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Why Women Engage in Anal Intercourse: Results from a Qualitative Study
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Grace L. Reynolds, Dennis G. Fisher, and Bridget Rogala
This study used qualitative methods to assess why women engage in heterosexual anal (receptive) intercourse (AI) with a male partner. Four focus groups which comprised women from diverse ethnicities were conducted. All groups were digitally recorded for transcription; transcripts were analyzed using the methods of grounded theory to determine themes. Women’s reasons for engaging in anal intercourse with a male partner can be described in broad categories including that the women wanted to have anal intercourse, either because of their own desire, to please a male partner, or they were responding to a quid pro quo situation. The riskiness of AI was assessed within relationship contexts. Past experience with AI including emotional and physical reactions was identified. Among the negative physical experiences of AI were pain and disliking the sensation, and uncomfortable side effects, such as bleeding of the rectum. Negative emotional experiences of AI included feelings of shame, disgust, and being offended by something her male partner did, such as spitting on his penis for lubrication. Positive physical experiences included liking the sensation. Many of the women also endorsed positive emotional experiences of AI, including that it was more intimate than vaginal sex, and that it was something they reserved only for special partners. The majority of AI episodes were unplanned and not discussed prior to initiation. Pain during AI was mitigated by the use of lubricants or illicit drugs. Even those women who found pleasure in AI expressed a preference for vaginal intercourse.
Keywords: Heterosexual anal intercourse, Anal sex, Women, Qualitative methods
Recent interest in heterosexual anal intercourse has been generated from several research perspectives. In the United States, general population surveys have suggested that the prevalence of anal intercourse among heterosexuals has increased over time (Leichliter, 2008). It is not possible to know from these surveys whether the prevalence of anal intercourse is actually increasing, or as some would suggest that the sexual repertoire of Americans has expanded to include anal intercourse, along with oral and vaginal sex (Leichliter, 2008; McBride & Fortenberry, 2010). There may now be less stigma attached to anal intercourse, and respondents to these general population surveys may be more comfortable admitting to the behavior (Mosher, Chandra, & Jones, 2005). Currently in the United States, there are no states that have laws criminalizing anal intercourse (Kelvin, Smith, Mantell, & Stein, 2009). The increase in the reporting of anal intercourse among heterosexuals has implications for public health efforts to educate individuals about the risks of sexually transmitted infections, including those that may be transmitted through anal contact (Fleming & Wasserheit, 1999; Gorbach et al., 2009; Gross et al., 2000; Halperin, 1999; Javanbakht et al., 2010; Tian et al., 2008).
Interest in anal intercourse has also come from research in human immunodeficiency virus (HIV) transmission. Several studies have quantified the increased risk of heterosexual transmission from one act of anal intercourse as compared to one act of vaginal intercourse (Boily et al., 2009; Leynaert, Downs, & de Vincenzi, 1998; Powers, Poole, Pettifor, & Cohen, 2008). The increased risk of HIV transmission through anal intercourse has been well documented in studies of homosexual and bisexual men; however, there has only recently been interest in documenting comparable risks among heterosexual samples. The studies that have used heterosexual samples have generally focused on parts of the world, such as South Africa, that have not only high rates of anal intercourse among heterosexuals, but also high HIV prevalence in the general population and high numbers of concurrent partners among heterosexuals (Kalichman et al., 2011; Thomas, 2009). Partner concurrency and the higher transmissibility of HIV through anal intercourse also make studying heterosexual anal intercourse compelling in the United States where the prevalence of HIV is high mainly in ethnic minority samples, such as African American and Latina women who have sex with men (McLellan-Lemal et al., 2012; Neblett & Davey-Rothwell, 2011; Reynolds, Fisher, & Napper, 2010). According to the U.S. Centers for Disease Control and Prevention (CDC, 2013), 86 % of HIV cases in women are attributable to heterosexual contact: 65 % of HIV infections in African American women and 17 % of HIV infections in Latina women are attributable to heterosexual contact. Research with women who have male partners recently released from jail or prison has also yielded high rates of anal intercourse (Bland et al., 2012; Swartzendruber, Brown, Sales, Murray, & DiClemente, 2011). Harawa and Adimora (2008) linked high incarceration rates among both men and women in the African American community with HIV through a number of mechanisms, including the role incarceration plays in reducing the number of male sexual partners available to African American women.
There is also research literature on heterosexual anal intercourse among drug-using subsamples, which has found a relationship between anal intercourse and both injection and non-injection drug use (Bogart et al., 2005; Lorvick, Martinez, Gee, & Kral, 2006; Powis, Griffiths, Gossup, & Strang, 1995; Risser, Padget, Wolverton, & Risser, 2009; Strang, Powis, Griffiths, & Gossup, 1994; Zule, Costenbader, Meyer, & Wechsberg, 2007), as well as use of prescription drugs and PD5 inhibitors such as Viagra (Fisher et al., 2006). Mackesy-Amiti et al. (2010) found that among drug-using women, anal sex was more likely to occur during transactional sex (sex for drugs or money) and was not associated with emotional closeness.
While this growing body of literature suggests that anal intercourse among heterosexual women may be more prevalent than previously assumed (particularly among drug-abusing samples of women), there is currently very little information about why these women are engaging in anal intercourse. While some have suggested that images of sexual behavior found in popular media may influence both men and women’s sexual behavior (Peterson & Hyde, 2010), the extent to which media images play a role in women’s decisions to engage in anal intercourse (or men’s requests for anal intercourse) is unclear. Similarly, while others have suggested that women’s decisions to engage in anal intercourse may be nested within complex gender relationships that privilege male pleasure and female subjugation (Hekma, 2008; Peterson & Hyde, 2010), the extent to which women reference traditional gender roles (e.g., men are interested in sex as conquests, while women are passive recipients of male advances) and sexual scripts (e.g., shared conventions about gender roles during sexual activity) when deciding to engage in anal intercourse remains unclear (Dworkin, Beckford, & Ehrhardt, 2007; Simon & Gagnon, 1986).
Social cognitive theory (Bandura, 1986) may help explain women’s decisions to have anal intercourse. Bandura stated that human behavior is learned from watching and interacting with other human beings. Women may learn about anal intercourse through male sex partners, and then they may suggest anal intercourse with new sex partners for a variety of reasons, including a desire to be responsive to his desires or because she has learned to like anal intercourse from the experience with a previous sex partner.
Gender stereotypes provide behavioral norms for a variety of social settings; in sexual situations, men and women may be compelled to follow behavioral expectations (Deaux & Lewis, 1984; Sanchez, Crocker, & Boike, 2005). Research has demonstrated that individuals may rely on these behavioral norms and gender stereotypes when engaging in sex with a new partner (Littleton & Axsom, 2003). Through these traditional gender roles and sexual scripts (e.g., gender and role conventions), women have been taught to prioritize their partners’ needs above their own, and this may be a strong motivator for women engaging in anal intercourse when the male partner desires it.
Gender and power theory, which focuses on the sexual division of labor, sexual division of power, and social norms associated with relationships between men and women, may also inform our understanding of heterosexual anal intercourse (Connell, 1987). Wingood and DiClemente (2000) extended Connell’s theory into public health to include behavioral and biological risk factors as explanations for women’s increased risk for HIV. Their model includes alcohol and drug use and high-risk steady partners who have been linked to anal intercourse. DePadilla, Windle, Wingood, Cooper, and DiClemente (2011) validated Wingood and DiClemente’s model with empirical data demonstrating the relationship between theoretical constructs of gender and power and condom use. Pulerwitz, Amaro, De Jong, Gortmaker, and Rudd (2002) found that the construct of sexual relationship power accounted for variation in the use of condoms for vaginal sex among Latina women, with greater perceived relationship power being associated with more condom use; their findings on the importance of relationship power were replicated in a study of anal intercourse in minority female adolescents, where greater relationship power was associated with the ability to refuse anal intercourse with a male partner (Roye, Tolman, & Snowden, 2013).
The current study sought to examine why heterosexual women engage in anal intercourse. Due to the limited nature of previous research on this topic, we opted for a more exploratory approach aimed at uncovering the broad range of reasons that women had for engaging in anal intercourse. Anal intercourse in this study refers to the penetration of a woman’s anus by her partner’s penis, and not the more general category of sexual behaviors, anal sex, which can include anal-oral contact and digital penetration. To enhance the relevance of this work for both the mental health and public health sectors, we also sought to examine women’s perception of risk related to anal intercourse and women’s emotional and physical experiences during the encounter itself.
Focus group methods were selected to uncover the wide range of reasons that drug-abusing women may have for engaging in heterosexual anal intercourse. Focus groups are particularly well suited for uncovering a full range of opinions, experiences, or concerns about a topic (Krueger, 1994). Given the limited nature of information on this topic, we thought that the types of generative discussions that take place during focus groups would yield the widest range of experiences, opinions, and insight into women’s reasons for and experiences of engaging in anal intercourse. Focus groups were also preferred by the participating outpatient drug treatment program because participants were familiar with group activities and settings.
A total of 32 women participated in four separate focus groups about heterosexual women’s experiences with anal intercourse. All participants were recruited through an outpatient drug treatment program and a community-based HIV and sexually transmitted infections (STI) testing program; the testing program was located at the Center for Behavioral Research and Services (CBRS), an organized research center of the California State University, Long Beach (CSULB). Women were invited to participate in the focus groups if they were at least 18 years of age and acknowledged having had anal intercourse with a man during a previous interview at CBRS and had past experience of illicit drug use. The majority had participated in some form of outpatient drug treatment, but some of the women had never received formal treatment for their drug use. All of the women answered “Yes” to the question “Have you ever in your life had receptive anal sex (your partner’s penis in your butt/anus)” during the initial screening procedures, but only 73 % reported having receptive penile-anal intercourse on the brief questionnaire administered immediately prior to the focus groups. Further questioning revealed that all of the participants had had anal intercourse, but some did not count it as such if the man did not ejaculate or if the woman insisted he withdraw because of pain.
The resulting sample consisted of 32 women from diverse ethnic backgrounds: 31 % were White, 41 % were Black/African American, and 28 % were Latino. The average age of the participants was 37 years (SD = 11.02, range 24–56), and 6 % of the women were currently married.
Women who met the screening criteria described above were invited to participate through a verbal invitation, a flyer, and/or a letter, and were offered $50 cash as an incentive. Each focus group was scheduled on a different day and time to maximize participation, but all focus groups were conducted at both the community-based drug treatment and the HIV/STI testing center from which the women had been recruited. Following the recommendations of Krueger (1994), each focus group consisted of 7–10 participants, and all focus groups were conducted by the first author who has experience with group facilitation and has worked extensively with the population served at both the drug treatment center and CBRS. The focus groups were constituted so that all the women in each group were of the same ethnicity; group 1 was African American, group 2 was Latina, and group 3 was White, but group 4 was mixed with approximately equal proportions of African American and White women.
Upon arrival at the focus group location, participants were first informed about the nature of the study and all associated risks and benefits. Informed consent was a two-stage process: women consented first to participate in the focus group and signed an informed consent form approved by the CSULB Institutional Review Board. The second stage consent process required the women to give separate consent to have the focus group digitally recorded for later transcription and coding. Only women who were willing to consent at both stages, that is, to participate in the focus group and to allow the group to be recorded, participated in the final focus groups. None of the women refused to be audio taped.
Women then answered a brief demographic questionnaire that elicited information on their age, self-reported ethnicity, and the number of biological children, whether they had had oral, vaginal, and anal intercourse at any point in their lifetime, and whether their last sexual encounter was with a man or a woman. The demographic questionnaire was followed by a description of focus group procedures and ground rules. Following the recommendations of Krueger (1994), the focus group protocol consisted of five generally worded questions about heterosexual anal intercourse with male partners, how often it had occurred in their lifetime, the frequency of anal intercourse with their current or most recent sexual partner, the context in which the anal intercourse event took place (type of partner, such as new, casual, and regular), the role of alcohol and illicit substances in facilitating the anal intercourse, and other relevant characteristics of the male partners (known to be bisexual, previous incarceration history) and any other information the women were willing to provide concerning the anal intercourse event itself (e.g., lubricants or enemas used, location such as a motel). Participants were allowed to respond spontaneously to each question and were not required to seek permission to speak or speak in a designated order. Although each participant was not required to answer each question, the facilitator did encourage participation from all women and made efforts to elicit diverging perspectives.
The audio files produced by the recording equipment in MP3 format were transcribed verbatim and imported into Dedoose, an on-line qualitative analysis program that facilitates coding, sorting, and displaying mixed method data. Specific analysis procedures followed many of the recommendations of Grounded Theory (Glaser, 1998; Miles & Huberman, 1994) and unfolded in several phases. In the first phase, the second author read over the transcripts and noted key ideas in the margins (a step known as marginal coding) (Miles & Huberman, 1994). In the second phase, a constant comparison method was used to group and organize the marginal codes conceptually. This inductive process resulted in a hierarchically organized codebook containing codes and subcodes that emerged from the data itself. In the third phase, Dedoose was used to mark excerpts from the transcripts. Excerpts were identified both conceptually (based on the beginning and ending of a distinct idea) and contextually (including all necessary information for accurate interpretation). The codebook was then uploaded to Dedoose and used to assign applicable codes to the excerpts. Dedoose was used to assess inter-rater reliability utilizing a random selection of one-third of the excerpts created by the second author. In most cases, disagreements involved omissions. This occurred when one person applied a code that was overlooked by the other person. When these omissions were counted as disagreements, the kappa coefficient was .79. When these omissions were left out of the calculations, kappa increased to .93, indicating that there were few outright disagreements in coding. All omissions and discrepancies were then discussed by the coders, and a consensus approach was used to assign final codes. Each of these codes and sample quotes are described in detail below.
The primary goal of the current study was to uncover a wide range of reasons as to why heterosexual, drug-abusing women engage in anal intercourse. Secondary goals included gaining a deeper understanding of the context of the anal intercourse, women’s perceptions of risk related to anal intercourse, women’s emotional and physical experiences during anal intercourse, and the role of substance abuse in all aspects of the anal intercourse encounter. Results related to each of these research questions are described in more detail below.
Results from the current study suggest that heterosexual, drug-using women engage in anal intercourse
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