In my last post I covered the safety and efficacy of acid-promoting tampons. Marc Abrahams, of Annals of Improbable Research and Ig Nobel fame, sent me an article about the intravaginal use of lime juice to prevent HIV by Nigerian women. The particular paper he sent me (Mauck et al. 2008) provided a fairly rigorous assessment of whether douching with 25%, 50% or full strength lime juice could be safely tolerated while reducing vaginal pH. But this paper opened up an entire world to me around broader issues of HIV/AIDS in Africa, about race, and the context-dependence of the way science is perceived.

Pucker up?

An important cultural practice among Nigerian female sex workers involves the use of lime and lemon juice douches (Imade et al. 2005; Mairiga et al. 2010; Sagay et al. 2009). Women report that douching with lemon and lime juice increases vaginal dryness and tightness (Mairiga et al. 2010), which makes me wonder for whom lime juice is improving sexual pleasure. In a survey of Nigerian sex workers, a majority of participants used lime juice douches, and those sex workers who douched had more sexual partners. The majority of these participants douched for sexual pleasure and hygiene first, and a slight majority also used it as contraception and to reduce infection (Mairiga et al. 2010). Most women used a 50% or 25% concentration of lime juice, diluting it with water. Further, participants who douched with lime juice actually had higher infection rates, including gonorrhea and bacterial vaginosis (Mairiga et al. 2010). The confounding effects of the greater number of sexual partners in the lime juice user group means there is no way from these data to tell if the lime juice is the cause for the increased incidence.

Other studies are more troubling. Unlike the acidic tampon folks, Sagay et al (2009) used colposcopy and Pap smears to assess the vaginal epithelium in women who used lemon or lime douches. Sagay et al (2009) found an association between lemon and lime juice douching with cervical dysplasias (abnormal changes in the cell wall), which puts one at increased risk for cervical cancer.

Then there is the study I was first sent by Marc (Mauck et al. 2008). The study authors grouped participants into groups that would douche or soak a tampon with water or lime juice dilutions of 25%, 50% and 100%. Of the 47 women enrolled in the study, 40 completed the full douching protocol. Two women from the 100% group and one woman from the 50% group discontinued due to severe vaginal epithelial disruption or irritation. But even among the women who completed, it’s not a pretty picture:

For instance, while plain water didn’t produce significant symptoms in the tampon or douche group, a majority of these participants had vaginal epithelial disruption based on colposcopy findings. Water is pH neutral, which is more alkaline than even a vagina with abnormal flora (women with bacterial vaginosis, for instance, often have a pH around 5.5). So any kind of water insertion from a soaked tampon or douching negatively alters the normal vaginal environment.

It’s clear, though, that the 100% and 50% lime juice concentrations were the worst for women. In addition to the epithelial disruptions noted above, women using concentrated lime juice via the tampon method had significantly raised local inflammatory markers including interleukin (IL)-8 (Mauck et al. 2008). Why is lime juice so harmful to vaginal health? It probably has something to do with all that citric acid, since lemon and lime juice have the highest citric acid content of all commercially available citrus juices (Penniston et al. 2008). Perhaps it reduces pH, but it is also an irritant that increases permeability of the cell wall and thus likely promotes, rather than reduces, infection.

To give you a sense of how awful inserting lime juice into your vagina is, here are the types of epithelial disruptions the study authors observed (Mauck et al. 2008):

Disrupted blood vessels

Peeling

Erythema (redness)

Discharge

Tenderness

So not only does lime juice not appreciably or consistently lower pH, it can hurt you and increase your risk of disease. You are practically shredding your vagina if you do this.

Broader sociocultural issues of puckering up

Given how much discomfort the women in the Mauck et al (2008) study experienced, I am sure that women who do douche with lime juice are well aware that it is not the most comfortable experience in the world. So, why do they do it?

As I mentioned earlier, most of the women surveyed about their lime juice douching practices are sex workers; surveys of family planning clients showed a far lower incidence (only 4 out of 100) compared to sex workers (163 out of 200) (Imade et al. 2005). Most of the women surveyed used diluted preparations of lime juice, at 25% or 50%, so it’s possible they had fewer symptoms than participants at the full concentration in the Mauck et al (2008). And remember, part of the allure of lime juice douching is that it supposedly increases sexual pleasure (Imade et al. 2005; Menard et al. 2010).

Dr. Rubidium happened to point me to an ethnographic study of douching practices in Haitian immigrant women that, while obviously about a different population, provides some context. I want to share a particularly useful quote:

“The reasons underlying feminine hygiene practices are multifaceted and are related to broader sociocultural norms defining what is expected of women, by men and by other women: to be pròp, or clean, with one’s body, inside and out; to be free of any vaginal secretions, which are often construed as infectious or otherwise dirty; and to be sere, or tight, to increase sexual pleasure for male partners. The practices have been adapted and reconstituted over time to fit the needs of women in particular historical and cultural contexts, although women commonly engage in feminine hygiene practices for prevention and treatment of infections and as part of routine personal hygiene” (Menard et al 2010: 264).

Here, you can see the ways in which both women and men may police women’s bodies, and unfortunately see normal, healthy vaginal activity (like discharge or secretions) as signs of uncleanliness. The authors later point out that a wet vagina may be seen as a sign of promiscuity and infection in this sample; this could further reinforce the idea that sex with a woman with a dry vagina is more enjoyable.

In this context, it’s hard to not place lime juice douching within the spectrum of cultural practices enforced to control women, from female genital cutting, to diets, to cosmetics, to scores of other ways women alter their bodies to fit a culturally-sanctioned norm. And just as we can demonstrate the ways in which women may choose these practices, or find empowerment in some of them, I don’t know that it is really possible to parse out a woman’s agency from the institutional inequities that increase her chances of making certain choices. That is, a woman may choose any of these actions and be well aware of the benefits and consequences, but she is still aware of, and sometimes constrained by, a culture that dictates both.

In a population where only about 2% of women have access to modern contraception practices but maternal mortality is 1,549 deaths per 100,000 births (Mairiga et al. 2010) (for comparison, maternal mortality in the US, while high for a developed country, is around 13.3 deaths per 100,000), I imagine women, particularly sex workers, are going to try just about anything to increase their economic output and decrease their chances of pregnancy and disease.

I found one website that tries to provide a balanced perspective on the usefulness of lime juice douching in preventing HIV. One contributor explains (without citations, so I couldn’t follow up) that lime juice can kill HIV, but that the concentrations needed to do so harm the vagina and actually increase the risk of HIV transmission. I appreciated the perspective of another contributor who tried to separate out the call to not douche with lime from other white culture-prescribed practices:

“As discussion continues about the ‘sensibility’ of using lime or lemon as a douching agent and its efficacy as an HIV preventive measure, I think it is an opportunity for us to look at this practice critically especially as it has taken deep roots in our society. It goes beyond Jos and I hope we all know. It will do us no good to look at it as ‘the white guys are here again’. Can we deny the reality that our women use lime to douche?”

Here, the author is reminding the reader of the ways in which other science and health recommendations come from white folks which, given the historical context of colonization, racism, slavery, genocide and oppression, is understandably met with suspicion. The author also seems to be pointing out that Nigerians are perfectly capable of interrogating this issue and figuring out a solution. And in fact, most of the papers I found on the topic had Nigerian lead authors, suggesting this isn’t just an issue where white folks are sweeping in and telling Nigerian women how to handle their bodies.

Douching of any kind, and lime juice douching in particular, does not provide contraception, does not reduce infection risk (it may even increase it), and causes significant vaginal irritation. Educating women about these issues is certainly important. But perhaps more important is to resolve the major economic and health inequities that drive women to make these decisions, and to create mechanisms to produce more scientists in developing countries. When women have more control over financial resources they are more likely to reject patriarchal or problematic cultural practices that cause physical harm. And when scientists have training and resources to ask the questions they find important or interesting, they can tackle the major problems facing their society.

This issue is a complicated one, and not one where I pretend to have the final word or any particularly strong expertise. So as always I welcome your thoughts and comments, including any places where any reader sees a need for me to think better on privilege, race, or gendered cultural practices.

Acknowledgments

I want to thank Dr. Rubidium for the suggestion on the Menard et al paper, and for sharing her perspective on an earlier draft of this post.

References

Imade GE, Sagay AS, Onwuliri VA, Egah DZ, Potts M, and Short RV. 2005. Use of lemon or lime juice douches in women in Jos, Nigeria. Sexual Health 2(4):237-239.

Mairiga A, Kullima A, and Kawuwa M. 2010. Social and health reasons for lime juice vaginal douching among female sex workers in Borno State, Nigeria. Afr J Prm Health Care Fam Med 2(1):Art #125, 124 pages.

Mauck C, Ballagh S, Creinin M, Weiner D, Doncel G, Fichorova R, Schwartz J, Chandra N, and Callahanm M. 2008. Six-day randomized safety trial of intravaginal lime juice. J Acquir Immune Defic Syndr 49:243-250.

Menard J, Kobetz E, Diem J, Lifleur M, Blanco J, and Barton B. 2010. The sociocultural context of gynecological health among Haitian immigrant women in Florida: applying ethnographic methods to public health inquiry. Ethnicity & Health 15(3):253-267.

Penniston K, Nakada S, Holmes R, and Assimos D. 2008. Quantitative assessment of citric acid in lemon juice, lime juice, and commercially-available fruit juice products. J Endourol 22(3):567-570.

Sagay A, Imade G, Onwuliri V, Egah D, Grigg M, Musa J, Thacher T, Adisa J, Potts M, and Short R. 2009. Genital tract abnormalities among female sex workers who douche with lemon/lime juice in Nigeria. Afr J Reprod Health 13(1):37-45.