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A duo of surgical researchers are urging more clinicians to talk to women about safe anal sex -- particularly for those who feel pressured by their partners to do so.
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8/12/22

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Anal sex isn’t the taboo sex act it used to be — especially among heterosexual women.
Indeed, the most recent statistics provided by the Centers for Disease Control and the National Center for Health Statistics showed that more than a third — 35% — of women aged 15 to 49 have tried anal sex with a male partner.
Those numbers, taken from a survey of more than 5,500 women between 2015 and 2019, are rising — perhaps by a lot, depending on who you ask. A similar survey of 880 “sexually active adults,” conducted by doctor-led butt health brand Future Method, showed that 70% of women have tried anal sex at least once.
In the spirit of a new age of sexual exploration and health awareness, a duo of surgical researchers published an editorial in the BMJ this week, urging more clinicians to talk to women about the potential risks of engaging in anal sex — particularly for those who feel pressured by their partners to do so.
“Clinicians may shy away from these discussions, influenced by society’s taboos,” wrote Tabitha Gana and Lesley Hunt, colorectal and consultant surgeons, respectively, with the UK’s National Health System. “By avoiding these discussions, we may be failing a generation of young women, who are unaware of the risks.”
Physicians and healthcare workers, especially those in primary care and family medicine, “have a duty to acknowledge changes in society around anal sex in young women, and to meet these changes with open neutral and non-judgemental conversations to ensure that all women have the information they need to make informed choices about sex,” the colleagues wrote.
Silence on the albeit sensitive subject, they continued, “exposes women to missed diagnoses, futile treatments, and further harm arising from a lack of medical advice.”
Gana and Hunt referred to a national survey of British women that outlined the top reasons why they’ve tried anal sex, including curiosity and personal pleasure. Unfortunately, for approximately a quarter of women, pressure from their male partners has played a significant role. The US is meanwhile expected to reflect similar trends.
“The pain and bleeding women report after anal sex is indicative of trauma, and risks may be increased if anal sex is coerced,” they wrote.
Anal sex can be safe and enjoyable for many, but the authors warned there are anatomical features to women that bring a different set of risks, such as incontinence, due to their “less robust” sphincter and weaker anal canal muscles compared to men. That’s one reason why women who engage in the act show increased rates of fecal incontinence and anal injury.
The surgeons point out that a majority of medical literature for patients pertaining to anal sex focuses on sexually transmitted illnesses, such as HIV, herpes and HPV — which can lead to certain cancers — but misses the aforementioned physiological risks, as well as the emotional toll of coercion.
In the absence of clinical guidance, women are looking to a “plethora of non-medical or pseudomedical websites to fill the health information void,” some of which “may increase societal pressure to try anal sex,” rather than helping women “make informed decisions,” the authors said.
“Hit television shows such as ‘ Sex and the City ‘ and ‘Fleabag’ may unwittingly add to the pressure, as they seem to normalize anal sex in heterosexual relationships or make it appear racy and daring,” they added.
Beyond shame or stigma, the doctors urge clinicians to overcome the fear of coming off as “judgmental” or even “homophobic” by raising these concerns with patients — insisting there are resources for them to learn how to approach the subject in a conscientious way.
“With better information, women who want anal sex would be able to protect themselves more effectively from possible harm, and those who agree to anal sex reluctantly to meet society’s expectations or please partners, may feel better empowered to say no,” Gana and Hunt conclude.

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Young women and anal sex
BMJ
2022 ;
378
doi: https://doi.org/10.1136/bmj.o1975
(Published 11 August 2022)

Cite this as: BMJ 2022;378:o1975

Tabitha Gana , ST8 general and colorectal surgery , Lesley M Hunt , consultant surgeon Author affiliations Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Sheffield, UK Correspondence to: L M Hunt lesley.hunt3@nhs.net
Faustino MJ . “It’s time to ease your fears—and your sphincter”: gender and power in contemporary media discourses of heterosexual anal sex . Gend Issues 2020 ; 37 : 241 - 60 doi: 10.1007/s12147-020-09250-7 .
Rosewarne L . School of shock: film, television and anal education . Sex Educ 2015 ; 15 : 553 - 65 doi: 10.1080/14681811.2015.1023285 .
Lewis R , Tanton C , Mercer CH , et al . Heterosexual practices among young people in Britain: evidence from three national surveys of sexual attitudes and lifestyles . J Adolesc Health 2017 ; 61 : 694 - 702 . doi: 10.1016/j.jadohealth.2017.07.004 pmid: 29169520
Hess KL , DiNenno E , Sionean C , Ivy W , Paz-Bailey G , NHBS Study Group . Prevalence and correlates of heterosexual anal intercourse among men and women, 20 US cities . AIDS Behav 2016 ; 20 : 2966 - 75 . doi: 10.1007/s10461-016-1295-z pmid: 26781872
Reynolds GL , Fisher DG , Rogala B . Why women engage in anal intercourse: results from a qualitative study . Arch Sex Behav 2015 ; 44 : 983 - 95 . doi: 10.1007/s10508-014-0367-2 pmid: 25378264
Fahs B , Gonzalez J . The front lines of the “back door”: navigating (dis)engagement, coercion, and pleasure in women’s anal sex experiences . Fem Psychol 2014 ; 24 : 500 - 20 doi: 10.1177/0959353514539648 .
Maynard E , Carballo-Diéguez A , Ventuneac A , Exner T , Mayer K . Women’s experiences with anal sex: motivations and implications for STD prevention . Perspect Sex Reprod Health 2009 ; 41 : 142 - 9 . doi: 10.1363/4114209 pmid: 19740231
Hutton HE , McCaul ME , Chander G , et al . Alcohol use, anal sex, and other risky sexual behaviors among HIV-infected women and men . AIDS Behav 2013 ; 17 : 1694 - 704 . doi: 10.1007/s10461-012-0191-4 pmid: 22566077
McBride KR , Fortenberry JD . Heterosexual anal sexuality and anal sex behaviors: a review . J Sex Res 2010 ; 47 : 123 - 36 . doi: 10.1080/00224490903402538 pmid: 20358456
Reynolds GL , Fisher DG , Rogala B . Why women engage in anal intercourse: results from a qualitative study . Arch Sex Behav 2015 ; 44 : 983 - 95 . doi: 10.1007/s10508-014-0367-2 pmid: 25378264
Štulhofer A , Ajduković D . Should we take anodyspareunia seriously? A descriptive analysis of pain during receptive anal intercourse in young heterosexual women . J Sex Marital Ther 2011 ; 37 : 346 - 58 . doi: 10.1080/0092623X.2011.607039 pmid: 21961443
Markland AD , Dunivan GC , Vaughan CP , Rogers RG . Anal intercourse and fecal incontinence: evidence from the 2009-2010 National Health and Nutrition Examination Survey . Am J Gastroenterol 2016 ; 111 : 269 - 74 . doi: 10.1038/ajg.2015.419 pmid: 26753893
Reginelli A , Mandato Y , Cavaliere C , et al . Three-dimensional anal endosonography in depicting anal-canal anatomy . Radiol Med 2012 ; 117 : 759 - 71 . doi: 10.1007/s11547-011-0768-4 pmid: 22228126
Brook G , Church H , Evans C , et al . 2019 UK national guideline for consultations requiring sexual history taking: clinical effectiveness group British Association for Sexual Health and HIV . Int J STD AIDS 2020 ; 31 : 920 - 38 . doi: 10.1177/0956462420941708 pmid: 32718268
Hebert LE , Newton SL , Webb ME . “Never anything about anal sex whatsoever”: young women’s reflections on sources of information about anal sex . Contraception (Stoneham) 2017 ; 96 : 303 doi: 10.1016/j.contraception.2017.07.151 .
Stewart J , Douglas G , O’Rourke T , Gammel C . Promoting safer sex in the context of heterosexual anal intercourse: a scoping review . J Clin Nurs 2021 ; 30 : 2111 - 30 . doi: 10.1111/jocn.15628 pmid: 33377555
Scottish Parliament. To ask the Scottish Government who designed the questionnaire for the Health and Wellbeing Census for schools in 2021-22. Question S6W-04881. 2021. https://www.parliament.scot/chamber-and-committees/written-questions-and-answers/question?ref=S6W-04881
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Tabitha Gana ST8 general and colorectal surgery , Lesley M Hunt consultant surgeon

Gana T , Hunt L M .

Young women and anal sex

BMJ 2022; 378 :o1975

doi:10.1136/bmj.o1975

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Young women and anal sex

Should covid-19 vaccines and drugs be “not for profit”?
Copyright © 2022 BMJ Publishing Group Ltd
Intended for healthcare professionals
Clinicians’ reluctance to discuss possible harms is letting down a generation of women
Anal intercourse is becoming more common among heterosexual couples. Within popular culture it has moved from the world of pornography to mainstream media. 1 It is no longer considered an extreme behaviour but increasingly portrayed as a prized and pleasurable experience. 2 In Britain, the National Survey of Sexual Attitudes and Lifestyle shows participation in heterosexual anal intercourse among 16 to 24 year olds rose from 12.5% to 28.5% over the past few decades. 3 Similar trends are seen in the US, where 30-44% of men and women report experience of anal sex. 4
Individual motivation varies. Young women cite pleasure, curiosity, pleasing male partners, and coercion as factors. 5 6 Up to 25% of women with experience of anal sex report they have been pressured into it at least once. 7 Hit television shows such as Sex and the City and Fleabag may unwittingly add to the pressure, as they seem to normalise anal sex in heterosexual relationships or make it appear racy and daring.
Anal intercourse is considered a risky sexual behaviour because of its association with alcohol, drug use, and multiple sex partners. 8 But it is also associated with specific health concerns. The absence of vaginal secretions, increased traumatic abrasions, and less common use of condoms increase the risk of sexually transmitted disease and anal malignancy. 9 Anal pain, bleeding, and fissures also occur as a result of anal intercourse. 10 11
Increased rates of faecal incontinence and anal sphincter injury have been reported in women who have anal intercourse. 12 Women are at a higher risk of incontinence than men because of their different anatomy and the effects of hormones, pregnancy, and childbirth on the pelvic floor. Women have less robust anal sphincters and lower anal canal pressures than men, 13 and damage caused by anal penetration is therefore more consequential. The pain and bleeding women report after anal sex is indicative of trauma, and risks may be increased if anal sex is coerced.
Effective management of anorectal disorders requires understanding of the underlying risk factors, and good history taking is key. Without it, patients are likely to present repeatedly with the same symptoms. Asking about anal sex is standard practice in genitourinary medicine clinics 14 but less common in general practice and colorectal clinics. Clinicians may shy away from these discussions, influenced by society’s taboos. However, with such a high proportion of young women now having anal sex, failure to discuss it when they present with anorectal symptoms exposes women to missed diagnoses, futile treatments, and further harm arising from a lack of medical advice.
More widely, public health education is lacking. 15 16 NHS patient information on anal sex considers only sexually transmitted diseases, making no mention of anal trauma, incontinence, or the psychological aftermath of the coercion young women report in relation to this activity. 17 A plethora of non-medical or pseudomedical websites fill the health information void. Rather than helping young women make informed decisions, some sites may increase societal pressure to try anal sex.
It may not be just avoidance or stigma that prevents health professionals talking to young women about the risks of anal sex. There is genuine concern that the message may be seen as judgmental or even misconstrued as homophobic. However, by avoiding these discussions, we may be failing a generation of young women, who are unaware of the risks. With better information, women who want anal sex would be able to protect themselves more effectively from possible harm, and those who agree to anal sex reluctantly to meet society’s expectations or please partners, may feel better empowered to say no.
Reluctance to discuss anal sex is not confined to healthcare. The Scottish government attracted criticism for proposing that questions about it should be included in the schools’ health and wellbeing census, prompting first minister Nicola Sturgeon to respond: “ Either we can bury our heads in the sand and pretend that young people are not exposed to the issues or the pressures that we know they are exposed to. Or we can seek to properly understand the reality that young people face and provide them with the guidance, the advice, and the services they need to make safe, healthy, and positive decisions.” 18
Healthcare professionals, particularly those in general practice, gastroenterology, and colorectal surgery, have a duty to acknowledge changes in society around anal sex in young women, and to meet these changes with open neutral and non-judgmental conversations to ensure that all women have the information they need to make informed choices about sex.
Competing interests: The BMJ has judged that there are no disqualifying financial ties to commercial companies. The authors declare no other interests. Further details of The BMJ policy on financial interests are here: https://www.bmj.com/sites/default/files/attachments/resources/2016/03/16-current-bmj-education-coi-form.pdf .
Provenance and peer review: Not commissioned; externally peer reviewed.
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