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Introduction
Men who have sex with men (MSM) are at high risk for anorectal STI; 10.3% of the MSM attending the STI outpatient clinic of Amsterdam tested positive for anorectal chlamydia and/or gonorrhoea in 2011. 1 Many MSM use rectal douches in preparation for sex, 2-6 mainly for hygienic reasons. 3 4 It has been suggested that rectal douching breaks down the mucosal barrier function and facilitates the acquisition of STI pathogens. 7 8 If shared, contaminated douche equipment itself could also be a transmission route. Thus, if douching or sharing douching equipment were to be associated with increased anorectal chlamydia and gonorrhoea prevalence, public health messages targeted at MSM should be adapted, and rectal douching or sharing equipment should be discouraged.
Several studies have shown higher STI prevalence among people who use rectal douches. 3 4 8-11 These studies, however, were limited by their design as they did not consider the anatomical location-urethral, pharyngeal or anorectal-of the STI, except for two case-control studies that only assessed Lymphogranuloma venereum (LGV). 8 11 To our knowledge, studies that assessed the association of rectal douching and anorectal, laboratory-confirmed chlamydia and/or gonorrhoea have not been performed to date.
In this cross-sectional study among MSM attending the STI outpatient clinic of Amsterdam, we elucidated the following questions: (1) Which proportion of MSM use rectal douches and/or share douche equipment with sex partners and what are characteristics of douching behaviour? (2) What are characteristics of MSM who use anorectal douches? (3) Are rectal douching and/or sharing douche equipment associated with anorectal chlamydia (including LGV) and anorectal gonorrhoea?
Methods
Study population
MSM were recruited at the STI outpatient clinic of the Public Health Service of Amsterdam, which is a low-threshold clinic annually serving approximately 30 000 visitors. 1 Individuals can attend the STI clinic anonymously, free of charge and without a referral by a medical doctor. Individuals are prioritised based on a short questionnaire to estimate risk of having an STI. 12 MSM are considered high-risk clients and get a full STI check, including physical examination. Because routinely collected anonymous data was used for this study, no ethical clearance was sought.
Demographic characteristics, rectal douching and sexual behaviour
All men, 18 years and older, who reported having sex with another men...