Pubic hair grooming practices in KwaZulu-Natal,South Africa: prevalence,side effects and association with sexually transmitted infections

Abstract

Pubic hair grooming is common in many countries, but little is known about this practice in Africa. Grooming has been positively associated with self-reported sexually transmitted infections (STIs). This study aimed to investigate the prevalence and safety of pubic hair grooming in two South African settings. In KwaZulu-Natal province, 1218 women participating in the Evidence for Contraceptive Options and HIV Outcomes Trial completed an interviewer-administered questionnaire on pubic hair grooming practices, and were tested for Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG) and herpes simplex virus type 2 (HSV-2). Pubic hair removal was reported by 705 (58.2%) of women. Common areas for grooming were the pubis (n = 616, 99.4%), vagina/perineum (n = 529, 85.3%) and inner thigh (n = 255, 41.1%). Half (n= 361, 51.4%) removed some or all of their pubic hair at least monthly and 59 (8.4%) once a week or more often. Common side effects reported included itching (n = 439, 77.1%) and pimples and blisters (n = 249, 43.9%). A quarter (n = 173, 24.5%) of groomers had a positive result for either or both of CT and NG compared to a fifth (n = 98, 19.4%) of non-groomers (p-value < 0.033). There was no difference between the groups for HSV-2. After adjusting for age and having more than one sex partner, groomers were significantly more likely to have CT or NG than non-groomers (OR: 1.31; 95% CI: 1.19–1.45). Similarly, those who experienced hair removal-related complications had 1.26 times the odds of testing positive for CT or NG (95% CI: 1.03–1.54). The practice of pubic hair removal is common and reporting of side effects is high in this population. These injuries could put women at a higher risk of STIs.

Keywords

Africa herpes simplex virus women

Background

Pubic hair grooming, defined as partial or full removal of pubic hair, is reported as a common practice among men and women in many countries.^1–12 The prevalence of grooming is higher in women compared to men,⁹,¹² and in younger age groups of both women and men.^3,4,6,9 Several studies report grooming prevalence as greater than 80% among women.^8–10 In one university in the United States (US), almost all (98.1%) of female students reported ever grooming.¹⁰ The most frequently reported method for pubic hair removal is shaving,¹,⁸,^10–12 but other methods such as waxing and laser removal are frequent.⁶,⁸,¹²

Pubic hair removal is associated with high rates of side effects, such as lacerations, itching, folliculitis, rashes and burns.⁷,¹¹,^13–16 A cross-sectional web-based national survey in the US found that over a quarter of the women who had ever groomed reported sustaining injuries such as lacerations, burns and rashes.¹⁴ Between 2002 and 2010, the number of genitourinary injuries related to grooming practices had increased fivefold in an emergency department setting in the US.¹⁵

Ever having groomed has been positively associated with a history of self-reported sexually transmitted infections (STIs) after adjusting for age and number of lifetime sexual partners.¹² However, a study among female university students in the US found no association of Neisseria gonorrhoeae (NG) or Chlamydia trachomatis (CT) infection with grooming.¹⁰

Despite the growing body of literature on pubic hair grooming, there has been limited research conducted outside of the US, especially in Africa. The Evidence for Contraceptive Options and HIV Outcomes (ECHO) Trial was an open-label, prospective randomized multicentre trial which compared the risk of HIV acquisition among 7829 HIV-1-negative women randomized to intramuscular depot medroxyprogesterone acetate (DMPA-IM), the levonorgestrel (LNG) implant or the copper intrauterine device (IUD) at 12 sites in Eswatini, Kenya, South Africa and Zambia from 2015 to 2018.¹⁷ This cross-sectional survey collected additional data and conducted a secondary analysis of the ECHO trial data in two sites in KwaZulu-Natal (KZN) South Africa to investigate the prevalence of pubic hair grooming and its association with STIs.

Methods

Women aged 16–35years were invited to enrol into the ECHO trial if they desired effective contraception and were willing to be randomized to any one of the three trial contraceptive methods (DMPA-IM, the LNG implant or the copper IUD). Follow-up visits occurred at one month, two months thereafter and every three months thereafter, up to 18 months.

At baseline, demographic information, baseline reproductive history and sexual risk behavior were collected. Sexual risk behaviour was repeated at every follow-up visit through to the final visit. Testing for STIs (NG, CT and HSV-2) was conducted at enrolment and the final ECHO study visit for all study participants. For the STI testing, endocervical swabs were collected by study staff and tested for CT and NG using PCR GeneXpert testing equipment, and for HSV-2, blood samples were collected and tested using Focus testing (Focus HerpeSelect 2 ELISA IgG). The study methodology and primary results have been previously reported.¹⁷ The primary outcomes of this secondary analysis are the occurrence of grooming practices, side effects of grooming and the association of pubic hair grooming with STI prevalence measured at final study visit.

Data on pubic hair grooming practices were collected during the final ECHO study visit pelvic examination. Between November 2017 and October 2018, all women exiting the study at two of the ECHO trial sites in KZN, South Africa (one urban, one peri-urban) were asked if they were willing to participate in a short (approximately 5–7 min) interviewer administered questionnaire, administered by trained study nurses (questionnaire provided as supplementary material). At the time of the pelvic examination, trained study nurses inspected the pubis, vagina, perineum and inner thigh for signs of hair removal. If hair removal was noted, nurses asked participants about methods used to remove hair, frequency of hair removal and injuries ever experienced. The definition of a groomer was a participant who after observation by a nurse was asked to confirm if they had removed any of their pubic hair. Study staff directly observed and confirmed any current side effects and sites of hair removal. Questionnaire responses were captured using the REDCap electronic data capture tools hosted at the University of the Witwatersrand.¹⁸ Data from REDCap were linked with the corresponding ECHO trial data. STI results (based on laboratory testing) from the final study visit were used for this analysis.

Data analysis

STI results and data on sexual behaviour were retrieved from the ECHO trial’s final study visit, while marital status and education were obtained from the baseline ECHO data. Both ECHO and pubic hair grooming data were descriptively analysed using R (3.6.0). Pearson’s Chi square with Yates’ correction was calculated for bivariate analysis of the relationship between grooming and the selected variables.

Multivariate analysis was performed using generalized estimating equations to account for the study site clusters. The regression analysis controlled for age and having more than one sex partner as possible confounders in the association between grooming and STIs.

Ethical considerations

The study was approved by the Human Research Ethics Committee at the University of the Witwatersrand (M141112) and the FHI 360 Protection of Human Subjects Committee. Consenting and client interviews were conducted in English or isiZulu, depending on participant preference.

Results

A total of 1211 consecutive women who attended their final ECHO study visit agreed to participate and no refusals were documented. The mean age was 24.5 years (Table 1). Although statistically significant, women who removed their pubic hair were only slightly younger than non-groomers (mean [SD], 24.2 [3.72] versus 24.9 [3.93]; p-value <0.01). There were no other differences noted between groomers and non-groomers.

Table 1.

Socio-demographic and sexual behaviour of pubic hair groomers and non-groomers.

	Non-groomers (N = 506; 41.8%)	Groomers (N = 705; 58.2%)	Total (N = 1211)	p-value
Age (years)				0.005
Mean (SD)	24.9 (3.93)	24.2 (3.72)	24.5 (3.82)
Marital status				0.531
Married	7 (1.4%)	7 (1.0%)	14 (1.2%)
Never married	498 (98.4%)	696 (98.7%)	1194 (98.6%)
Education				0.927
Post-secondary	111 (21.9%)	156 (22.1%)	267 (22.0%)
Primary or secondary	395 (78.1%)	548 (77.7%)	943 (77.9%)
Site location				0.228
Urban	297 (58.7%)	438 (62.1%)	735 (60.7%)
Peri-urban	209 (41.3%)	267 (37.9%)	476 (39.3%)
Sexual behaviours (in the past three months)
> one sex partner	21 (4.2%)	18 (2.6%)	39 (3.2%)	0.121
New sex partner	16 (3.2%)	21 (3.0%)	37 (3.1%)	0.855
Any unprotected sex^a	320 (70.6%)	479 (73.1%)	799 (72.1%)	0.364
Had primary sex partner	482 (95.3%)	671 (95.2%)	1153 (95.2%)	0.949
Mean (SD) number of sex acts in the last three months	23.3 (19.3)	23.0 (17.7)	23.1 (18.4	0.786

^aAny unprotected sex includes participants who, in the last three months, had sex at least once and said they never, rarely, sometimes or often used a condom.

Almost all women (n = 1153, 95.2%) reported a primary sex partner for the previous three months, 799 (72.1%) said they had sex at least once and did not always use a condom. There were no significant differences in sexual behaviours between groomers and non-groomers.

Pubic hair removal was reported by 705 (58.2%) women, with a slightly higher prevalence noted at the urban site (59.6%) versus the peri-urban site (56.1%).

Half (51.4%) of the groomers removed some or all of their pubic hair at least monthly and 8.4% once a week or more often (Table 2). The most common method used to remove hair was razors (78.3%, n = 552), while 17.3% (n = 122) used hair removal creams. Ever having experienced side effects related to hair removal was reported by 567 (80.4%) of women. The most commonly reported side effects of grooming were itching (77.1%, n = 439), and pimples or blisters (43.9%, n = 249). In 32 (4.5%) women these injuries were observed on the day of examination. Most (86.4%, n = 490) of these complications were attributed to razors, less (10.9%, n = 62) to hair removal creams and 13 (2.3%) to scissors. Hair removal creams contributed to over a third of cases of reported burning, whereas razors contributed to all cases of injuries.

Table 2.

Pubic hair grooming practices and complications.

Practice	Groomers N = 705 % (n)
Frequency of hair removal
Depends/no regular timing	22.3 (157)
Less than monthly	17.9 (126)
Less than weekly but at least once a month	51.4 (361)
Once a week or more frequently	8.4 (59)
Hair removal method^a
Razor	78.3 (552)
Hair removal creams	17.3 (122)
Scissors	6.1 (43)
Other methods	3.1 (22)
Wax strips	0.7 (5)
Hot wax	0.1 (1)
Hair removal site
Pubis	87.4 (616)
Vagina/perineum	75.0 (529)
Inner thigh	36.2 (255)
All three sites	34.2 (241)
No hair removal observed	12.1 (85)
Ever experienced side effects^a n = 567
Itching	77.1 (439)
Pimples/blisters^b	43.9 (249)
Rash	25.0 (144)
Inflammation of hair follicles	12.0 (68)
Bleeding	11.8 (67)
Burning	6.5 (37)

^aMultiple responses given.

^bSelf-reported and not known if pimples were pustules or blisters were bullous impetigo.

Pubic hair removal was visibly noted during examination by study staff for 620 (87.9%) of the 705 groomers (Table 2). The most common areas for grooming were the pubis (87.4%, n = 616) and the vagina/perineum (75.0%, n = 529).

A quarter (24.5%, n = 173) of groomers had a positive result for either or both of CT and NG compared to a fifth (19.4%, n = 98) of non-groomers (Table 3). Grooming and having positive results for either or both STIs were significantly associated (χ² = 4.24, p-value < 0.05). Approximately half of both groomers and non-groomers were HSV-2 positive with no significant difference between the groups.

Table 3.

Prevalence of sexually transmitted infections in pubic hair groomers and non-groomers.

	Non-groomers (n = 506; 41.8%)	Groomers (n = 705; 58.2%)	Total (n = 1211)	p-value
C. trachomatis or N. gonorrhoeae				0.03
Both negative	408 (80.6)	532 (75.5)	940 (77.6)
Either/both positive	98 (19.4)	173 (24.5)	271 (22.4)
HSV-2^a				0.49
Indeterminate	56 (11.1)	67 (9.5)	123 (10.2)
Negative	190 (37.6)	285 (40.4)	475 (39.3)
Positive	259 (51.3)	353 (50.1)	612 (50.6)

HSV-2: Herpes simplex virus type 2.

^aOne omitted due to missing values.

Multivariate analysis

After adjusting for age, having more than one sex partner and accounting for site clustering, groomers were significantly more likely to have STIs (i.e. CT or NG) than non-groomers (OR: 1.31; 95% CI: 1.19–1.45). Similarly, those who experienced hair removal-related complications had 1.26 times the odds of testing positive for STIs (95% CI: 1.03–1.54). High frequency groomers had 2.55 times the odds of having STIs (95% CI: 2.20–2.95) while low frequency groomers had less of an association with STIs (OR: 1.22; 95% CI: 1.12–1.34) when compared to non-groomers (Table 4).

Table 4.

Multivariate analysis controlling for age (younger or equal to 25 years) and having more than one sex partner.

	STI (C. trachomatis orN. gonorrhoeae)
	OR	CI
Groomers (versus non-groomers)	1.31	1.19–1.45**
Complications from grooming (versus no complications)	1.26	1.03–1.54*
High frequency groomers (versus non-groomers)	2.55	2.20–2.95**
Low frequency groomers (versus non-groomers)	1.22	1.12–1.34**

STI: sexually transmitted infection.

High frequency groomers removed pubic hair weekly or more often.

*p < 0.05; **p < 0.01.

Discussion

Pubic hair removal is common in this population, with a grooming prevalence of 58.2%. This is slightly lower than that seen in studies from New Zealand, the United Kingdom, Australia and the United States, where grooming rates between 65 and 95% are reported among women.^5,8,9,11,12

Although these data showed statistical significance in mean age between groups, groomers were younger by less than one year in their mean age compared to that of non-groomers. However, our study age range was limited to women aged 18–35 years. Previous findings that groomers are consistently younger than non-groomers have included wider age ranges including those over 60 years.^3–4 The age difference has been attributed to pubic hair removal motivations, increasingly targeting younger women, influencing both western and non-western cultural norms.³,¹⁰,¹²

Similar to other reported studies,¹,⁸,^10–12 using a razor to remove pubic hair was the most common method of hair removal and the leading cause of hair removal side effects. Although typical side effects reported are similar to previously published studies, the prevalence of side effects ever experienced by women in our study was much higher.^13–16 Some of these side effects could be considered minor and may be transient. Yet, they may result in epidermal microtears, potentially increasing susceptibility to infections during skin-to-skin contact. It has previously been hypothesized that removing pubic hair can be a risk for complications including STI acquisition; however, in many of these studies, STIs or complications were self-reported.^11–13 Conversely, the increased prevalence of grooming has seen a decrease in reporting of pubic lice.¹⁹ In our analysis, groomers had a higher prevalence of either or both of CT and NG. Given that pubic hair removal practices may introduce vulnerability in the way of injuries to the pubic area, it is plausible that when compromised, grooming might contribute to STI risk. However, grooming is potentially confounded by sexual behaviours. Studies in the US, Australia and Brazil have found that pubic hair removal was associated with increased sexual activity or having a sexual partner.^1,5,6,20,21 Our study did not find an association of grooming with sexual activity and this is likely to be related to the study population who were seeking effective contraception and who were required to be sexually active at enrolment.¹⁷

In our research, almost three of four women in both groomer and non-groomer groups did not always use condoms in the last three months, making it a possible contributing factor to STI risk. Considering that HIV and STI prevalence in South African women aged 25–49 years is high,^22,23 pubic hair removal practices may be an additional acquisition risk factor that warrants further investigation.

This exploratory study did not collect information on pubic hair removal motivations; however, literature, albeit from outside of Africa, cite hygienic reasons, appearance, partner preference, religion and social norms as common personal motivations for grooming.^{3,7,8,10,11,20,24} In a nationally representative survey of 3316 women aged 18–65 years residing in the US, women reported that they groomed for situations of sex, vacation and health care professional visits.¹

Despite the growing body of literature on pubic grooming, there has been limited research conducted outside of the US, especially in Africa. However, there is a substantial body of literature on ‘vaginal practices’ in Africa. These practices are well defined, with seven distinct categories including external genital washing, internal cleansing, application, insertion, ingestion, steaming/smoking and surgical/cutting.²⁵ Yet, the removal of pubic hair is not one that fits within these categories, nor has it been well explored. A review of the types of vaginal practices should be considered to include pubic hair grooming.

Limitations

This exploratory study is limited in several areas. It was a cross-sectional survey which did not allow for more in-depth questioning on motivations for pubic hair grooming and detail on the frequency of injuries. The association of HIV with grooming is not presented in our analysis as data for this study were only collected at the exit visit and no questions on history of grooming were asked in the interview. The study only collected data on three STIs and we cannot rule out the possibility of reverse causation.

Although pubic hair removal proved to be prevalent, this study was conducted in only one province. Thus, it may not be representative of other populations in South Africa.

Conclusions

This study has been the first to report the prevalence of pubic hair grooming in sub-Saharan Africa and indicates that grooming is a common practice. Our study had several strengths, first the visual inspection and confirmation of site of grooming. Many other studies investigating grooming have been limited to surveys or questionnaires without visual confirmation. Second, the STI testing was conducted on all women participating in the pubic hair grooming questionnaire. Grooming methods and experience of injuries in this study are in line with studies reporting from other regions in the world; however, prevalence of injury reporting is higher. More research needs to be conducted on personal motivations for grooming in Africa and safer grooming interventions should be developed.

Supplemental Material

sj-pdf-1-std-10.1177_0956462420941709 - Supplemental material for Pubic hair grooming practices in KwaZulu-Natal, South Africa: prevalence, side effects and association with sexually transmitted infections

Supplemental material, sj-pdf-1-std-10.1177_0956462420941709 for Pubic hair grooming practices in KwaZulu-Natal, South Africa: prevalence, side effects and association with sexually transmitted infections by Mags Beksinska, Bethel Lulie, Ivana Beesham and Jenni Smit in International Journal of STD & AIDS

Footnotes

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Mags Beksinska

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