Young women and anal sex
BMJ 2022; 378 doi: https://doi.org/10.1136/bmj.o1975 (Published 11 August 2022) Cite this as: BMJ 2022;378:o1975
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Dear Editor,
We thank Waters and Dewsnap for sharing their views. It is necessary to clarify factual points.
They assert “one quoted study shows the impact of anal sex on faecal incontinence was greater in men”. This is not what the paper reports. Markland et al(1) report anal intercourse was a factor contributing to faecal incontinence, in adults, especially in men i.e. anal intercourse was an independent cause for faecal incontinence. Unsurprisingly the odds ratio for this was greater in men, where parity was not a necessary inclusion in the multivariate analysis. However, this implies nothing about the impact of the problem, and overall incontinence rates were higher amongst women than men (8.3 versus 5.6%).
Waters and Dewsnap state “another (paper) does not describe higher risk in women”(2). However, the paper referenced is not a publication about the risks of anal sex. It is a review article about heterosexual behaviour. We would recommend it to readers wishing to understand the reasons women give for participating in anal sex. Its comprehensive coverage will help them understand motivations including coercion as a factor for some women. If readers wish to learn more about the possible risks of anal sex, we have also cited appropriate publications on this subject.
Waters and Dewsnap criticise our editorial for not offering practical advice on lubrication. This is an area where meaningful data is not currently available. Lubrication may prevent or reduce some types of trauma, however it is not immediately obvious how it can prevent stretching and diffuse internal anal sphincter trauma. Future observational and endoanal ultrasound studies may be able to shed light on this, and ascertain if lubrication could prevent or reduce some injuries.
We have highlighted data showing anal sex is increasingly common i.e. normal, among heterosexual couples and agree with Waters and Dewsnap it would be unhelpful for a medical journal to publish something which implies otherwise.
We agree updated patient and public health information is required. Further research is needed, if we are to close knowledge gaps and fully empower women to make their own choices. Until then, those giving advice need to be fully conversant with the current literature including its limitations. Where there is a paucity of information, this should be openly acknowledged.
References
1) Markland AD, Dunivan GC, Vaughan CP, Rogers RG. Anal intercourse and fecal incontinence: evidence from the 2009-2010 National Health and Nutrition Examination survey. Am J Gastroenterol 2016;111:269-74. doi:10.1038/ajg.2015.419 pmid:26753893
2) McBride KR, Fortenberry JD. Heterosexual anal sexuality and anal sex behaviours: a review. J Sex Res 2010;47:123-36. Doi:10.1080/00224490903402538 pmid:20358456
Competing interests: No competing interests
Dear Editor
Discussion about sex, particularly the neglected topic of anal sex in women, is uncommon in general medical journals and raising of awareness is a generally positive thing. However, we are concerned this has been framed in a negative and judgmental way.
There may be potential physical trauma from anal sex, and anatomical differences could play a role, but there is a risk of trauma from all sexual intercourse. Evidence that anal sex is more ‘dangerous’ in women is lacking; one quoted study shows the impact of anal sex on faecal incontinence was greater in men [1]; another does not describe higher risk in women [2]. The editorial lacks advice about minimising risk, such as using lubrication or condoms, a missed opportunity to offer practical advice.
There is excessive emphasis on coercion and pressure. All coercive sexual activity, anal or otherwise, is highly concerning and questions non-consensual sex are routine in sexual health services. The idea television promotes anal sex, rather than reflecting a practice undertaken, and enjoyed, by many is judgemental. Whilst surveys show an increase in the proportion of people reporting anal sex, the impact of societal ‘norms’ and stigma can drive underreporting of some sexual behaviours [3]. It is feasible that under-reporting of anal sex has declined over time due to broader awareness and acceptability.
An article in a medical journal implying anal sex is not normal will do little to challenge taboos. We agree all healthcare professionals should be able to have neutral and non-judgmental conversations about anal sex to ensure women can make informed choices. Anal sex is normal for many so we must normalise questions about it in healthcare settings. Updated NHS patient information is critical to ensure women can have safe, pleasurable anal sex if they choose to do so.
Dr Laura Waters, Consultant Physician Sexual Health & HIV, CNWL NHS Trust, London. Chair of the British HIV Association
Dr Claire Dewsnap, Consultant Physician Sexual Health & HIV, Sheffield Teaching Hospital NHS Foundation Trust. President British Association of Sexual Health & HIV.
References
1. Markland AD, Dunivan GC, Vaughan CP, Rogers RG. Anal Intercourse and Fecal Incontinence: Evidence from the 2009-2010 National Health and Nutrition Examination Survey. Am J Gastroenterol. 2016 Feb;111(2):269-74
2. McBride KR, Fortenberry JD. Heterosexual anal sexuality and anal sex behaviors: a review. J Sex Res2010;47:123-36
3. King BM. The Influence of Social Desirability on Sexual Behavior Surveys: A Review. Arch Sex Behav. 2022 Apr;51(3):1495-1501.
Competing interests: No competing interests
Dear Editor
We thank Merli and Goodyear for their valuable comments regarding coercion, instrumentation, sexually transmitted disease, and sensitive engagement by all relevant specialities.
Goodyear asserts iatrogenic instrumentation carries a very low risk of anal trauma. Although flexible endoscopes are safe, circular staplers are more analogous in circumference to the erect penis. This procedure is known to cause internal sphincter damage, demonstrable on endoanal ultrasound (1) and contributing to the faecal leakage seen in low anterior resection syndrome.
There was equal male and female participation in Markland et al. Faecal incontinence rates were higher amongst those reporting anal intercourse and after multivariable adjustment, anal intercourse remained a predictor of faecal incontinence in women (2).
Goodyear questions our focus on young women. Our clinical experience indicates this is an under recognised issue and there is a rise in reported participation with anal intercourse, by young women. Goodyear is correct in stating Hess et al (3) include adults up to 60 years, however the mean age was 38 years. Other publications highlight the increase in anal intercourse amongst young adults. Whilst not wishing to downplay concerns about older women or men, they were not the primary focus of our editorial.
Both parity (or future parity) and anatomical differences are relevant. Women have congenitally shorter anal sphincters and less functional reserve than men. This means a similar degree of sphincter damage is likely to have greater adverse consequences for them. More detailed observational data is needed before we can reach conclusions about the relative value of lubrication, and or anal relaxation techniques in protecting women from anal trauma.
References
1) Iatrogenic sphincter injuries. Jones, O.M., Lindsey, I. (2007). Iatrogenic Sphincter Lesions. In: Ratto, C., Doglietto, G.B., Lowry, A.C., Påhlman, L., Romano, G. (eds) Fecal Incontinence. Springer, Milano. https://doi.org/10.1007/978-88-470-0638-6_26
2) Markland AD, Dunivan GC, Vaughan CP, Rogers RG. Anal Intercourse and Fecal Incontinence: Evidence from the 2009-2010 National Health and Nutrition Examination Survey. Am J Gastro 2016;111(2):269-74
3) Hess KL, DiNenno E, Sionean C, Ivy W, Paz-Bailey G, Group NS. Prevalence and Correlates of Heterosexual Anal Intercourse Among Men and Women, 20 U.S. Cities. AIDS and behavior 2016;20(12):2966-75
Competing interests: No competing interests
Dear Editor
Gana, Hunt and the BMJ should be commended for bringing an emerging but insufficiently addressed aspect of sexual behaviour into the spotlight [1].
When 30-40% of women aged 20-49 years report anal intercourses [2,3], healthcare providers indubitably should become familiar with the multifaced aspects of a practice that appears to have already become part of routine sexual repertoire.
The authors maintain that a relevant proportion of women does not engage in anal sex prompted by their own desire and personal sexual gratification, but instead pressed or coerced by their partners [1].
Health sexuality, including anal sex, requires a respectful approach, self-determination, and the possibility of having a pleasurable and safe experience, free from pressure. Coercion is a serious condition and should be reported according to law, as forced anal intercourse without consent denotes intimate partner violence. Moreover, in these circumstances the risk of infectious and traumatic aftermaths is increased, as preventive measures may be infrequently adopted [4].
When a woman shares freely with her partner the decision to undertake anal intercourse, providing information on how to mitigate risks of potential infectious and traumatic harms, in addition to describing them, seems of utmost importance.
With regard to sexually transmitted infections, including chlamydia, gonorrhoea, syphilis, HIV, and HPV [3], women should be warned that the risk is common to all types of penetrative sex. A woman made fully aware of infectious risk may acquire sufficient negotiating power for condom use. Counselling should be aimed not only at averting unprotected anal intercourses, but also at categorically avoiding alternating anal and vaginal penetrations.
To mitigate the risk of traumatic harms, lubricants should be recommended, limiting the choice to non-oil-based ones to prevent condom damage and reduced infection protection. Anal foreplay, including progressive digital dilation aided with lubricants, may reduce the risk of traumatic abrasions, bleeding, fissures, and anal pain. Awareness of potential trauma may ensure women sufficient negotiating power for the adoption of sphincter relaxation techniques and lubricants.
Limited evidence is available on the likelihood of sphincter injury severe enough to cause faecal incontinence after consenting anal intercourses. In general, faecal incontinence prevalence estimates are marginally higher in women than in men, although the prevalence of receptive anal intercourse seems substantially higher in women (over one out of three) than in men (about one in 20) [2].
According to Gana and Hunt, because of anatomic and functional anorectal differences, women are more prone than men to develop faecal incontinence as a consequence of anal sex [1]. However, in the National Health and Nutrition Examination Survey, the effect of receptive anal intercourse was significantly larger in men than in women, as faecal incontinence rates in those reporting versus not reporting anal intercourse were 11.6% and 5.3% in men, and 9.9% and 7.4% in women [2]. Overall, traumatic risk appears associated with the type of approach at anal intercourse, and a learning process has been suggested to reduce pain [5].
Finally, we believe that gynaecologists, midwives, and nurses should be included, in addition to GPs, gastroenterologists, and colorectal surgeons, among the healthcare providers best suited to convey appropriate information regarding potential harms of anal sex and provide practical instructions aimed at mitigating risks.
References
1. Gana T, Hunt LM. Young women and anal sex. BMJ. 2022;378:o1975.
2. Markland AD, Dunivan GC, Vaughan CP, Rogers RG. Anal Intercourse and Fecal Incontinence: Evidence from the 2009-2010 National Health and Nutrition Examination Survey. Am J Gastroenterol. 2016;111:269-74.
3. Habel MA, Leichliter JS, Dittus PJ, Spicknall IH, Aral SO. Heterosexual Anal and Oral Sex in Adolescents and Adults in the United States, 2011-2015. Sex Transm Dis. 2018; 45:775-782.
4. Hess KL, Javanbakht M, Brown JM, Weiss RE, Hsu P, Gorbach PM. Intimate partner violence and anal intercourse in young adult heterosexual relationships. Perspect Sex Reprod Health. 2013;45:6-12.
5. Stulhofer A, Ajduković D. A mixed-methods exploration of women's experiences of anal intercourse: meanings related to pain and pleasure. Arch Sex Behav. 2013;42:1053-62.
Competing interests: No competing interests
Dear Editor
Monkeypox (mpox) is not considered a sexually transmitted infection (STI); however, it can be contracted during sexual activity, including anorectal intercourse. International cohort studies report that 74-88% of patients diagnosed with mpox present with anogenital lesions. [1],[2] While men who have sex with men (MSM) represent the vast majority of these presentations, as of 21 August 2022, women comprised approximately 1.5% of U.S. 2022 monkeypox cases.[3] The editorial by Gana and Hunt [4] reminds us that women are at risk for acquiring infections during anorectal intercourse.
As anorectal intercourse is associated with mpox transmission, clinicians should consider mpox in women reporting rectal pain or other symptoms of proctitis following this activity. Due to frequent co-infections, these women should also be assessed for STIs, e.g., syphilis, gonorrhea, and chlamydia. Immunocompromised patients are at risk for severe mpox. A woman presenting with significant rectal pain and severe mpox should prompt investigations for HIV or other immunocompromising conditions, including cancer and autoimmune disorders.
We agree with Gana and Hunt [4] regarding the importance of increasing awareness of healthcare professionals on the prevalence of anorectal intercourse in women but would not limit assessment to the young. Patients of any sex, gender, or age presenting with symptoms of proctitis should be gently queried about anorectal intercourse. If affirmed, clinicians should consider mpox and STIs in the differential diagnosis. A 3I Tool (Identify-Isolate-Inform)[5] facilitates identification of mpox cases.
References
1. Thornhill JP, Barkati S, Walmsley S, et al. Monkeypox Virus Infection in Humans across 16 Countries - April-June 2022. N Engl J Med. 2022;387(8):679-691. DOI: 10.1056/NEJMoa2207323
2. Patel A, Bilinska J, Tam JCH, et al. Clinical features and novel presentations of human monkeypox in a central London centre during the 2022 outbreak: descriptive case series. BMJ. 2022;378:e072410. DOI:10.1136/bmj-2022-072410
3. Centers for Disease Control and Prevention. Monkeypox Cases by Age and Gender, Race/Ethnicity, and Symptoms. Updated August 21, 2022. Accessed August 27, 2022.https://www.cdc.gov/poxvirus/monkeypox/response/2022/demographics.html
4. Gana T, Hunt LM. Young women and anal sex. BMJ. 2022;378:o1975. DOI: 10.1136/bmj.o1975
5. Koenig KL, Beÿ CK, Marty AM. Monkeypox 2022 Identify-Isolate-Inform: A 3I Tool for frontline clinicians for a zoonosis with escalating human community transmission. One Health. 2022; 15:100410. DOI: 10.1016/j.onehlt.2022.100410
Competing interests: No competing interests
Dear Editor
Thank you for drawing attention to this important issue. In 1983 while finishing my master’s thesis and building a sexual function questionnaire for my study, I obtained my test/retest validity and reliability data for the tool using heterosexual female graduate students. Ano-rectal intercourse activity was reported by 10% of the graduate students and none of the diabetics in my small pilot study.
If ano-rectal intercourse is becoming more common, then perhaps it is time to begin anal PAP screening on those women reporting such sexual practices—similar to what is currently being done with the MSM population—to screen for HPV.
Martha E Brown, MSN, NP-C
Family Nurse Practitioner
Competing interests: No competing interests
Dear Editor
The authors' arguments in this editorial, though well intended, raise a number of problems. Presumably
their opinion arises from their experience in dealing with anorectal disease. They are correct in
emphasising that a comprehensive sexual history should include all forms of sexual behaviour, where
appropriate, and for drawing attention to the prevalence of anal intercourse (AI). Such history taking
entails considerable sensitivity and a need to avoid inducing shame or guilt. With specific reference to
anorectal disease, those of us who deal with these patients are aware that such a history should include
not just intercourse but the insertion of any objects into the anorectal area.
The authors imply that AI should be considered risky sexual behaviour, citing associations with factors
such as alcohol usage. But these associations apply to all sexual behaviour, not simply AI, and should be
considered separately. They also cite practices associated with intercourse such as lubrication or STDs,
but these are also common to other sexual behaviour. Coercion, in particular, should be considered a
form of sexual violence and managed accordingly.
The evidence that AI is inherently dangerous compared to other sexual behaviour is slight and should be
addressed by appropriate sexual health education to minimise risk. Instrumentation of the anorectal
region and lower GI tract, when properly performed, for instance with adequate preparation,
communication and lubrication carries a very low risk of injury, implying that insertion is not per se
associated with trauma.
The issues raised apply also to men, but it was unclear why the editorial was specifically addressed to
“young women”, given that one of their sources (4) included women aged 18-60, and another source
(12) applied primarily to men (and did not directly address sphincter injury). Nor does the discussion of
sphincter anatomy and physiology take into account parity.
Given the media attention given to this editorial, it would be unfortunate if the editorial created fear
and guilt in the general population. However, I would emphasise the concluding paragraph, that health
professionals should have a high level of awareness and be willing to provide accurate information to Ensure informed choices in sexual behaviour.
Competing interests: No competing interests
Dear Editor
It may be time to update the nomenclature. Vaginal intercourse with penile/device penetration should be renamed as vulvo-vagino-cervical intercourse while anal intercourse with penile/device penetration should be renamed as ano-rectal intercourse. While oral intercourse with penile/device penetration should be renamed as oro-pharyngeal intercourse, oral sex per current nomenclature with or without tongue penetration can be limited to oral cavity connecting with vulvo-vagina and/or ano-rectum. This updated nomenclature may enhance general population's understanding about anatomical structures involved in various forms of sexual activity.
Competing interests: No competing interests
Dear Editor
Major issue across the diagnostic spectrum in urology. See attached. https://europepmc.org/article/med/18634737
Skillful history taking the key.
What we teach …
“Need to ask you some questions about sex”
“Are you sexually active ?”
“Have you ever had a sexually transmitted infection”
“Is anal sex something you do or have done ?”
“The reason to ask is that anal sex can trigger some nasty infections”
Tim O’Brien
Competing interests: No competing interests
Young women and anal sex: evidence-based advice avoiding normative or moralising positions
Dear Editor
We are highly in favour of promoting awareness of how to achieve optimal sexual health. However, the editorial’s framing of the issue and the proposed or implied solutions suffer from several limitations.
Overinterpretation of weak evidence informs statements that can be perceived as fear mongering. For instance, the association between anal sex and alcohol use is based on findings from a study in the US of men and women living with HIV, which cannot be easily generalised (ref 8). Stating that anal sex is associated with greater faecal incontinence in women compared with men is based on a descriptive study of ultrasonographic features of the anal canal (ref 13) and a cross-sectional study in which the adjusted odds of incontinence were higher in men reporting anal intercourse (OR 2.8) than in women (OR 1.5) (ref 12).
Some other statements, such as those about the influence of popular TV shows, come across as uncomfortably normative and potentially moralising. A puzzling link is also made with homophobia: it is not explained how asking straight women about anal sex might be perceived as homophobic.
All sexual practices can lead to lesions in both sexes, including vaginal tears and penile fractures. The article does not specify which methods can reduce the risk of anal lesions towards a healthy sexuality, including adequate lubrication. Rather, there are confusing statements about protection and coercion that appear to assume women are primarily forced into the practice, and thus protection comes from outright avoidance of the practice. If women are being coerced to engage in anal sex, is the problem primarily about anal sex or about coercion?
Our task as physicians is to help patients to achieve optimal sexual health by providing evidence-based advice and avoiding normative or moralising positions. We found the editorial comes short on both accounts.
Competing interests: No competing interests