those that are more porous. Additionally, some women describe the difficulty with this cleaning method, due to electrical components within the SEA. Further, it may be unreasonable to discourage women from sharing SEAs.

Despite a subset of women in our study engaging in sexual behaviors that may potentially lead to STI transmission or gynecological infections when using a SEA (such as sharing SEAs with partners without barrier protection or irregular cleaning behaviors), there was little consensus among the participants of our study regarding how SEAs affect the risk of sexual encounters and behaviors. Indeed, participant perception on the topic was varied with answers ranging from being uncertain how SEAs impact sexual risk to women believing SEAs could lower or heighten risk. Together, our findings suggest that women need access to evidence-based information on safe SEA use and hygiene.

Although this study revealed the sexual behaviors, hygiene practices, and perceived risk surrounding SEA use among people who identify as women, there are limitations to the current study. We utilized targeted recruitment to increase the diversity of our participants, but we had a relatively small number of participants within the sexual practices group WSW. This resulted in 27/792 or 3.4% of our study population self-identifying as having sex with women (WSW). Although a relatively small percentage, it is over twice the national average of women self-identifying as lesbian (1.6%, (Ward, 2014)), suggesting that our study population was largely representative of the US nationally, regarding sexual behaviour practices. Additionally, it is over twice the percent included in previous studies and we had substantially more WSWM participants, by both number and percent, in our study (cite Herbenick 2009, Prevalence). Yet, this limitation likely hindered our ability to reach statistical significance in certain analyses, such as ever using a SEA and frequency of SEA use. Additionally, the SEARCH Study was not limited by geographical region, as noted in Table 2. This could make it difficult to understand the nuances of geographical or cultural considerations when utilizing SEAs.

It is important to note that the SEARCH study was conducted during the global COVID-19 pandemic. The cross-sectional survey was conducted in April 2020, during which time COVID-19 had already been declared a National Emergency in the United States and a number of communities had varying levels of lockdowns in place. In China, where containment measures were far stricter than the United States, a study showed that nearly a third of surveyed participants, regardless of relationship status, reported an increase in frequency of masturbation (Li et al., 2020). Likewise, researchers in Australia found a similar increase in solo masturbation and sex toy use, particularly among women and men who reported having less sex, due to the isolation of COVID-19 pandemic related lockdowns (Coombe et al., 2021). In Italy, nearly two-thirds of surveyed men and women did not report a decrease in solo masturbation (Cito et al., 2021). Yet, among those with decreased masturbation practices, the reasons were often cited as lack of desire or poor privacy (Cito et al., 2021). It is unclear whether the COVID-19 pandemic impacted our findings, as we did not specifically address this question in the SEARCH study. The increase in prevalence of SEA use found in our study could have been due to the COVID-19 pandemic, as is suggested by the aforementioned studies, or could be a reflection of changing norms, sex positivity, and increased availability of SEAs among the younger participants (aged 18–35 years) included in the SEARCH Study. More research is necessary to understand the nuanced reasons that young women may be more likely to use SEAs than previously reported.

We found that the qualitative interviews were a particularly useful methodology for understanding the complexities of sexual behaviors and decision-making regarding SEA use and hygiene practices. A clear limitation is that only women who feel comfortable speaking openly and honestly about SEA use are likely to volunteer as participants in the interview. Additionally, although qualitative methods are an informative and powerful tool, we are unable to draw generalizable conclusions from this type of data. Furthermore, our study only included those who identify as women and we were unable to capture other groups that may engage in SEA use, including men who have sex men and members of the transgender or gender nonconforming community.

With the prevalence of SEA use among women increasing, it is an opportune time to consider the sexual behaviors, hygiene practices, and behaviors that women may engage in during SEA use that may put them at increased risk for negative health outcomes. Overall, we found that there are a wide variety of sexual behaviors among women that are not restricted by sexual practice group. Therefore, it is imperative that we equip women with the knowledge and tools necessary to engage in their chosen sexual behaviors safely, with confidence, and in a sex positive manner. Our findings support a need for increased patient-centered education regarding evidenced-based safe SEA use and hygiene that can be tailored to individual patients, who may engage in different SEA sexual behaviors based on sexual practices.

Data Availability Statement

Data supporting our results or analyses presented here can be accessed by contacting the corresponding authors.