JOURNAL OF SEX RESEARCH, 47(2–3), 123–136, 2010

Copyright # The Society for the Scientific Study of Sexuality
ISSN: 0022-4499 print=1559-8519 online
DOI: 10.1080/00224490903402538

Heterosexual Anal Sexuality and Anal Sex Behaviors: A Review
Kimberly R. McBride
Department of Psychological and Brain Sciences, Indiana University; and
The Academic Edge, Inc.

J. Dennis Fortenberry
Department of Pediatrics, Section of Adolescent Medicine,
Indiana University School of Medicine
Little research addresses the role of anal sexuality and anal sexual behaviors as a widely
practiced but relatively less frequent element of a heterosexual sexual repertoire. However,
the importance of anal sex in sexual health is increasingly well-defined by epidemiological
and clinical studies. This article reviews existing data on a range of heterosexual anal sex
practices and provides conceptual and methodological recommendations for new research.

Heterosexual anal intercourse is associated with
increased risk for HIV and other genital and anal
sexually transmitted infections (STIs; Buchacz, van der
Straten, Saul, Shiboski et al., 2001; Halperin, 1999).
Increasing rates of anal cancer may be attributable to
more prevalent practice of anal intercourse and to the high
prevalence of human papillomavirus (HPV) infection
(Eng, 2006; Scott, Khoury, Moore, & Weissman, 2008).
However, most research on anal intercourse addresses
men who have sex with men (MSM), with relatively little
attention given to anal intercourse and other anal sexual
behaviors between heterosexual partners (Halperin,
1999). Heterosexual penile–anal intercourse has been treated as analogous to coitus in most published research.
Research is quite rare that specifically differentiates the
anus as a sexual organ or addresses anal sexual function
or dysfunction as legitimate topics. As a result, we do
not know the extent to which anal intercourse differs
qualitatively from coitus. The purpose of this article is to
review literature in four primary areas of heterosexual
anal sex research—history and culture, prevalence and
frequency, public health and sexual health issues, and
behavioral antecedents and correlates—and to provide
recommendations for future research.

Terminology
The terms anal sex and anal intercourse are typically
used synonymously to refer to a dyadic sex act involving
Correspondence should be addressed to Kimberly R. McBride,
Department of Psychological and Brain Sciences, Indiana University,
1101 E. 10th St., Bloomington, IN 47405. E-mail: kmcbride@indiana.
edu

insertion and thrusting of one partner’s penis in the anus
of the other (Merriam-Webster Dictionary Online,
2009). The term sodomy sometimes indicates anal intercourse in historical, journalistic, and legal settings, but
will not be used here. The Internet site Sex-Lexis.com
(2009) lists more than 200 slang terms for anal intercourse, although many refer to same-sex rather than
opposite-sex behavior. In this article, anal sex is used
to encompass anal intercourse, as well as other anal sexual behaviors, such as oral–anal contact (analingus) and
penetration by fingers or other objects. The term anal
intercourse refers specifically to penile–anal intercourse.

Historical Overview and Shifting Cultural Norms
Historical Overview
Depictions of heterosexual anal sex can be found in
art and artifacts dating to antiquity (Reinisch, ZiembaDavis, & Sanders, 1990). Peruvian Moche stirrup-spout
pots, erotic ceramic vases, from 300 AD may be some of
the earliest and most prolific examples of such representations (see Figure 1). A survey of Moche pots found
that 31% depicted heterosexual anal intercourse, significantly more than any other sexual act (Tannahill, 1992).
Chinese and Japanese shunga, woodblock prints and
painted handscrolls, produced between the 16th and
19th centuries, depict a vast array of sexual practices,
including heterosexual anal sex. Erotic French lithography and photography from the late 19th and early 20th
centuries include both images of penile–anal intercourse,
as well as digital–anal penetration. Erotica from the
same period has described heterosexual anal sex acts.
Today, images of heterosexual anal sex are so highly

definitive written documentation no longer exists. 2006). Image courtesy of the Kinsey Institute for Research in Sex.’’ published in New York Magazine. the character. Texas. Martin. providing further evidence of public interest.MCBRIDE AND FORTENBERRY Figure 1. anti-sodomy laws have been used to punish same-sex sexual behaviors. Men’s Style. sexual liberties. there seems to be a shift in the focus of content. Virginity literature has found ‘‘gifting’’ to be a primary theme in . and sexual expressions. anti-sodomy laws can be traced to the colonial period and were still enforced in several states until 2003 when the U. Despite continued cultural stigma. Shifting Cultural Norms Heterosexual anal sex has been present in the spectrum of erotic imagination and behavior for 124 hundreds. & Gebhard. Supreme Court ruled such laws unconstitutional (see Lawrence v. The sexual use of the term sodomy as a synonym for anal intercourse among homosexual men is attributed to the Byzantine emperor Justinian I (538 AD). ‘‘100% vaginal. Rather. however. combined with scientific documentation of increased behavioral prevalence. Note.’’ and ‘‘double penetration’’). and books. Example of a Peruvian Moche stirrup-spout pot. the proliferation of materials and references in popular culture. the behavior received only brief mention (e. when her boyfriend asked her to engage in anal sex. Gender. hereticism was increasingly associated with fornication and sodomy. A recent Internet search (conducted by us) of the term ‘‘heterosexual anal sex’’ yielded 790.S. Historians have traced earlier bans to 149 BC. 1998) detailed the dilemma of the character. if not thousands. sodomy and its biblical proscription have influenced the meaning and acceptability of anal intercourse behavior in Western culture. The term sodomy is broadly defined as anal penetration or oral copulation with a member of the opposite or same sex. In terms of theorizing heterosexual anal sexuality and behavior. feature interviews with men and women who practice anal sex (EM & LO. 2003). Pomeroy.’’ another behavior that was once stigmatized but is now accepted as highly prevalent.’’ ‘‘100% anal. Although there has been no systematic study of public interest or opinion of heterosexual anal sex.’’ published in Men’s Style. Charlotte. Since these times. references can be found in almost all forms of popular media. Historically. Scientific data documenting a rise in behavioral prevalence has prompted some news media to suggest that anal sex is the ‘‘new oral sex. A review of the first 500 sites indicated that some sites depict pornographic and erotic images or chats. Kinsey. is the surprised recipient of the ‘‘stinky pinky’’ when his wife inserts her finger into his anus.’’ ‘‘no anal. anecdotal evidence suggests that attention to heterosexual anal sex in the popular culture has risen over the past decade. including Tristan Taormino’s best-selling book The Ultimate Guide to Anal Sex for Women (Taormino. In the United States. 2007). songs. 2007). 1953) in the scientific literature until the emergence of HIV and AIDS in the 1980s.g. and Reproduction.000 links to media articles and Web sites. thus linking the behaviors to witchcraft and satanism. Laws banning acts of sodomy can be traced to documents written between 500 and 600 AD. Changing norms may affect the frequency of heterosexual anal sex behaviors and suggests that there is a role for the ‘‘exotic’’ in the sexual repertoires of some heterosexuals. For example. of years. Shifting norms have several implications for understanding heterosexual sexual relations. whereas articles published within the past five years focused on laws. and ‘‘Is Anal Sex the New Deal Breaker.. 2009). but many report scientific findings or provide information about anal sexual health. including magazines. A number of ‘‘how-to’’ guides have been published. the role of the ‘‘exotic’’ may be important. Magazine articles such as ‘‘The Bottom Line. including sexual problems and what constitutes ‘‘safer’’ sex or responsible sex. prevalent in pornographic films and Web sites that the sites advertise material based on whether it includes anal sex (e. Perhaps due to the cultural and legal sanctions associated with anal sex.g. In addition to the apparent rise in media interest. or with an animal (Merriam-Webster Dictionary Online. movies. 2007. Charlie. A search of newspaper articles and newswire press releases (also conducted by us) for the past two decades indicated that early coverage (1986– 1996) of anal sex focused on risk for HIV and AIDS. may together suggest shifting cultural norms. Attention to heterosexual anal sex has not been limited to the news media. In the pilot episode of the television program Californication (McMartin & Freundlich. particularly anal sex among men. an episode of the television program Sex and the City titled ‘‘Valley of the TwentySomething Guys’’ (King & Maclean.. television programs. During the Medieval Inquisition (1184).

4% of women reported lifetime heterosexual anal intercourse (Mosher. 2000. a 1992 survey had found that 25.to 24-year-olds and peaked among 30. Shifting norms may also have implications for the reification of gendered sexual norms. 1995.2%. propensity for sensation-seeking) is unknown. Bogart et al. 1994). but no vaginal intercourse. and participation in other risk behaviors (e. Characteristics of heterosexual men and women who engage in anal intercourse include younger age. 2000). Michael.. through substance-related disinhibition) or distal (e. such as the male as the penetrator and the female as the penetrated. Hill. with 2. Meyer. The percentage of participants reporting heterosexual anal sex was significantly higher among 20. Houston. 1995). These changes were seen regardless of gender or study site and were consistent across racial and ethnic groups. Husman.. cohabitation. 2005.HETEROSEXUAL ANAL SEXUALITY experiences of virginity loss (Carpenter. 2000. Gorbach et al. 1991). reporting heterosexual anal intercourse during their most recent sexual event (Laumann et al.6% of women aged 18 to 44 had engaged in heterosexual anal intercourse in their lifetime. Gifting may influence some acts of heterosexual anal intercourse and deserves further investigation. respectively. Reinisch. Gurman & Borzekowski. although observed rates of anal intercourse have been found to be higher within the contexts of serious or long-term relationships. 2002).g. A study of sexually active women in California found that of the respondents who reported 125 ... Wilson et al. & Aral (2007) found that 34% men and 30% women (N ¼ 12. injection drug use.. Gagnon. & Wechsberg.. 1991. Based on an extensive review of the research. 2005). 2000. 1994. Further. Laumann et al. history of STIs (Bogart et al. 1994). Laumann. Reinisch & Hill. 1995. Chandra. Both men and women with a history of same-sex partners are more likely to report anal intercourse (Foxman. Demographic and behavioral characteristics. Lewis & Watters. Laumann et al.. Lewis & Watters. Fang.. 2000. Fenton.. In Project RESPECT. 2007. increasing from 9% to 22% among women and 9% to 21% among men (Satterwhite et al. Costenbader. Using data from the National Survey of Family Growth. anal intercourse occurs among more women annually than among MSM—four million versus one million. 1992). little is known about the characteristics of lower risk populations. Chandra. Recent studies have reported higher prevalence rates of heterosexual anal intercourse... Sanders. Misegades. 2009. Zule. Gorbach et al. Most of the data about heterosexual anal intercourse is based on research conducted in samples with behavioral and demographic characteristics (e. Ethnic and racial group differences in rates of anal intercourse are inconsistent. & Jones. Reinisch.. 2005. 2001... unprotected intercourse. Page-Shafer... & Holmes. the proportion of participants reporting anal intercourse in the previous three months was two times higher in RESPECT II (1999–2000) than in Project RESPECT (1993–1995).545) published in 1995 found 8% of men and 6% of women reported engaging in heterosexual anal intercourse at least monthly throughout the previous year (Erickson et al. & Ziemba-Davis. & McFarland. and sex in exchange for money. 1998b).g. & Peralta.g. Studies exploring prevalence by gender report that women participate in anal intercourse at roughly equal or slighter higher rates than men (Baldwin & Baldwin.6% of men and 20. & Michaels.. respectively. (2008) found that the use of sex toys was associated with anal intercourse in men and women. 1995. higher number of lifetime sex partners. Halperin.. injection drug use or offering sex in exchange for money) that place them at relatively high risk for HIV and STI transmission. & Hill. Prevalence and Frequency Prevalence Estimates of lifetime prevalence of anal intercourse range from 6% to 40%. 547) reported ever participating in heterosexual anal sex. Halperin (1999) pointed out that even if this estimate is inflated twofold. with up to 10% of heterosexuals reporting at least one instance in the previous year (Baldwin & Baldwin. Erickson et al. 1995). 1994). A population-based study (n ¼ 3. Leichliter. 2007). which may suggest heterosexual anal sex becomes part of the sexual repertoire as individuals age... Erickson et al. within the past six months. suggesting an historical increase in reporting rather than a cohort effect. A large scale survey found that 38. 1999. The National Health and Social Life Survey (NHSLS) has been a frequently cited source of prevalence data for anal intercourse (Laumann et al. Liddon. A study assessing the prevalence of anal intercourse among HIV-seronegative women at high risk for HIV exposure (n ¼ 1. 1998a. 1995. Moreover.. 1994).to 34-year-olds. Gross et al. The NHSLS found a past 12 months prevalence rate of 10% among men and 9% among women. Voeller (1991) estimated that at least 10% of sexually active American women engage in receptive anal intercourse with some regularity. The extent to which the association of heterosexual anal sex among these populations is causal (e. 2004.g. and marriage when compared to casual partnerships (Erickson et al. Gross et al.2% of men between the ages of 20 and 39 and 32.268) found that 32% of participants reported at least one instance of anal intercourse within the preceding six months (Gross et al. although Hispanic men and White women have generally been found to report the highest rates (Erickson et al.3% and 1. 2007). the increase in reports of anal intercourse also occurred across age groups. 1995. Aral. One percent of the sample (n ¼ 17) reported anal intercourse.

However. Misegades et al. two or more partners.. and many have dichotomized response options. 2001). Voeller suggested that such reticence is to be expected with certain behaviors and that this reticence may have played some role in HIV and AIDS studies that have failed to identify anal sexuality in participants. Adler. 2004. Few studies have explored the reasons for lower condom use during anal versus vaginal intercourse.. Herbenick. To what extent underreporting has influenced the accuracy of estimations of incidence and prevalence of anal sex among heterosexuals is speculative. Houston et al. higher frequencies of anal intercourse were found among participants with main partners (about once per week) compared to those with casual partners (about once per month. Watters. Among adolescents. Among intravenous drug users. stating patients initially denied engaging in anal intercourse and only acknowledged and discussed this aspect of their sexuality at the second or third interview. Futterman. 1995). 12%. they do little to further our understanding of the factors associated with specific events. Further. & Tschann. 1990. & Shaffer. Wilson et al. 1994). A study of 2.. Although the small sample size limits the ability to make inferences. A study that investigated the underreporting of sensitive behaviors. with rates being lower for anal intercourse among both men and women.6% of women with a steady partner and 7. 2007). typically ‘‘yes’’ or ‘‘no. such as those used in the NHSLS survey (Laumann et al. Consistent condom use for anal intercourse was associated with having consistent condom use for vaginal intercourse. Lewis. Further. in the past year). McBride and Janssen (2007) found that the majority of men (n ¼ 631) and women (n ¼ 856) who reported heterosexual anal intercourse in the past 12 months were in exclusive. it has been suggested that measurement techniques. 2005. Findings suggested significant differences in condom use. whereas 63% never used condoms. Leichliter et al. Voeller (1991) commented on the Bolling (1977) study. Dell. 27. 2000.g. aged 12 to 18 years. 2007). Despite what is known about anal sex. The majority of studies that have measured it have used lifetime items or items assessing a specified period of time (e. Public Health and Sexual Health Issues Condom Use Condom use for anal intercourse among heterosexuals is typically low. 1999). have resulted in additional underestimations of prevalence (Halperin. respectively. Civic. condom non-usage rates for anal intercourse are 70% or higher (Bogart et al.357 heterosexuals found that for anal intercourse in the past three months. & Case. Recent data from 350 adolescents. 1995... found that participants (n ¼ 63) were more willing to admit to having an abortion than to engaging in anal intercourse (Smith. Methodological problems make estimating actual condom use for heterosexual anal intercourse problematic because the majority of studies investigating condom use fail to distinguish between vaginal and anal sex. 2008).. Hein et al. with less use for anal intercourse than for vaginal intercourse (Baldwin & Baldwin. 29.MCBRIDE AND FORTENBERRY ever having had anal intercourse. Data from a sample of 266 men who reported heterosexual anal intercourse within the past 30 days found a mean of 4.. Houston et al.. However.3% of women with a casual partner had engaged in anal intercourse within the previous two months (Misegades et al. showed that prevalence rates of anal intercourse among individuals with a main partner and those with casual partners were similar (16% vs.. with a particular interest in abortion. 1989. respectively).’’ As a result. Although prevalence rates document the occurrence of anal sex in 126 heterosexual populations. & Robbins. 1999). Sanders. Specifically. the findings suggest that anal sexual behaviors are underreported.. sample sizes have often not been large enough to conduct statistical analyses that specifically focus on anal intercourse in heterosexual men and women. is an underestimation.’’ The few studies that have attempted to elicit more accurate responses have reported considerably higher rates of prevalence (Erickson et al. Holm. 2000. condom use rates for anal intercourse between 0% and 47% are reported (Catania et al.6 (Mdn ¼ 2) occurrences (McBride & Reece. Gurman & Borzekowski. Reece. Because behavioral frequency can have significant implications for understanding the importance of anal sex in sexual health. Hein. and anal intercourse with a casual or new partner (Tian et al. Frequency The frequency of heterosexual anal intercourse is poorly documented. McBride. such as anal intercourse.. Ehde. 2008. McBride and Janssen (2007) found that relationship . but much less information relates to behavioral frequency. a large body of literature documents the prevalence of heterosexual anal sex.. McBride and Janssen (2007) explored the relationship between condom use for vaginal intercourse versus anal intercourse in a sample of heterosexuals who reported both behaviors..3% of participants consistently used condoms. 2007. 1995. 2008). the NHSLS survey asked participants to respond solely in regards to one’s ‘‘regular or secondary partner. 1999). 2001). Underreporting taboo behaviors. according to Halperin (1999) it must be assumed that self-reported data for historically taboo sex practices. & Fortenberry. 1995. assessing its actual incidence will be important to identifying subpopulations that may be at increased risk of negative health outcomes. monogamous relationships: 69% and 73%. RotheramBorus.

(2008) suggest that anal sexual contact occurs in the absence of anal intercourse. manual–anal sex. manual penetration. 24% (n ¼ 63) had put their mouth on their partner’s anus. 2007) calling for attention to behaviors beyond anal intercourse such as oral–anal.. although prevalence rates of such behaviors are lower in those without penile–anal intercourse experience. Silverman & Gross. manual stimulation. (1995) found that among married respondents who reported engaging in anal intercourse.00 2. and oral–anal contact. or anal sex toy use. Anal Sexual Behaviors in the Past 30 Days by Lifetime History of Insertive Heterosexual Penile–Anal Sex (N ¼ 1. Although not addressing anal intercourse specifically. McBride. 10% reported inserting a finger into their partner’s anus. A recent study investigated the prevalence of heterosexual anal sex behaviors in a sample of heterosexual men (n ¼ 1. Further.00 3. & Crosby. Graham.60 6. among college students. 53% reported that they had inserted a finger into a female partner’s anus within the past 30 days. Thompson. Further. Mean Number of Times the Behavior was Performed in Past 30 Days by Lifetime History of Insertive Heterosexual Anal Sex (N ¼ 1.56 6. 2000). 1989.HETEROSEXUAL ANAL SEXUALITY status and number of sexual partners significantly predicted condom use among men. ‘‘I just knew my partner was safe’’ (Civic.99 5. However. Potential mechanisms of increased HIV and STI risk.00 2.. 2008). Yager. These findings suggest that heterosexual anal sexual contact is not limited to penile–anal intercourse. 1999). the most commonly endorsed reason for condom non-use during anal intercourse was.00 2. Non-intercourse anal sexual behaviors.299) and women (n ¼ 1.478) Yes (n ¼ 266) Variable Anal insertive intercourse Inserted finger in partner’s anus Received finger in anus Placed mouth on partner’s anus Received mouth on anus No (n ¼ 1.919) with anal intercourse experience and found that 51% of men and 43% of women had participated in at least one act of oral–anal sex. The second-most commonly endorsed reason was related to pregnancy: ‘‘We didn’t need to use a condom because pregnancy was not an issue. condom use was more likely to occur for anal intercourse with a casual partner (47%) versus a main partner (21%).90 5. 50% of women and 45% of men did not use condoms because they felt they were at ‘‘no risk’’ for a sexually transmitted disease.75 3.29 Mdn — 2. However. Among the men with insertive anal intercourse experience (n ¼ 266). 2008. Studies assessing condom use errors have implications for STI risk associated with anal intercourse.00 4. The paper stated that the failure to consider non-intercourse anal sex behaviors may result in inaccurate estimates of sexual health risk.478). These findings suggest that because anal intercourse alone does not result in pregnancy. The American Association of Sexuality Educators. Similarly. McBride et al.212) M Mdn M 4.00 3. men with no insertive anal intercourse experience reported lower rates of anal sex behaviors. 2007). which may serve as a further disincentive to use (Grady & Tanfer. and Therapists published a position paper in Contemporary Sexuality (Melby.52 2. a study utilizing a convenience sample of 260 undergraduates found that 83% did not use a new condom when switching between vaginal and anal sexual behaviors (Yarber. the mechanisms by which anal intercourse increases risk—to the extent these are Table 2.75 4. In comparison.’’ A recent study found that. condom breakage. and discomfort occur more commonly during anal intercourse than vaginal intercourse. Anal intercourse was significantly more likely to be used as a method of contraception by adolescents in casual partnerships when compared to those with main partners (Houston et al. whereas only relationship status was found to be a significant predictor for women.62 3. Heterosexual anal intercourse is a risk factor for both HIV-seroconversion and STI transmission (Halperin. & Martin. there is not a need to use contraception. such behaviors may have significant implications for the risk of STI transmission and other aspects of sexual health. In this group (N ¼ 1. findings by McBride et al.00 5. 2004).00 127 . Counselors. This perceived safety may serve as a disincentive for condom use despite the potential for STI exposure and transmission. Further. Reiss & Leik. 1997.212) n % n % n ¼ 266 n ¼ 151 n ¼ 63 n ¼ 63 n ¼ 40 18 53 24 24 15 — n ¼ 125 n ¼ 35 n ¼ 49 n ¼ 23 10 3 4 2 a mouth on their anus. whereas other behaviors were reported at rates ranging from 2% to 4% (see Tables 1 and 2). Erickson et al. and sex toys for anal sex.50 3. 24% (n ¼ 63) had received a finger in their anus.478) Yes (n ¼ 266) Variable Anal insertive intercourse Inserted finger in partner’s anus Received finger in anus Placed mouth on partner’s anus Received mouth on anus No (n ¼ 1. and 15% (n ¼ 40) had received Table 1.212). in a sample of adolescents. Sanders. distinguishing between men with insertive anal intercourse experience and those without (McBride & Reece. Data are scarce on non-intercourse anal sex behaviors such as digital-penetration. slippage. and Hill (2009) investigated the prevalence of non-intercourse anal sex behaviors among a sample of men (n ¼ 1. 1993). 1994. Sanders. Other studies have identified themes associated with the perceived risks of STI and HIV infection and pregnancy as being associated with condom use.

Branson.000). 2002). anal HPV has been associated with a higher lifetime number of female sexual partners and a higher frequency of sex with female partners in the past month (Nyitray et al. roughly two to three cases per 100. as the study was conducted using a sample of rats. or associated with non-intercourse anal sexual behaviors (Moscicki et al. Skurnick et al. Like cervical cancers.. Williams et al. Naftalin (1992) proposed that human semen contains at least two different components which facilitate the degeneration of the membrane that supports the colonic epithelial cell layer. 2004. In the anus. 2008). 2008). Factors associated with variability in rectal HIV shedding are not well-established. Abrasions to the penile skin may also occur during anal intercourse. 2005. Winer et al. 2007).. 1992.. anal intercourse and HIV transmission were conducted in samples of MSM. In the cervix. Most genital HPV infections are clinically inapparent. & Shrag... Palefsky and Rubin (2009) reported that there is biologic similarity between the cervix and the anus with respect to cells infected by HPV.. anal cancers are associated with HPV infection (Joseph et al. Hernandez et al. and increased presence of types of cells directly infected by specific organisms (Naftalin. 2001. & Steketee. 2008. 128 Studies of the prevalence of anal HPV in men have primarily focused on samples of HIV-positive men and MSM. increased rectal viral shedding among infected women would also account for increased female-to-male transmission risk. Anal cancer in the general population is still relatively rare (i.. Recent findings from a study of 222 heterosexual men. although anal intercourse is . whereas the prevalence of cervical cancers in women has declined. Maher. Although penile cancers are associated with HPV. In some samples of women. Palefsky et al. increasing the possibility of HPV infection should the partner be infected. HIV. with increased risk among those who are infected with HIV (Bower et al. Palefsky et al. inflammatory responses to cleansers. or semen. HPV appears to preferentially infect squamous epithelium of the anus at the junction of columnar epithelium of the rectum (Palesfsky & Rubin. Johnson et al. Longitudinal findings suggest that anal HPV infections in healthy women resolve quickly. basal squamous epithelial cells in order to cause infection. Palefsky et al. compared to vaginal sex (Varghese... Ranjan.. and are usually resolved by the immune system. 2004. HPV preferentially infects squamous epithelial cells on the exocervix at the junction with columnar epithelium of the endocervical canal. & Mehta. 2003). Three general types of increased risk have been suggested to be associated with anal intercourse: trauma to the anus and rectum associated with penile insertion and thrusting. no studies document the frequency or extent of local trauma associated with anal sex. 2004) but not all (Tseng.. who reported no lifetime same-sex experience.. The most likely explanation for increased susceptibility to male-to-female HIV transmission associated with anal intercourse has to do with the denser population of Chemokine (C-C motif) receptor 5 (CCR5)-bearing immune cells in the rectal mucosa. Mack. Receptive anal intercourse is associated with increased risk of anal cancer among women in some studies (Daling et al. A study of men with HPV-infected female partners found that 76% were HPV DNA positive (Nicolau et al. & Peters. However.... 2001). Stier. Morgenstern. especially among infected women (Zuckerman et al. compared to other tissues (Grivel et al. 2009). Krown. Presumably. Tabet et al. found an overall anal HPV prevalence rate of 24. 2009).MCBRIDE AND FORTENBERRY understood—likely differ by organism (and tropism for specific tissue types) and whether transmission is male-to-female or female-to-male. They suggested that the HPV target area is where there is transition between two types of epithelium.. Moscicki et al. 2005. 1999...e. HPVs and anal cancers.. These basal cells are typically covered by several layers of non-nucleated squamous cells. are limited. This difference may help account for the increased incidence of anal cancers in women. we find no data that directly links anal intercourse to increased risk of HPV-associated penile cancer. Chiao. 2003.8% (Nyitray et al. it has been found that the prevalence of anal HPV is actually higher than the prevalence of cervical HPV infection (Melbye et al. The prevalence of anal cancers in heterosexual men and women has risen steadily over the past four decades. Scott et al. 1994). 1999). Anal epithelia could be especially susceptible if inadequate lubrication were associated with anal intercourse (or penetration by other objects). 1992. 1998). Abrasion of the superficial squamous epithelial cells during intercourse is thought to allow access of HPV to its target cells. however.. in men. 1996. 2004.. The per-act risk of HIV transmission is estimated to be five times higher for receptive anal intercourse and 1. and none have attempted to demonstrate reduction in local trauma associated with lubricant use. HPV requires direct access to nucleated... Clearance rates of anal HPV may differ when compared to vaginal clearance rates (Shvetsov et al. 2001. 2008). For example. Unprotected anal intercourse is a key risk factor associated with heterosexual HIV transmission (European Study Group. It is important to note that in all of these studies.3 times higher for insertive anal intercourse. 2007). leading to heightened risk for HIV and STI transmission. 2003). HPVrelated cancers likely occur in the absence of reported anal intercourse because of underreporting or because of virus contained in vaginal discharge. lubricants. Peterman. 2005). Sharma. The inferences from these findings.

receptive anal intercourse before vaginal intercourse is independently associated with the acquisition of bacterial vaginosis (Cherpes. Schreeder et al. 1997). Fortenberry. For example. . Early stages of anal cancer can be identified by Papanicolaou cytology. Anal bleaching is a procedure that lightens the dark skin around the anus. and other STIs.. 2008. Perdue. & Ayers.. and Orr (2008) published results from a daily diary study of sexual behavior in adolescent women. at least among MSM. Commercially available water-based lubricants typically contain glycerin or propylene glycol. and anal intercourse in the previous 129 . herpes. although many women use saliva. tetracaine.. 2007).. 1982). These issues are relevant because most studies of anal sex and vaginal microflora changes are associational. The active agents can include lidocaine. The extent to which these products may have negative sexual health consequences is unknown.. 2007. warning against potential health hazards associated with use.. Behavioral Antecedents and Correlates There has been virtually no systematic investigation of the individual and interpersonal factors that motivate behavioral occurrence and frequency of heterosexual anal sex. The U.HETEROSEXUAL ANAL SEXUALITY among the non-viral factors found to delay clearance (Shvetsov et al. greater negative mood. What is currently known is primarily based on retrospective studies. mycoplasma genitalium. 2008). research suggests that alcohol and other substance use is associated with anal intercourse experience. Some commercially available lubricants cause vaginal irrita- tion. However. Lubricants and other products. Fuchs et al. Kim et al. analogous to screening for cervical cancer. Fuchs et al. & Krohn. Hensel. 2006. Bogart et al.g. However. using a cream that contains up to 20% hydroquinone. McPeak. A number of studies link anal intercourse to changes in vaginal microflora and reproductive tract infections.. desensitizing cream or anal douches). Astatke. For example. careful study of use with anal intercourse is important (Buck et al. Food and Drug Administration issued an advisory in February 2007. Men who used anal enemas were 7. Odaka. . Silicone-based lubricants typically do not contain preservatives and are also compatible with latex (but not with silicone sex toys). the lack of event-level data makes it impossible to determine if alcohol or substances were used at the time that anal sex occurred. 2005. Koutsky.. higher sexual interest. Busch.. 2003). keeping it attractive. Although unstudied among heterosexuals. Sharma et al.S.. .. Smith. 2004). & Corey. Gross et al. 2001. and genital herpes [HSV–2]) and anal intercourse experience. which can increase the likelihood of STI transmission (Newton. Meyn.g. 2000.. 2009. Koziol. 2004). suggesting potential for more severe damage to the potentially more fragile rectal epithelia (Adriaens & Remon. and bleach the area to lighten it up. benzocaine. 1993. As development of vaginal microbicides proceeds. & Peairs. (2009) reported finding no relationship between vaginal and urethral STI (chlamydia trachomatis. The mechanisms by which anal intercourse influences vaginal microflora are unclear because overlap in the two microbial communities is substantial (Van der Pol et al. . Baldwin & Baldwin. Topical desensitizing creams are used to make anal sex more comfortable by numbing the anus (Hilton. or lubricated condoms (or use no lubrication at all) for anal intercourse (Exner et al. Gorbach et al.. rectal douching and enema use may increase HIV and STI risk among MSM (Coates et al. maintaining a good-looking booty’’ (Exner et al. Hydroquinone is a suspected carcinogen and banned in several counties. Saah. neisseria gonorrhoeae. 1988. chlamydia. you know. & Munoz. trichomonas vaginalis. Longfield. alcohol use. Ashley. including event-level data on heterosexual anal intercourse. 2008). 2009). . no data document reduction in anal cancer rates or improvement in survival associated with such screening. no coitus in the previous week. 2007)... Screening studies where both genital and anal or rectal specimens are obtained show that anal intercourse is an STI risk factor. All of these products are compatible with latex condoms. Gonorrhea. Piper. as preservatives... Many studies have reported higher STI rates among heterosexuals with anal intercourse experience when compared to those without (Auslander et al. on the glans or beneath the foreskin) has not been assessed. but only for men (Nelson et al. 2008). A variety of sexual lubricants is commercially available. A participant in a recent qualitative investigation of rectal microbicide use discussed the practice of anal bleaching as associated with preparation for anal intercourse. The influence of these products on HIV and STI transmission is not extensively studied. findings from other studies found no such association. Sudol & Phillips. Hillier. lifetime history of anal intercourse was associated in univariate (but not multivariate) analyses with herpes simplex virus–Type 2 (HSV–2) seropositivity (Wald. . however.8 times more likely to develop proctitis associated with lymphogranuloma venereum stains of chlamydia trachomatis (De Vries et al. Carriage of typically ano-rectal organisms on the penis (e. and prilocaine—all of which may pose health risks when absorbed systemically. as well as one or more parabens. Petroleum-based lubricants continue to be in relatively common use. including the United Kingdom.. For example. 2007). 2008). The procedure is done solely for cosmetic purposes. Few studies address potential adverse effects of other products associated with anal sex (e. ‘‘. 2007. Shain. . 2009). vaginal fluids. So there is really a lot that goes into it . stating. 2000. The results indicated that days with both anal intercourse and vaginal intercourse were associated with younger age.

including intimacy–trust–gifting. except in passing mention (Bancroft. . Yarber. 1999). Wosnitzer & Bridges. & Kanouse. no coitus in the past week. . . 2008). who identified as virgins. The coupling of prevalent heterosexual anal sex images in pornography and erotica and the rise in behavioral prevalence has led to the suggestion that pornography may be influencing the actual incidence of anal sex. a qualitative analysis of the articles ‘‘The Bottom Line. In addition. 1996). anal sex is very . It is known that anal intercourse occurs less frequently than vaginal intercourse.’’ Few published studies explore virginity as a motivating factor for anal sex. Much of the initial interest in understanding the relationship between heterosexual anal intercourse and virginity was sparked by findings from a study conducted by Sanders and Reinisch (1999). Six broad categories were identified. such as abstinence-based sexuality education and the proliferation of anal sex images of heterosexual couples in pornography. (EM & LO. McBride in September 2007. & Wilson. Intimacy–trust–gifting: ‘‘For me. although monogamous partners may eventually change or extra-relational partners may affect risk. but also to anal sexuality. 2006). At best. these findings suggest that ‘‘virginity’’ may play a role in the occurrence of anal intercourse among adolescents. 19% of respondents did not consider anal intercourse to be sex (Sanders & Reinisch.. found that 1% of the sample had engaged in heterosexual anal intercourse during the previous year (Schuster. to date. there has been speculation about the extent to which social and cultural factors.026) in Grades 9 through 12. Sayad. anal sex may be a part of their sexuality.’’ (Male respondent) Taboo–forbidden–erotic: ‘‘.’’ (Male respondent) Control–domination: ‘‘For most of my friends. The researchers found that among a sample of 589 college students. was conducted by Kimberly R. intimate. vaginal intercourse). Pornography and erotica. a focus group study that evaluated the language and meaning that abstinenceonly-until-marriage program participants (8–17 years old) assigned to the term abstinence found that anal intercourse was only mentioned in one focus group of six that were conducted (Goodson. chat room messages on a number of other sites were reviewed. It is also known that heterosexual anal intercourse is often reported to occur within the context of a committed. 2003). monogamous partnership. novelty–variety. an individual who engages in anal intercourse but abstains from vaginal sex may still label herself a ‘‘virgin. a blog that related to the Men’s Style article was reviewed. and relationship status–context. and those found to be recurrent were organized into conceptual categories. 2009. & De Vault. Although the significance of the role of virginity as it relates to heterosexual anal intercourse activities cannot be established based on three studies. The influence of pornography on sexual behaviors is documented in adolescents and adults. Days that consisted of anal intercourse only were associated with vaginal bleeding. These findings suggest that event-level contextual factors may influence the occurrence of heterosexual anal intercourse. however. pain–pleasure. much more so than regular sex. 2007). and is associated with other behavioral risk characteristics. 2007. .MCBRIDE AND FORTENBERRY week. Hyde & Delamater. Vega & Malamuth. Because much of the research.’’ published in Men’s Style (Men’s Style. . We could not find any evidence to support or refute the possibility.. but all had discussions of anal sexual behaviors—typically. taboo–forbidden–erotic. An apparently prevalent assumption (with associated social and legal proscriptions) is that penile–vaginal intercourse is ‘‘normal’’ heterosexual sexuality. three widely cited human sexuality texts give no specific 130 attention to heterosexual anal sex. No new themes arose. Strong. little consideration has been given not only to anal sexual pleasure. For example. control–domination. More recently. Bell. have contributed to the recent rise in behavioral prevalence. intercourse. heterosexual anal sexual behaviors are treated as marginal corollaries to coitus. Sites were diverse in content and audience. Researchers have often overlooked the latter because the risk for infection is low. For these individuals and couples. Within the context of a relationship. particularly its effects on aggression and risk taking (Brown & L’Engle. is associated with low levels of condom use. 2007). To confirm themes. a study of urban high school students (N ¼ 2. and days with anal intercourse and coitus in the previous week. Anal sexuality. it’s sort of a domination thing. has been conducted within an infection risk paradigm.’’ published in New York Magazine. Thus.e. 2008. 2007) and ‘‘Is Anal Sex the New Deal Breaker. Examples of quotations supporting each category are as follows: . To better understand feelings toward heterosexual anal sex and the individual meanings ascribed to the behavior.’’ (Female respondent) Novelty–variety: ‘‘Variety is sexy. it is likely that some heterosexuals incorporate anal sexual behaviors into their sexual repertoires on a regular basis (McBride et al. Suther.’’ (Female respondent) Pain–pleasure: ‘‘I think it can feel good for anyone—except if you’re too uptight about it. Pruitt. On a broader level. 2009. . Virginity. but the meanings associated with it might be distinct from those attached to other forms of sexual behavior within the repertoire (i. and breaking taboos is sexy. Quotations from individuals who were interviewed for the articles or who posted comments on the blog were analyzed for themes.

Sociocultural scripts for sexual behavior may contribute to such findings. studies have assessed risk by measuring condom use and other behavioral risk factors. these studies suggest that women’s ratings of pleasure are lower than men’s. the quotations suggest that for a certain number of heterosexuals. it is clear that we are faced with an ‘‘information gap. & Nachimson. none has clearly related experiences of pleasure to behavioral motivation. will be important to understanding anal sexuality. Although prevalence rates of anal intercourse are roughly the same by sex. The extent to which coercion or violence play a role in some acts of anal sex must be considered. most of the advice was consistent with that of professional sexual health educators and therapists. perhaps even provocative. Bogart. we know next to nothing about people’s feelings toward anal pleasure. Gilbert. A study that investigated the prevalence and correlates of anal sex among young. 2009. A study that explored young women’s motivations for engaging in anal intercourse found that 58% of the women in their sample who had engaged in anal intercourse reported doing so at the request of their male partner (Flannery et al. with heterosexual men rating anal intercourse significantly more pleasurable than women (Pinkerton. Jack Morin. Cherry. as well as the meanings individuals attach to these behaviors. A number of messages discussed aspects of preparation and gave advice—typically. one study found that 47% of their all-female sample reported anal intercourse experience. it is difficult to determine whether intercourse was unwanted or coercive. 2003). suggesting that pleasure may be a behavioral motivation for some women who engage in anal activities. especially in studies of Americans.’’ For example.’’ Remarkably. Relationship status–context: ‘‘I first did it with my husband. Although this information is interesting. A small number of studies have briefly commented on sexual pleasure as one aspect of anal sex.g. Dominant sexual scripts are phallocentric and value ‘‘insertive’’ sexual behavior over 131 . wrote: This brief overview represents virtually all that is known about anal sexuality in the United States. Sexual pleasure.’’ (Female respondent) Although not generalizable. 2001). An earlier study of gender differences in college students’ attitudes toward sexual behaviors found that men had significantly more positive attitudes toward anal intercourse than women did (Wilson & Medora. Belcher.. butt-plug. 2005). For example.’’ (Female respondent) . 2003). anal intercourse is pleasurable. Gender and sexual agency. and also indicates the limited scope of research into other times and societies. over two decades later. except anal intercourse. & Hill. dildo.’’ and ‘‘incorporate anal play prior to penile penetration. a study investigating intimate partner violence and HIV risk among methadone-maintained women (n ¼ 416) in New York City found that intimate partner violence (sexual or physical) was associated with having unprotected anal intercourse (El-Bassel. when we compare it with the depth and detail of materials available about other sensual=sexual behaviors. It was a regular part of our married sex life. the nature of these data makes it impossible to determine whether the opinions presented are representative of anal intercourse experiences for a substantial number of practitioners or whether they reflect a small number of individuals who happen to enjoy or prefer this form of sexual interaction over vaginal sex.. 1990). or vibrator). Wu. higher pleasure ratings were correlated with increased behavioral frequency for all behaviors.. However.HETEROSEXUAL ANAL SEXUALITY meaning. 1998). Understanding how anal sex behaviors are introduced and negotiated. Many of the chats that were reviewed focused on the importance of cooperation and communication among partners. Similarly. however. inner-city women found that participants who reported having a main partner mostly take the lead ‘‘in deciding what you do when you have sex’’ was significantly associated with unprotected anal intercourse (Friedman et al. The findings from the aforementioned studies raise questions about the role of gender and sexual agency in acts of heterosexual anal sex. virtually nothing is known about people’s attitudes toward heterosexual anal pleasure and its influence on behavioral motivations. (p. Cecil. and perhaps considered more intimate than vaginal sex. Typically. Among women. Anal intercourse was seen as something that had to be worked toward by both partners in order for it to be a mutually pleasurable experience. & Abramson. Because both of the studies inquired about unprotected anal intercourse and not intercourse itself. exciting. Williams. It required more planning than vaginal intercourse. with the majority evaluating it as a negative experience (Rogala & Tyden.’’ ‘‘go very slow. including proper preparation. Go. ‘‘use a lot of lube. 14) Morin’s passage was written in 1986. Few studies have devoted attention to sexual pleasure as a motivating factor for anal sex. A study that investigated the associations between the pleasurability of various sexual activities and behavioral experiences with the activities found gender main effects for anal intercourse. 2003). you’re literally tight assed. Kalichman. Sexual coercion and intimate partner violence have been consistently linked to the risk for HIV and STIs (Josephs & Abel. and I enjoyed it. However. These data do not provide information on whether this result differs markedly from gender differences in coital initiation or whether the 58% of women found anal sex to be unpleasurable or unerotic. 45% of the overall sample of women said that they had engaged in anal receptive penetration with a finger or sex toy (e. in his 1986 book on anal pleasure and health.

anal intercourse is practiced. Findings suggest that practices. Simultaneously. such as desensitizing creams and anal bleaches. Pervasive gendered scripts coupled with the stigma associated with anal sex make receptive anal intercourse one of the least desirable sexual behaviors in Western culture. there is a cultural assumption that women should view anal sex as undesirable or unerotic and that participation in the behavior can only legitimately result from some level of coercion or acquiescence. to consider anal sex predominantly as a marginal or atypical heterosexual behavior contributes to its 132 continued stigmatization. Findings from studies by McBride and Reece (2008). Low condom usage rates indicate that anal intercourse may not be perceived as ‘‘risky’’ because it does not. 2005). Research that includes questions about anal sex behaviors other than intercourse will allow us to gather information from participants who may be at heightened risk. such as oral–anal contact or manual stimulation. the sexual science of heterosexual anal sex seems to follow closely the larger phallocentric sociocultural scripts that ‘‘insertive’’ sexual behaviors are more acceptable (and even erotic) than ‘‘receptive’’ sexual behaviors. That fewer men were found to have been the receptive partner than the insertive partner for any given behavior is not surprising. such as anal douching and sexual lubricant use. Public health and sexual health issues. This perspective does not allow for wanted anal sex. including anal masturbation. 2008). for some with regularity. sexual scientists will need to be aware of their own biases and assumptions. Much like vaginal sex. and the willingness to report. As a result. will add precision to estimates of risk. By disallowing the possibility of pleasure in anal sex. have not been studied. for the majority of the sample. And. Sexual health experts often recommend the use of sexual lubricants to facilitate anal penetration and. Documenting frequency rates of both anal intercourse and other anal sex behaviors. That stigma never contributes to sexual health is among the many harsh lessons of the worldwide epidemics of HIV and AIDS. yet would not be identified by research focusing solely on penile–anal intercourse. cultural discourses are reinforced. traditional measures of sexual behavior may not capture men who are the receptive partners in anal sex with a woman. population-based studies have found an increase in behavior among both men and women over the past decade (Mosher. the measurement of anal sex behaviors has been limited to penile–anal insertive or to penile– anal receptive intercourse. these assumptions confine our understanding of human sexuality to traditional notions of gendered sexual behavior. McBride et al. anal sex experience has not been explored. To understand heterosexual anal sexual behavior. which marginalizes the sexuality of women who find anal sex pleasurable or erotic. particularly as these may affect measurement. beyond the potential for negative sexual health outcomes. The ways in which stigma shapes individual interpretations of. However. although doing so may give insight into experiences of sexual pleasure. Very few efforts have been made to understand receptive anal sex behaviors in heterosexual men with female partners. Among men. Recommendations for Research Prevalence and frequency. and McBride et al. sexual lubricants have been used in research as a surrogate for rectal microbicides. Ignoring the possibility that men may be engaging in receptive anal sex behaviors severely limits our ability to accurately estimate risk. Regardless of the accuracy of prevalence estimates. result in pregnancy. the data document men participating in receptive anal sexual behaviors with female partners. Simultaneously. given dominant sexual scripts. A recent study of anal intercourse practices in women found that. the context . recently. Moreover. both oral–anal and manual–anal contact. Documenting the effects of product use will be important to estimating risk. which implies a male partner. From this perspective. These findings may help explain low levels of condom use. the associated risks to sexual health remain unknown. Data from large-scale. alone.MCBRIDE AND FORTENBERRY ‘‘receptive’’ sexual acts. Other anal products. As a result. Discussion Anal sex is clearly part of the contemporary heterosexual sexual repertoire and has been for centuries. Research has assumed that anal sex behaviors in women are strictly receptive. anal intercourse was unplanned (Exner et al. The degree to which sexual science endorses these larger scripts reinforces the idea that anal sex is simply an atypical and more dangerous version of coitus. Exploration of practices associated with anal sex behaviors is also needed. Chandra. it will be necessary to broaden the scope of research efforts. & Jones. To accurately assess risks to sexual health. occurring in heterosexual men who report having only had female sexual partners. in heterosexual populations. as well as acquiescence. progress in a new understanding of human sexuality and sexual behavior is unlikely. (2008). may have significant implications for sexual health. it has been demonstrated that certain sexual lubricants may compromise sexual health by causing irritation that may increase the likelihood of disease exposure and transmission. For example. Phallocentric discourses and the stigma associated with anal sex have influenced the study of heterosexual anal sex by sexual scientists. (2009) document receptive anal sex behaviors..

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