Anal sex

Anal sex has always been a highly controversial subject, and the controversy that surrounds it looks set to continue into 2012 because evidence accumulates that this practice may sometimes lead to anal cancer.

'Fisting' which means putting the hand into the rectum; this activity is rare among heterosexual couples.

Taboos and infection

There are taboos surrounding the various types of anal sex and particularly anal intercourse. These may arouse strong feelings of moral indignation, guilt and anxiety. It is important to remember that while some people find these activities repugnant, others may find them stimulating, exciting and a normal part of their sexual intimacy. Research shows that, whether we like it or not, the anal area is equipped with many erotic nerve endings in both men and women. So it's not surprising that many couples (including a lot of heterosexual ones) derive pleasure from some form of 'bottom stimulation'. What about infection? Most sexual activities carry a risk of transmission of sexually transmitted diseases (STDs) ranging from gonorrhoea and herpes to hepatitis B and HIV. There's evidence that anal intercourse carries a higher transmission risk than almost any other sexual activity. Information about these risks is given below.

What is it?
Anal sex means sexual activity involving the bottom in particular, the type of intercourse in which the penis goes into the anus. It's often referred to as 'rectal sex'. Anal sex does carry considerable health risks, so please read our advice carefully. Our impression is that anal sex has become rather more common in heterosexual couples, partly because they have watched 'blue movies' in which this activity so often occurs. One small study carried out in 2009 suggested that in the UK, 30 per cent of pornographic DVDs feature rectal intercourse. Often, it is presented as something that is both routine and painless for women. In real life, this is not the case. Other types of sexual activity which involve the anus include:

'postillionage' which means putting a finger into the partner's bottom insertion of 'butt plugs' which are sex toys that dilate the anal opening and create a sensation of fullness use of vibrators on or in the anus (please see cautionary note below) 'rimming' which is oral-anal contact; this carries a significant risk of infection

Consent
What consenting adults enjoy sexually in the privacy of their homes is their own business provided that the law does not prohibit it.

The key issues are legality and consent. In the UK, anal intercourse is now a legal activity between consenting men and women aged 16 and over, in both heterosexual and homosexual relationships, except in Northern Ireland where it's 17 and over. In some countries it is still a criminal offence punishable by long custodial sentences, and corporal or even capital punishment. It remains forbidden in some states of the USA, though in practice a Supreme Court decision of 2003 appears to invalidate these state laws. Anal intercourse is legally forbidden in some former colonies of Britain, notably in the West Indies. Consent freely given by both partners is an essential feature of sexual activity in a loving relationship. Many individuals, both men and women, may have secret fantasies involving anal intercourse but feel unable to discuss them with their partner. Some may try and pressurize their partner to have anal intercourse, even though the partner does not share their interest. Some partners will reluctantly acquiesce, others may be pressured or even physically forced to allow it. Forcing or pressurizing a partner to submit to an activity that they find distasteful or degrading is completely unacceptable behavior. Intoxication with drugs or alcohol is associated with lowering inhibitions and experimentation with unusual or unsafe sexual behavior and can lead to serious consequences. Some male gay couples use the drugs known as 'poppers' (nitrates) to try to relax the anal sphincter and so make penetration

easier. But these agents do carry some risk of side-effects. It should be remembered that in the absence of freely given consent, the very serious criminal offences of assault and rape are committed. Therefore, it's essential that both partners agree that they wish to try anal sex as a part of their sexual repertoire and that they are sure of the legal position on anal intercourse in the country that they are in.

Who does it?

There is a common misconception that anal sex is practiced almost exclusively by gay men. This is certainly not the case. It's widely claimed that one third of gay couples do not include anal intercourse in their lovemaking. According to one estimate, about a third of heterosexual couples have tried it from time to time. It's thought that about 10 per cent of heterosexual couples have anal intercourse as a more regular feature of their lovemaking. In absolute numbers, more heterosexual couples have anal sex than homosexual couples, because many more people are heterosexual.

Is it safe?
Anal sex, if practiced with care, is possible for most couples. It does, however, carry health risks and there are safer sexual practices that couples can enjoy. The main health risks, which affect both heterosexual and homosexual couples, are described below.

Human papilloma virus (HPV): there is no doubt that anal intercourse carries a greater risk of transmission of HIV the virus that can cause acquired immunodeficiency syndrome (AIDS) than other sexual activities, particularly for the receptive partner. Human papilloma virus and warts: this virus can be transmitted during anal intercourse and that may lead to anal warts. HPV and anal cancer: unfortunately, certain strains of HPV virus do have carcinogenic (cancer-provoking) potential. There are some types of HPV that cause cancer of the cervix in women and probably also cancer of the throat. Round about the beginning of the present century, research showed that HPV could be isolated from the tissues of many anal cancers. By 2008, it became clear that people who had been anally penetrated by multiple partners were unusually likely to get carcinoma of the anus. A Danish study has recently suggested that gay men may have a 17-fold increase in risk of anal cancer but close inspection of this paper reveals that the number of people involved was very small. So the case is not quite proven yet, but there are enough data to suggest that if you are going in for anal intercourse, it's safest to do it with only one regular partner. Hepatitis A (infectious hepatitis): this is a viral infection that can cause jaundice and abdominal pain. Hepatitis A is not usually a lifethreatening illness, although sufferers can feel quite ill. It can be transmitted by oral-anal contact. Hepatitis C: is a cause of progressive and sometimes fatal chronic liver disease. Hepatitis C

may be transmitted by anal intercourse, although this seems to be a rare occurrence. Sharing of equipment for intravenous drug use is a far more important risk for transmission. Escherichia coli (E. coli): may sometimes cause mild to severe, or even (very rarely) fatal, gastroenteritis. It is one of many viruses and bacteria that can be transmitted by oral-anal contact. Some E. coli strains (uropathic E. coli) can also cause urinary tract infections (UTIs), ranging from cystitis to pyelonephritis a serious kidney infection. E. coli very readily crosses the short distance between the female anus and the female urinary opening, so causing a urinary infection. Anal intercourse can facilitate this transfer, particularly if it is immediately followed by vaginal intercourse.

Protection
Avoiding anal sex altogether is of course the best way of avoiding these risks. There are other, safer sexual practices that can be exciting and rewarding, but many couples may still wish to try the anal route. The use of condoms and water-based lubricants, such as K-Y Jelly, will offer some protection. Other lubricants may cause condoms to split, as will over-energetic thrusting without adequate lubrication. Specially toughened condoms designed for anal intercourse may offer more protection.

How to have intercourse safely

anal

Drugs and anal sex

Anal intercourse involves the penetration of the anus and rectum with the erect penis for the purpose of sexual stimulation. It is possible for both men and women to 'receive' it, although care is needed for it to be safe and comfortable. Ensure the anal area is clean and the bowel is empty. This is important both aesthetically and practically. If the bowel is empty, there is no risk of the receptive partner passing faeces. First try gently inserting a lubricated finger, perhaps covered by a condom or glove into the anus. This will enable the receiving partner to find out whether penetration is comfortable and enjoyable. Having managed to accommodate one finger, you can run it around the anal canal gently stretching it. This must be done delicately so as not to cause pain or injury. If this is successfully achieved, the couple may agree to try with a well-lubricated penis or with a butt plug (a broad-based anal dilator), dildo or vibrator (see below about the risks of sex aids and anal sex). Gentleness, care, adequate lubrication and anal relaxation are required, not the insertive partner pushing harder! If condoms are used for penile penetration, which is advisable to reduce the risk of sexually transmitted disease, it is important to use a water-based lubricant. The insertive partner must be gentle with any thrusting, so as to give the receptive partner time to allow the sphincter to relax. With time and practice, this may become easier.

Muscle relaxant drugs (amyl nitrate, butyl nitrate, glyceryl trinitrate) have been tried to make anal intercourse easier or more comfortable. We do not recommend this. Amyl nitrate 'poppers' sold in small bottles for inhalation, are popular in the gay community and have a reputation both for enhancing the intensity of orgasm and helping relax the anal sphincter. There's no real evidence to support these assertions and its use is not recommended by medical authorities. It is important to remember that amyl nitrate is a potent drug with many side-effects, including facial flushing, headaches, dizziness and low blood pressure, which may lead to faintness and loss of consciousness. Amyl nitrate, when taken with Viagra (sildenafil), may cause a catastrophic drop in blood pressure with potentially fatal consequences. Other nitrates may have the same effect. All erectioninducing drugs, including Viagra (sildenafil), Cialis (tadalafil)and Levitra tablets (vardenafil), can be very dangerous if you are using nitrates. Local anaesthetics, such as lignocaine (lidocaine) cream or even locally applied cocaine, have been used to reduce anal pain during intercourse. Again, we strongly advise against this. By numbing the anal skin there is a real risk of causing serious injury to the anal sphincter through overvigorous thrusting. By following the steps above it is possible to gently dilate the sphincter for comfortable intercourse. The purpose of pain is to make us aware that we are causing injury and, therefore, local anaesthetics

should be avoided. Another problem with local anaesthetics is that they may make the penis of the insertive partner numb. This may lead to problems with erection, orgasm and ejaculation.

One additional risk from the use of sex aids in anal sex is that of losing the aid into the rectum. Some medical school pathology museums have a wide selection of novel foreign bodies recovered from the rectums of both men and women, ranging from vibrators to milk bottles. Human ingenuity seems to know no bounds in this area, but it is incredibly foolish to insert potentially breakable objects into the anus and terrible injuries may result. If you do lose a sex aid into the rectum you should attend the Accident and Emergency department of your local hospital as soon as possible, however embarrassing it may be. The situation will only get worse if it is neglected and the object may break or become more difficult to recover. In general, you should only use a sex aid which is designed for the anus. Butt plugs and anal vibrators have a broad base, which makes it difficult to 'lose' them inside the rectum. Vaginal vibrators are not designed in this way, and can easily slip inside and buzz their way up the colon. Some have been recovered by surgeons from far inside the abdomen. If they are still vibrating when the patient arrives at the hospital, they produce an interesting but alarming phenomenon called 'the rotating umbilicus sign'. Don't let this happen to you.

Fisting
This means putting the whole hand into the rectum. With adequate relaxation it's physically possible, and it may be acceptable and enjoyable for some couples. But the diameter of the hand is so much greater than that of the penis that there's an increased risk of anal injury. For that reason, we do not recommend this practice. In reality, anal fisting is very rarely used by heterosexual couples.

Rimming
Rimming involves oral contact with the anus for sexual stimulation. This involves a high risk of transmission of infection. So we cannot recommend this practice.

Sex aids and anal sex a cautionary note

Some couples like to use sex aids for insertion into the anus. Certain individuals may use them for solitary sexual stimulation. The same principles apply as for genital insertion in that relaxation is essential. Sex aids must be kept clean and washed carefully between use. Condoms may be placed over sex aids as an additional precaution.

McKinley Health Center

Who does it?

Anal Sex: Questions and Answers

Know your anatomy

A variety of people engage in anal sex and stimulation despite their sexual orientation. 25% of heterosexual undergraduate students have experimented with anal sex at one point in their lives. This statistic is also consistent with national trends for heterosexual adults.

The anus is the entry to the rectum; it is one and half inches long, and is surrounded by two rings of muscles: the external sphincter and the internal sphincter. External sphincter - muscle that is closest to the anal opening. It can be contracted at will because it is controlled by the central nervous system. Internal sphincter - internal muscle that is involuntarily controlled by the body. The internal sphincter cannot be contracted. Rectum - tube like structure made of soft tissue that is eight to nine inches in length and is surrounded by muscles. The rectum is able to expand, like the anus or vagina.

Health considerations

What is anal sex?

Anal Intercourse - Anal intercourse is sexual activity that involves insertion of the penis or a sex toy into the anus. Rimming - Rimming is a slang expression that refers to oral stimulation of the anus. The official term for this is analingus. Manual Stimulation - Manual stimulation can include rubbing the anus externally or insertion of a finger(s) - ones own or a partners into the anal opening and gently rotated. Fisting - Fisting is a form of anal sex in which several fingers or even the entire hand and forearm are inserted into the rectum and sometimes into the lower colon.

Unprotected anal intercourse is considered a high-risk activity for both males and females. People who have unprotected anal intercourse are at high risk for many sexually transmitted infections, including HIV due to lack of natural lubrication, which can lead to tears and exposure to blood. Condom use during anal sex is a must. Sexually Transmitted Diseases (STDs) can and do occur around the anus and inside the rectum, including intestinal parasites, gonorrhea, HIV, chlamydia, syphilis, herpes, HPV, and hepatitis. Oral sex, including rimming, or analingus, can put both partners at risk for hepatitis, herpes, HPV, and parasites. If you notice any pain, sores, discharge, or lumps around or inside the anus, make an appointment with a health care provider as soon as possible. Appointments can be made at McKinley Health Center by calling Dial-A-Nurse at 333-2700. For heterosexual couples, pregnancy can occur if semen is deposited near or around the vaginal opening. Anal complications not related to anal sex include: irritable bowel syndrome, hemorrhoids, fissures or tears. If you are suffering from any of these medical concerns, do not engage in anal sex until you have consulted with a physician.

Taking care of hygiene

Proper hygiene should also be taken into account with anal sexual activity. With routine daily hygiene, the anus is as clean as other parts of your body. It contains its own natural bacteria to help fight against infections. The main function of the rectum is to act as a passageway for feces. But feces are not normally stored in the rectum except just prior to a bowel movement. Small amounts may remain in the rectum, especially if the feces are not well formed. Anal douching before lovemaking sex may help some people especially who are concerned with cleanliness to relax. Additionally, the use of enemas before anal sex can be used to feel cleaner and to prevent the need to evacuate the bowels during sex. However, enemas may cause trauma to the rectum which can increase the risk for HIV and other STDs. It may be best to allow a few hours to pass after an enema before anal sex. Using anti-bacterial soap after direct contact with feces is also recommended. Slipping a soapy finger inside you while showering is another good way to cleanse the anal area. Remember to go light on the soap as it can be irritating to your insides.

Putting safety first

and communicate with your partner about how you feel - sex play that is painful or uncomfortable should not continue. To prepare for anal sex, the first thing to do is to relax. The sphincter muscles around the anus will not allow things to pass through unless you relax and take it slow. If you are not comfortable with anal sex, then dont do it! Empower yourself to choose what sexual acts are most pleasurable in meeting your sexual needs. Its also important not to pressure partners to engage in anal sex if they are not comfortable. Remember to always use only waterbased lubricants with latex condoms. The anus does not produce a sufficient amount of lubricant for comfortable intercourse and adding more lubricant reduces the risk of tearing anal tissue and having a condom break. A thicker lubricant may be needed for anal sex. For safer rimming, people use latex barriers - thin pieces of latex - placed over the anus. This acts as a barrier between the mouth and anus. Plastic wrap and cut-open condoms can also be used as a barrier for analingus. Like condoms, some latex barriers come in different flavors. It is also important to utilize latex gloves during digital intercourse or finger sex or fisting of with the anus.

Proper use of latex condoms or female condoms can significantly reduce the risk of contracting dangerous infections such as HIV. Men and women can contract an STI during anal sex. The risk for HIV increases for the receptive partner, whether male or female. To prevent other infections, do not insert a penis or sex toy into the mouth or vagina after its been inserted in the rectum until your partner puts on a new condom or cleans the sex toy in between (rubbing alcohol, or a mixture of one part bleach to 9 parts water). Anal sex should not be painful. It is also important to stop if anything hurts

Why do some people do it?

The anus is full of thousands of nerve endings both inside and outside, making it very sensitive. For some people, the anus is an erogenous zone that can respond to sexual touch and stimulation. The highest concentration of nerve endings is around the anal opening itself. The outer portion of the rectum, like the vagina, has several nerve endings. The inner portion responds mostly to pressure. Some people enjoy

the feelings of pressure and fullness once they understand that these sensations do not presage an impending bowel movement. In men, the prostate - which is just beyond the rectal wall, a few inches in, towards the front of the body - can be a source of pleasure when massaged by a finger, an object, or a penis. Also, the lower end of the penis, or "bulb", is near the anal opening. It is stimulated indirectly by most types of anal sex. Anal pleasure can be psychological as well as physical.

Baldwin, J. I., & Baldwin, J. D. (2000). Heterosexual anal intercourse: An understudied high-risk sexual behavior. Archives of Sexual Behavior, 29, 357-373.

Can anal sex lead to orgasm?

Most people require direct genital stimulation in order to climax. On the other hand, a few people have orgasms only with anal stimulation. A minority of men and women can achieve orgasm from anal sex without direct genital stimulation. Women probably do so through pelvic muscle contractions - and a small minority even through the sheer excitement of being anally penetrated. When men experience an orgasm from anal stimulation, they tend to focus on the prostate. They may they are also be responding to indirect stimulation of the penile bulb. Orgasms from anal stimulation are most likely to occur when the participants become thoroughly absorbed in their sensations and fantasies (as with vaginal or oral sex).

References Melby, T. (2007). Anal Sex: An extraordinary taboo. Contemporary Sexuality Vol. 41 No. 11 Hutcherson, H. (2002). What your mother never told you about sex. New York: NY: G. P. Putnams Son. Sexuality. Org: Society for human sexuality.

Alice, I heard that anal sex causes the rectum/anus to become larger and creates problems with going to the bathroom. Can you please tell me what the risks are when it comes to anal sex beyond the normal STI/STD and pregnancy risk? Are there any risks involved with anal sex that are not involved with oral or vaginal? Thanks in advance. Anal Wonders Dear Anal Wonders, Anal sex enthusiasts can relax (a good thing to do during anal sex!), because contrary to what you heard, anal sex does not loosen the anus or cause an inability to control bowel movements. However, there can be risks associated with anal sex other than sexually transmitted infections (STIs), so it's important to take steps to minimize these risks. Friction, the enemy of pleasure and safety during sex, is produced during anal sex, much as it is during vaginal sex. However, friction may be more of an issue during anal sex because the lining of the anus is more delicate and produces less natural lubricant than the vagina. Steps to safer anal sex include:

the anus and rectum. This is because the lining of the rectum is not as heavy as the lining of the vagina, so it is more susceptible to tears. If the anus or rectum does get torn, it does not heal as quickly. Because feces that pass through the rectum contain bacteria, any tear in the lining is at risk of getting infected. Lining tears may lead to other problems such as an anal abscess, which can make transmission of STIs and HIV more likely. This is why unprotected anal sex is often considered riskier than unprotected oral or vaginal sex. The tips above will help you avoid tears and other uncomfortable complications. In extreme cases, a tear in the lining can develop into a fissure (a larger tear or crack) and may extend outside of the bowel. This is called a fistula and it is a significant medical issue because it allows feces to pass outside of the bowel, and requires major surgery to repair. Additionally, there is some suggestion that anal sex may worsen existing hemorrhoids, so you may want to carefully consider anal sex activities if you have them. Pregnancy is not a concern during anal sex (unless vaginal sex is also included on your agenda). And although you already seem aware, it is important to mention that STIs, including HIV, can be passed to or from an anal sex partner, so using condoms is always a good idea. So, whether you are a beginner, an old hat, or simply curious, you can relax, move slowly, and enjoy.

Being very gentle and moving slowly Using plenty of lubricants (not just saliva) Using a condom Avoiding spermicide, which may irritate the rectum Never moving from anal to vaginal sex without first changing condoms Stopping if there is severe pain during penetration

Anal sex may make a person more susceptible to bacterial infection around

Anal Sex Safety and Health Concerns

An estimated 90% of men who have sex with men and as many as 5% to 10% of sexually active women engage in receptive anal intercourse. Often referred to simply as anal sex, anal intercourse is sexual activity that involves inserting the penis into the anus. People may engage in anal intercourse, which has health risks, because the anus is full of nerve endings, making it very sensitive. For some recipients of anal sex, the anus can be an erogenous zone that responds to sexual stimulation. For the giving partner, the anus may provide a pleasing tightness around the penis. While some people find anal sex enjoyable, the practice has downsides and requires special safety precautions.
Is Anal Sex Safe?

theanus.Our external tissue has layers of dead cells that serve as a protective barrier against infection. The tissue inside the anus does not have this natural protection, which leaves it vulnerable to tearing and the spread of infection. The anus was designed to hold in feces. The anus is surrounded with a ring-like muscle, called the anal sphincter, which tightens after we defecate. When the muscle is tight, anal penetration can be painful and difficult. Repetitive anal sex may lead to weakening of the anal sphincter, making it difficult to hold in feces until you can get to the toilet. However, Kegel exercises to strengthen the sphincter may help prevent this problem or correct it. The anus is full of bacteria. Even if both partners do not have a sexuallytransmitted infection or disease, bacteria normally in the anus can potentially infect the giving partner. Practicing vaginal sex after anal sex can also lead to vaginal and urinary tract infections.

Anal sex has a number of health risks. Anal intercourse is the riskiest form of sexual activity for several reasons, including the following:

The anus lacks the natural lubrication the vagina has. Penetration can tear the tissue inside the anus, allowing bacteria and viruses to enter the bloodstream. This can result in the spread of sexually transmitted infections including HIV. Studies have suggested that anal exposure to HIV poses 30 times more risk for the receptive partner than vaginal exposure. Exposure to the human papillomavirus (HPV) may also lead to the development of anal warts and anal cancer. Using lubricants can help some, but doesn't completely prevent tearing. The tissue inside the anus is not as well protected as the skin outside

Anal sex can carry other risks as well. Oral contact with the anus can put both partners at risk for hepatitis, herpes, HPV, and other infections. For heterosexual couples, pregnancy can occur if semen is deposited near the opening to the vagina. Even though serious injury from anal sex is not common, it can occur. Bleeding after anal sex could be due to a hemorrhoid or tear, or something more serious such as a perforation (hole) in the colon. This is a dangerous problem that requires immediate medical attention. Treatment involves a hospital stay, surgery, and antibiotics to prevent infection.
Preventing Anal Sex Problems

The only way to completely avoid anal sex risks is to abstain from anal sex. If you engage in anal sex, it is always important

to use a condom to protect against the spread of infections and diseases. Following are more tips for increasing anal sex safety:

Avoid inserting a penis into the mouth or vagina after it's been inserted in the anus until your partner puts on a new condom. Use plenty of lubricant to reduce the risk of tissue tears. With latex condoms, always use a water-based lubricant. Relax prior to insertion of the penis to help reduce the risk of tears. Taking a warm bath before anal sex or lying on your stomach may make insertion easier. Stop if anal sex is painful. If you experience bleeding after anal sex or you notice a sores or lumps around the anus or a discharge coming from it, see your doctor as soon as possible.