Heterosexual Anal Sexuality and Anal Sex Behaviors: A Review

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Heterosexual Anal Sexuality and Anal Sex Behaviors: A Review
Kimberly R. McBrideab; J. Dennis Fortenberryc
a Department of Psychological and Brain Sciences, Indiana University, b The Academic Edge, Inc., c
Department of Pediatrics, Section of Adolescent Medicine, Indiana University School of Medicine,
Online publication date: 30 March 2010
To cite this Article McBride, Kimberly R. and Fortenberry, J. Dennis(2010) 'Heterosexual Anal Sexuality and Anal Sex
Behaviors: A Review', Journal of Sex Research, 47: 2, 123 — 136
To link to this Article: DOI: 10.1080/00224490903402538
URL: http://dx.doi.org/10.1080/00224490903402538

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JOURNALOFSEXRESEARCH,47(2–3),123–136,2010
Copyright#TheSocietyfortheScientificStudyofSexuality
ISSN:0022-4499print=1559-8519online
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
10 practices and provides conceptual and methodological recommendations for new research.
0
2

e
n
u
J

9
2 Heterosexual anal intercourse is associated with insertionandthrustingofonepartner’spenisintheanus
3
:4 increased risk for HIV and other genital and anal of the other (Merriam-Webster Dictionary Online,
6
1
sexually transmitted infections (STIs; Buchacz, van der 2009). The term sodomy sometimes indicates anal inter-
:
t
A Straten, Saul, Shiboski et al., 2001; Halperin, 1999). course in historical, journalistic, and legal settings, but
]
ty Increasing rates of anal cancer may be attributable to will not be used here. The Internet site Sex-Lexis.com
i
s
r moreprevalentpracticeofanalintercourseandtothehigh (2009) lists more than 200 slang terms for anal inter-
e
v
ni prevalence of human papillomavirus (HPV) infection course, although many refer to same-sex rather than
U
n (Eng, 2006; Scott, Khoury, Moore, & Weissman, 2008). opposite-sex behavior. In this article, anal sex is used
r
e
t However, most research on anal intercourse addresses toencompassanalintercourse,aswellasotheranalsex-
s
e
hw menwhohavesexwithmen(MSM),withrelativelylittle ualbehaviors,suchasoral–analcontact(analingus)and
t
or attention given to analintercourse and other analsexual penetration by fingers or other objects. The term anal
N
[
behaviors between heterosexual partners (Halperin, intercourse refers specifically to penile–anal intercourse.
:
y
B 1999).Heterosexualpenile–analintercoursehasbeentrea-
d
de ted as analogous to coitus in most published research.
a
o
l Research is quite rare that specifically differentiates the
wn Historical Overview and Shifting Cultural Norms
Do anus as a sexualorgan or addresses anal sexual function
or dysfunction as legitimate topics. As a result, we do
Historical Overview
not know the extent to which anal intercourse differs
qualitativelyfromcoitus.Thepurposeofthisarticleisto Depictions of heterosexual anal sex can be found in
review literature in four primary areas of heterosexual art and artifacts dating to antiquity (Reinisch, Ziemba-
anal sex research—history and culture, prevalence and Davis, & Sanders, 1990). Peruvian Moche stirrup-spout
frequency, public health and sexual health issues, and pots,eroticceramicvases,from300ADmaybesomeof
behavioral antecedents and correlates—and to provide theearliestandmostprolificexamplesofsuchrepresen-
recommendationsforfutureresearch. tations (see Figure 1). A survey of Moche pots found
that 31% depicted heterosexual anal intercourse, signifi-
cantlymorethananyothersexualact(Tannahill,1992).
Terminology Chinese and Japanese shunga, woodblock prints and
painted handscrolls, produced between the 16th and
The terms anal sex and anal intercourse are typically 19th centuries, depict a vast array of sexual practices,
usedsynonymouslytorefertoadyadicsexactinvolving including heterosexual anal sex. Erotic French lithogra-
phy and photography from the late 19th and early 20th
centuriesincludebothimagesofpenile–analintercourse,
Correspondence should be addressed to Kimberly R. McBride,
as well as digital–anal penetration. Erotica from the
DepartmentofPsychologicalandBrainSciences,IndianaUniversity,
same period has described heterosexual anal sex acts.
1101E.10thSt.,Bloomington,IN47405.E-mail:kmcbride@indiana.
edu Today, images of heterosexual anal sex are so highly
MCBRIDEANDFORTENBERRY
hundreds, if not thousands, of years. Despite continued
cultural stigma, anecdotal evidence suggests that atten-
tion to heterosexual anal sex in the popular culture has
risen over the past decade. A recent Internet search
(conducted by us) of the term ‘‘heterosexual anal sex’’
yielded 790,000 links to media articles and Web sites.
A review of the first 500 sites indicated that some sites
depict pornographic and erotic images or chats, but
many report scientific findings or provide information
about anal sexual health. Scientific data documenting
ariseinbehavioralprevalencehaspromptedsomenews
media to suggest that anal sex is the ‘‘new oral sex,’’
another behavior that was once stigmatized but is now
acceptedashighlyprevalent.Inadditiontotheapparent
rise in media interest, there seems to be a shift in the
focus of content. A search of newspaper articles and
Figure 1. Example of a Peruvian Moche stirrup-spout pot. Note. newswire press releases (also conducted by us) for the
Image courtesy of the Kinsey Institutefor Research in Sex, Gender,
past two decades indicated that early coverage (1986–
andReproduction.
1996) of anal sex focused on risk for HIV and AIDS,
0
1 whereas articles published within the past five years
0
2
e prevalent in pornographic films and Web sites that the focusedonlaws,sexualliberties,andsexualexpressions.
n
Ju sitesadvertisematerialbasedonwhetheritincludesanal Attention to heterosexual anal sex has not been

9
2 sex (e.g., ‘‘100%vaginal,’’ ‘‘no anal,’’ ‘‘100% anal,’’ and limited to the news media. Rather, references can be
3
:4 ‘‘double penetration’’). found in almost all forms of popular media, including
6
1 The term sodomy is broadly defined as anal penetra- magazines, television programs, movies, songs, and
:
t
A tion or oral copulation with a member of the opposite books. For example, an episode of the television pro-
]
ty or same sex, or with an animal (Merriam-Webster gram Sex and the City titled ‘‘Valley of the Twenty-
i
rs Dictionary Online, 2009). The sexual use of the term Something Guys’’ (King & Maclean, 1998) detailed the
e
v
ni sodomyasasynonymforanalintercourseamonghomo- dilemmaofthecharacter,Charlotte,whenherboyfriend
U
n sexual men is attributed to the Byzantine emperor askedhertoengageinanalsex.Inthepilotepisodeofthe
r
te Justinian I (538 AD). During the Medieval Inquisition televisionprogram Californication(McMartin&Freun-
s
e
hw (1184), hereticism was increasingly associated with dlich,2007),thecharacter,Charlie,isthesurprisedreci-
t
or fornication and sodomy, thus linking the behaviors to pient of the ‘‘stinky pinky’’ when his wife inserts her
N
[ witchcraft and satanism. Since these times, sodomy and fingerintohisanus.Magazinearticlessuchas‘‘TheBot-
:
y
B its biblical proscription have influenced the meaning tom Line,’’ published in New York Magazine, and ‘‘Is
d
de andacceptabilityofanalintercoursebehaviorinWestern Anal Sex the New Deal Breaker,’’ published in Men’s
a
lo culture. Style,featureinterviewswithmenandwomenwhoprac-
n
w
o Laws banning acts of sodomy can be traced to tice anal sex (EM & LO, 2007; Men’s Style, 2007). A
D
documentswrittenbetween500and600AD.Historians numberof‘‘how-to’’guideshavebeenpublished,includ-
have traced earlier bans to 149 BC; however, definitive ing Tristan Taormino’s best-selling book The Ultimate
written documentation no longer exists. Historically, GuidetoAnalSexforWomen(Taormino,2006),provid-
anti-sodomy laws have been used to punish same-sex ing furtherevidenceof public interest.
sexual behaviors, particularly anal sex among men. In Although there has been no systematic study of
the United States, anti-sodomy laws can be traced to public interest or opinion of heterosexual anal sex, the
the colonial period and were still enforced in several proliferation of materials and references in popular
states until 2003 when the U.S. Supreme Court ruled culture, combined with scientific documentation of
such laws unconstitutional (see Lawrence v. Texas, increased behavioral prevalence, may together suggest
2003). Perhaps due to the cultural and legal sanctions shifting cultural norms. Shifting norms have several
associatedwithanalsex,thebehaviorreceivedonlybrief implicationsforunderstandingheterosexualsexualrela-
mention (e.g., Kinsey, Pomeroy, Martin, & Gebhard, tions, including sexual problems and what constitutes
1953) in the scientific literature until the emergence of ‘‘safer’’ sex or responsible sex. Changing norms may
HIV and AIDS in the 1980s. 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. In terms of
Shifting Cultural Norms
theorizing heterosexual anal sexuality and behavior,
Heterosexual anal sex has been present in the the role of the ‘‘exotic’’ may be important. Virginity lit-
spectrum of erotic imagination and behavior for erature has found ‘‘gifting’’ to be a primary theme in
124
HETEROSEXUALANALSEXUALITY
experiences of virginity loss (Carpenter, 2002). Gifting (Satterwhite et al., 2007). These changes were seen
mayinfluencesomeactsofheterosexualanalintercourse regardless of gender or study site and were consistent
and deserves further investigation. Shifting norms may across racial and ethnic groups. Further, the increase
also have implications for the reification of gendered in reports of anal intercourse also occurred across age
sexual norms, such as the male as the penetrator and groups, suggesting an historical increase in reporting
the female as the penetrated. rather than a cohort effect. Using data from the
NationalSurveyofFamilyGrowth,Leichliter,Chandra,
Liddon, Fenton, & Aral (2007) found that 34% men
and 30% women (N¼12, 547) reported ever partici-
Prevalence and Frequency
pating in heterosexual anal sex. The percentage of
participants reporting heterosexual anal sex was signif-
Prevalence
icantly higher among 20- to 24-year-olds and peaked
Estimates of lifetime prevalence of anal intercourse among 30- to 34-year-olds, which may suggest hetero-
rangefrom6%to40%,withupto10%ofheterosexuals sexual anal sex becomes part of the sexual repertoire
reporting at least one instance in the previous year as individuals age.
(Baldwin&Baldwin,2000;Laumann,Gagnon,Michael,
& Michaels, 1994; Misegades, Page-Shafer, Halperin, & Demographicandbehavioralcharacteristics. Charac-
McFarland, 2001; Reinisch, & Hill, 1995; Reinisch, teristics of heterosexual men and women who engage
Sanders, Hill, & Ziemba-Davis, 1992). Based on an in anal intercourse include younger age, higher number
0
1 extensive review of the research, Voeller (1991) esti- of lifetime sex partners, history of STIs (Bogart et al.,
0
2
e mated that at least 10% of sexually active American 2005;Ericksonetal.,1995;Grossetal.,2000;Laumann
n
Ju women engage in receptive anal intercourse with some et al., 1994), and participation in other risk behaviors

9
2 regularity. Halperin (1999) pointed out that even if this (e.g., unprotected intercourse, injection drug use, and

3
:4 estimate is inflated twofold, anal intercourse occurs sexinexchangeformoney;Bogartetal.,2005;Gorbach
6
1 among more women annually than among MSM—four et al., 2009; Wilson et al., 1999; Zule, Costenbader,
:
t
A million versus one million, respectively. Meyer,&Wechsberg,2007).Bothmenandwomenwith

]
ty TheNationalHealthandSocialLifeSurvey(NHSLS) a history of same-sex partners are more likely to report
i
rs hasbeenafrequentlycitedsourceofprevalencedatafor anal intercourse (Foxman, Aral, & Holmes, 1998a,
e
v
i anal intercourse (Laumann et al., 1994). The NHSLS 1998b). Gorbach et al. (2008) found that the use of sex
n
U
n found a past 12 months prevalence rate of 10% among toys was associated with anal intercourse in men and
r
te menand9%amongwomen,with2.3%and1.2%,respec- women. Studies exploring prevalence by gender report
s
e
w tively, reporting heterosexual anal intercourse during that women participate in anal intercourse at roughly
h
t
or their most recent sexual event (Laumann et al., 1994). equalorslighterhigherratesthanmen(Baldwin&Bald-
N
[ A population-based study (n¼3,545) published in 1995 win,2000;Ericksonetal.,1995;Lewis&Watters,1991;
:
y
B found 8% of men and 6% of women reported engaging Reinisch & Hill, 1995). Ethnic and racial group differ-

d
de in heterosexual anal intercourse at least monthly ences in rates of anal intercourse are inconsistent,
a
lo throughout the previous year (Erickson et al., 1995). A although Hispanic men and White women have gener-
n
w
o studyassessingtheprevalenceofanalintercourseamong ally been found to report the highest rates (Erickson
D
HIV-seronegativewomenathighriskforHIVexposure et al., 1995; Gross et al., 2000; Laumann et al., 1994).
(n¼1,268) found that 32% of participants reported Mostofthedataaboutheterosexualanalintercourse
at least one instance of anal intercourse within the is based on research conducted in samples with beha-
preceding six months (Gross et al., 2000). One percent vioral and demographic characteristics (e.g., injection
of the sample (n¼17) reported anal intercourse, but drug use or offering sex in exchange for money) that
no vaginal intercourse, within the past six months. placethematrelativelyhighriskforHIVandSTItrans-
Recent studies have reported higher prevalence rates mission. The extent to which the association of hetero-
of heterosexual anal intercourse. A large scale survey sexual anal sex among these populations is causal
found that 38.2% of men between the ages of 20 and (e.g., through substance-related disinhibition) or distal
39 and 32.6% of women aged 18 to 44 had engaged (e.g., propensity for sensation-seeking) is unknown.
in heterosexual anal intercourse in their lifetime; a Moreover, little is known about the characteristics of
1992 survey had found that 25.6% of men and 20.4% lower risk populations, although observed rates of anal
of women reported lifetime heterosexual anal inter- intercourse have been found to be higher within the
course (Mosher, Chandra, & Jones, 2005). In Project contextsofseriousorlong-termrelationships,cohabita-
RESPECT, the proportion of participants reporting tion, and marriage when compared to casual partner-
anal intercourse in the previous three months was two ships (Erickson et al., 1995; Gurman & Borzekowski,
times higher in RESPECT II (1999–2000) than in 2004; Houston, Fang, Husman, & Peralta, 2007; Lewis
Project RESPECT (1993–1995), increasing from 9% & Watters, 1991). A study of sexually active women in
to 22% among women and 9% to 21% among men California found that of the respondents who reported
125
MCBRIDEANDFORTENBERRY
ever having had anal intercourse, 29.6% of women with heterosexual populations, they do little to further our
asteadypartnerand7.3%ofwomenwithacasualpart- understanding of the factors associated with specific
ner had engaged in anal intercourse within the previous events. Data from a sample of 266 men who reported
two months (Misegades et al., 2001). McBride and heterosexual anal intercourse within the past 30 days
Janssen (2007)foundthatthemajorityofmen(n¼631) found a mean of 4.6 (Mdn¼2) occurrences (McBride
and women (n¼856) who reported heterosexual anal & Reece, 2008; McBride, Reece, Herbenick, Sanders, &
intercourse in the past 12 months were in exclusive, Fortenberry, 2008). Recent data from 350 adolescents,
monogamousrelationships:69%and73%,respectively. aged 12 to 18 years, showed that prevalence rates of
anal intercourse among individuals with a main partner
Underreporting taboo behaviors. Despite what is and those with casual partners were similar (16% vs.
known about anal sex, according to Halperin (1999) it 12%, respectively). However, higher frequencies of
must be assumed that self-reported data for historically anal intercourse were found among participants with
taboosexpractices,suchasanalintercourse,isanunder- main partners (about once per week) compared to
estimation.Astudythatinvestigatedtheunderreporting those with casual partners (about once per month;
ofsensitivebehaviors,withaparticularinterestinabor- Houstonet al., 2007).
tion, found that participants (n¼63) were more willing
toadmittohavinganabortionthantoengaginginanal
intercourse (Smith, Adler, & Tschann, 1999). Although
Public Health and Sexual Health Issues
thesmallsamplesizelimitstheabilitytomakeinferences,
0
201 the findings suggest that anal sexual behaviors are Condom Use

e underreported.Further,it hasbeensuggestedthat mea-
n
Ju surement techniques, such as those used in the NHSLS Condom use for anal intercourse among heterosex-
9
2 survey (Laumann et al., 1994), have resulted in addi- uals is typically low, with less use for anal intercourse
3
:4 tional underestimations of prevalence (Halperin, 1999). than for vaginal intercourse (Baldwin & Baldwin, 2000;
6
: 1 Specifically, the NHSLS survey asked participants to Civic, 2000; Ehde, Holm, & Robbins, 1995; Gurman &
t
A respondsolelyinregardstoone’s‘‘regularorsecondary Borzekowski, 2004; Hein, Dell, Futterman, Rotheram-
]
ty partner.’’ The few studies that have attempted to elicit Borus,&Shaffer,1995;Leichliteretal.,2007;Misegades
i
ers more accurate responses have reported considerably et al., 2001). McBride and Janssen (2007) explored the
v
ni higher rates of prevalence (Erickson et al., 1995). relationshipbetweencondomuseforvaginalintercourse
U
n To what extent underreporting has influenced the versusanalintercourseinasampleofheterosexualswho
r
te accuracy of estimations of incidence and prevalence of reported both behaviors. Findings suggested significant
s
e
hw anal sex among heterosexuals is speculative. However, differences in condom use, with rates being lower for
t
or Voeller (1991) commented on the Bolling (1977) study, anal intercourse among both men and women. A study
N
[ stating patients initially denied engaging in anal inter- of 2,357 heterosexuals found that for anal intercourse
:
y
B courseandonlyacknowledgedanddiscussedthisaspect in the past three months, 27.3% of participants consis-
d
de of their sexuality at the second or third interview. Voel- tentlyusedcondoms,whereas63%neverusedcondoms.
a
lo ler suggested that such reticence is to be expected with Consistent condom use for anal intercourse was asso-
n
w
Do certain behaviors and that this reticence may have ciated with having consistent condom use for vaginal
played some role in HIV and AIDS studies that have intercourse, two or more partners, and anal intercourse
failed to identify anal sexuality in participants. withacasualornew partner(Tian etal.,2008).Among
intravenousdrugusers,condomnon-usageratesforanal
intercourseare70%orhigher(Bogartetal.,2005;Lewis,
Frequency
Watters,&Case,1990;Wilsonetal.,1999).Amongado-
The frequency of heterosexual anal intercourse is lescents, condom use rates for anal intercourse between
poorly documented. The majority of studies that have 0% and 47% are reported (Catania et al., 1989; Hein
measured it have used lifetime items or items assessing et al., 1995; Houstonet al.,2007).
a specified period of time (e.g., in the past year), and Methodological problems make estimating actual
many have dichotomized response options, typically condom use for heterosexual anal intercourse proble-
‘‘yes’’ or ‘‘no.’’ As a result, a large body of literature matic because the majority of studies investigating
documents the prevalence of heterosexual anal sex, but condomusefailtodistinguishbetweenvaginalandanal
much less information relates to behavioral frequency. sex. Further, sample sizes have often not been large
Becausebehavioralfrequencycanhavesignificantimpli- enough to conduct statistical analyses that specifically
cations for understanding the importance of anal sex in focus on anal intercourse in heterosexual men and
sexual health, assessing its actual incidence will be women.
important to identifying subpopulations that may be Few studies have explored the reasons for lower
atincreasedrisk of negative health outcomes.Although condom use during anal versus vaginal intercourse.
prevalence ratesdocument theoccurrence ofanalsexin McBride and Janssen (2007) found that relationship
126
HETEROSEXUALANALSEXUALITY
status and number of sexual partners significantly Table 1. Anal Sexual Behaviors in the Past 30 Days by
predicted condom use among men, whereas only rela- Lifetime History of Insertive Heterosexual Penile–Anal Sex
tionship status was found to be a significant predictor (N¼1,478)
for women. Other studies have identified themes asso-
Yes(n¼266) No(n¼1,212)
ciatedwiththeperceivedrisksofSTIandHIVinfection
and pregnancy as being associated with condom use. Variable n % n %
Ericksonetal.(1995)foundthatamongmarriedrespon-
Analinsertiveintercourse n¼266 18 —
dentswhoreportedengaginginanalintercourse,50%of
Insertedfingerinpartner’sanus n¼151 53 n¼125 10
women and 45% of men did not use condoms because Receivedfingerinanus n¼63 24 n¼35 3
they felt they were at ‘‘no risk’’ for a sexually trans- Placedmouthonpartner’sanus n¼63 24 n¼49 4
mitted disease. Similarly, among college students, the Receivedmouthonanus n¼40 15 n¼23 2
most commonly endorsed reason for condom non-use
during anal intercourse was, ‘‘I just knew my partner
a mouth on their anus. In comparison, men with no
was safe’’ (Civic, 2000). The second-most commonly
insertive anal intercourse experience reported lower
endorsed reason was related to pregnancy: ‘‘We didn’t
rates of anal sex behaviors. In this group (N¼1,212),
need to use a condom because pregnancy was not an
10%reportedinsertingafingerintotheirpartner’sanus,
issue.’’Arecentstudyfoundthat,inasampleofadoles-
whereas other behaviors were reported at rates ranging
cents, condom use was more likely to occur for anal
from 2% to 4% (see Tables 1 and 2).
intercourse with a casual partner (47%) versus a main
McBride, Sanders, and Hill (2009) investigated the
0
1 partner (21%). Anal intercourse was significantly more
20 prevalenceofnon-intercourseanalsexbehaviorsamong
ne likelytobeusedasamethodofcontraceptionbyadoles- asampleofmen(n¼1,299)andwomen(n¼1,919)with
Ju cents in casual partnerships when compared to those
anal intercourse experience and found that 51% of men
9
2 with main partners (Houston et al., 2007). These find-
3 and 43% of women had participated in at least one act
6:4 ings suggest that because anal intercourse alone does of oral–anal sex, manual–anal sex, or anal sex toy use.
1 notresultinpregnancy,thereisnotaneedtousecontra-
: These findings suggest that heterosexual anal sexual
t
A ception. This perceived safety may serve as a disincen-
] contact is not limited to penile–anal intercourse.
ity tive for condom use despite the potential for STI Further, findings by McBride et al. (2008) suggest that
rs exposure and transmission.
e anal sexual contact occurs in the absence of anal inter-
v
i Studiesassessingcondomuseerrorshaveimplications
Un course, although prevalence rates of such behaviors
rn for STI risk associated with anal intercourse. Although are lower in those without penile–anal intercourse
te not addressing anal intercourse specifically, a study
s experience. The American Association of Sexuality
e
w utilizing a convenience sample of 260 undergraduates
th Educators,Counselors,andTherapistspublishedaposi-
Nor foundthat83%didnotuseanewcondomwhenswitch- tion paper in Contemporary Sexuality (Melby, 2007)
[ ing between vaginal and anal sexual behaviors (Yarber,
: calling for attention to behaviors beyond anal inter-
y
B Graham, Sanders, & Crosby, 2004). Further, condom
d course such as oral–anal, manual penetration, and sex
ade breakage, slippage, and discomfort occur more com- toys for anal sex. The paper stated that the failure to
lo monly during anal intercourse than vaginal intercourse,
n consider non-intercourse anal sex behaviors may result
w
o which may serve as a further disincentive to use (Grady
D in inaccurate estimates of sexual health risk.
&Tanfer,1994;Reiss&Leik,1989;Silverman&Gross,
1997; Thompson,Yager,& Martin, 1993).
Potential mechanisms of increased HIV and STI
risk. Heterosexual anal intercourse is a risk factor
Non-intercourse anal sexual behaviors. Data are
for both HIV-seroconversion and STI transmission
scarce on non-intercourse anal sex behaviors such as
(Halperin, 1999). However, the mechanisms by which
digital-penetration, manual stimulation, and oral–anal
anal intercourse increases risk—to the extent these are
contact. However, such behaviors may have significant
implications for the risk of STI transmission and other
Table 2. MeanNumberofTimestheBehaviorwasPerformed
aspects of sexual health. A recent study investigated
in Past 30 Days by Lifetime History of Insertive Heterosexual
the prevalence of heterosexual anal sex behaviors in a
Anal Sex(N¼1,478)
sample of heterosexual men (n¼1,478), distinguishing
between men with insertive anal intercourse experience Yes(n¼266) No(n¼1,212)
and those without (McBride & Reece, 2008; McBride
Variable M Mdn M Mdn
et al., 2008). Among the men with insertive anal inter-
course experience (n¼266), 53% reported that they Analinsertiveintercourse 4.60 2.00 —
hadinsertedafingerintoafemalepartner’sanuswithin Insertedfingerinpartner’sanus 6.99 5.00 3.75 2.00
the past 30 days. Further, 24% (n¼63) had received a Receivedfingerinanus 5.56 3.00 3.62 2.00
Placedmouthonpartner’sanus 6.90 4.00 3.75 2.00
finger in their anus, 24% (n¼63) had put their mouth
Receivedmouthonanus 5.52 3.50 4.29 2.00
on their partner’s anus, and 15% (n¼40) had received
127
MCBRIDEANDFORTENBERRY
understood—likely differ by organism (and tropism for Studies of the prevalence of anal HPV in men have pri-
specific tissue types) and whether transmission is marily focused on samples of HIV-positive men and
male-to-female or female-to-male. Three general types MSM.Recentfindingsfromastudyof222heterosexual
of increased risk have been suggested to be associated men, who reported no lifetime same-sex experience,
with anal intercourse: trauma to the anus and rectum found an overall anal HPV prevalence rate of 24.8%
associated with penile insertion and thrusting; inflam- (Nyitray et al., 2008).
matory responses to cleansers, lubricants, or semen; Receptive anal intercourse is associated with inc-
and increased presence of types of cells directly infected reasedriskofanalcanceramongwomeninsomestudies
by specific organisms (Naftalin, 1992; Tabet et al., (Daling et al., 2004; Hernandez et al., 2005; Moscicki
1999). et al., 1999; Sharma, Ranjan, & Mehta, 2004) but not
all (Tseng, Morgenstern, Mack, & Peters, 2003). HPV-
HIV. Unprotected anal intercourse is a key risk related cancers likely occur in the absence of reported
factor associated with heterosexual HIV transmission anal intercourse because of underreporting or because
(European Study Group, 1992; Skurnick et al., 1998). of virus contained in vaginal discharge, or associated
The per-act risk of HIV transmission is estimated to with non-intercourse anal sexual behaviors (Moscicki
be five times higher for receptive anal intercourse and et al., 2003; Winer et al., 2003). For example, in men,
1.3timeshigherforinsertiveanalintercourse,compared anal HPV has been associated with a higher lifetime
tovaginalsex(Varghese,Maher,Peterman,Branson,& number of female sexual partners and a higher fre-
Steketee, 2002). quency of sex with female partners in the past month
0
1 Themostlikelyexplanationforincreasedsusceptibil- (Nyitrayetal.,2008).AstudyofmenwithHPV-infected
0
2
e ity to male-to-female HIV transmission associated with female partners found that 76% were HPV DNA
n
Ju anal intercourse has to do with the denser population positive (Nicolau et al., 2005).

9
2 of Chemokine (C-C motif) receptor 5 (CCR5)-bearing PalefskyandRubin(2009)reportedthatthereisbio-

3
:4 immune cells in the rectal mucosa, compared to other logic similarity between the cervix and the anus with
6
1 tissues(Griveletal.,2007).Presumably,increasedrectal respect to cells infected by HPV. They suggested that
:
t
A viral shedding among infected women would also theHPVtargetareaiswherethereistransitionbetween

]
ty account for increased female-to-male transmission risk. two types of epithelium. In the cervix, HPV preferen-
i
rs Factors associated with variability in rectal HIV shed- tially infects squamous epithelial cells on the exocervix
e
v
i ding are not well-established, especially among infected at the junction with columnar epithelium of the endo-
n
U
n women(Zuckermanetal.,2007).Itisimportanttonote cervical canal. In the anus, HPV appears to preferen-
r
te that in all of these studies, anal intercourse and HIV tially infect squamous epithelium of the anus at the
s
we transmission were conducted in samples of MSM. junction of columnar epithelium of the rectum
h
t
or Naftalin (1992) proposed that human semen contains (Palesfsky & Rubin, 2009). HPV requires direct access
N
[ at least two different components which facilitate the to nucleated, basal squamous epithelial cells in order
:
By degenerationofthemembranethatsupportsthecolonic to cause infection. These basal cells are typically cov-

d
de epithelial cell layer, leading to heightened risk for HIV ered by several layers of non-nucleated squamous cells.
a
lo and STI transmission. The inferences from these find- Abrasion of the superficial squamous epithelial cells
n
ow ings, however, are limited, as the study was conducted during intercourse is thought to allow access of HPV
D
using a sample of rats. to its target cells. Anal epithelia could be especially sus-
ceptible if inadequate lubrication were associated with
HPVs and anal cancers. Like cervical cancers, anal anal intercourse (or penetration by other objects).
cancersareassociatedwithHPVinfection(Josephetal., However, no studies document the frequency or extent
2008;Palefskyetal.,2001;Scottetal.,2008).Thepreva- oflocaltraumaassociatedwithanalsex,andnonehave
lence of anal cancers in heterosexual men and women attempted to demonstrate reduction in local trauma
has risen steadily over the past four decades, whereas associated with lubricant use. Abrasions to the penile
the prevalence of cervical cancers in women has skin may also occur during anal intercourse, increasing
declined. Anal cancer in the general population is still the possibility of HPV infection should the partner
relatively rare (i.e., roughly two to three cases per be infected. Although penile cancers are associated
100,000), with increased risk among those who are with HPV, we find no data that directly links anal
infected with HIV (Bower et al., 2004; Chiao, Krown, intercourse to increased risk of HPV-associated penile
Stier, & Shrag, 2005; Johnson et al., 2004; Palefsky cancer.
et al., 2001). In some samples of women, it has been MostgenitalHPVinfectionsareclinicallyinapparent,
found that the prevalence of anal HPV is actually and are usually resolved by the immune system. Clear-
higher than the prevalence of cervical HPV infection ance rates of anal HPV may differ when compared to
(Melbye et al., 1996; Palefsky et al., 2001; Williams vaginalclearancerates(Shvetsovetal.,2009).Longitudi-
et al., 1994). This difference may help account nalfindingssuggest that analHPV infections inhealthy
for the increased incidence of anal cancers in women. women resolve quickly, although anal intercourse is
128
HETEROSEXUALANALSEXUALITY
among the non-viral factors found to delay clearance tion, suggesting potential for more severe damage to
(Shvetsov et al., 2009). Early stages of anal cancer can the potentially more fragile rectal epithelia (Adriaens
be identified by Papanicolaou cytology, analogous to & Remon, 2008; Fuchs et al., 2007; Sudol & Phillips,
screening for cervical cancer. However, no data docu- 2004). As development of vaginal microbicides pro-
ment reduction in anal cancer rates or improvement in ceeds, careful study of use with anal intercourse is
survivalassociatedwithsuch screening. important (Buck et al., 2006; Fuchs et al., 2007; Long-
field, Astatke, Smith, McPeak, & Ayers, 2007).
Gonorrhea,chlamydia,herpes,andotherSTIs. Many Fewstudiesaddresspotentialadverseeffectsofother
studies have reported higher STI rates among hetero- products associated with anal sex (e.g., desensitizing
sexuals with anal intercourse experience when com- cream or anal douches). Although unstudied among
pared to those without (Auslander et al., 2009; heterosexuals, rectal douching and enema use may
Baldwin & Baldwin, 2000; Bogart et al., 2005; Gross increase HIV and STI risk among MSM (Coates et al.,
et al., 2000; Kim et al., 2003). For example, lifetime 1988; Koziol, Saah, Odaka, & Munoz, 1993; Schreeder
history of anal intercourse was associated in univariate et al., 1982). Men who used anal enemas were 7.8 times
(but not multivariate) analyses with herpes simplex morelikelytodevelopproctitisassociatedwithlympho-
virus–Type 2 (HSV–2) seropositivity (Wald, Koutsky, granuloma venereum stains of chlamydia trachomatis
Ashley, & Corey, 1997). However, findings from other (De Vries et al., 2008). Topical desensitizing creams are
studies found no such association. Gorbach et al. used to make anal sex more comfortable by numbing
(2009) reported finding no relationship between vaginal the anus (Hilton, 2007). The active agents can include
0
1 and urethral STI (chlamydia trachomatis, neisseria lidocaine, tetracaine, benzocaine, and prilocaine—all of
0
2
e gonorrhoeae, mycoplasma genitalium, trichomonas whichmayposehealthriskswhenabsorbedsystemically.
n
Ju vaginalis, and genital herpes [HSV–2]) and anal inter- TheU.S.FoodandDrugAdministrationissuedanadvi-

9
2 course experience. Screening studies where both genital sory inFebruary2007, warning againstpotentialhealth

3
:4 and anal or rectal specimens are obtained show that hazards associated with use. The extent to which these
6
1 anal intercourse is an STI risk factor, but only for products may have negative sexual health consequences
:
t
A men (Nelson et al., 2007). isunknown. Anal bleachingisaprocedurethatlightens

]
ty A number of studies link anal intercourse to changes the dark skin around the anus. The procedure is done
i
rs in vaginal microflora and reproductive tract infections, solelyforcosmeticpurposes,usingacreamthatcontains
e
v
i which can increase the likelihood of STI transmission up to 20% hydroquinone. Hydroquinone is a suspected
n
U
n (Newton, Piper, Shain, Perdue, & Peairs, 2001; Sharma carcinogen and banned in several counties, including
r
te et al., 2004). For example, receptive anal intercourse the United Kingdom. A participant in a recent qualita-
s
e
w before vaginal intercourse is independently associated tive investigation of rectal microbicide use discussed
h
t
or with the acquisition of bacterial vaginosis (Cherpes, thepracticeofanalbleachingasassociatedwithprepara-
N
[ Hillier,Meyn,Busch,&Krohn,2008).Themechanisms tionforanalintercourse,stating,‘‘...andbleachthearea
:
y
B by which anal intercourse influences vaginal microflora to lighten it up, you know, keeping it attractive.... So

d
de areunclearbecauseoverlapinthetwomicrobialcommu- there is really a lot that goes into it...maintaining a
a
lo nitiesissubstantial(VanderPoletal.,2009).Carriageof good-lookingbooty’’ (Exner etal., 2008).
n
w
o typically ano-rectal organisms on the penis (e.g., on the
D
glans or beneath the foreskin) has not been assessed.
Behavioral Antecedents and Correlates
These issues are relevant because most studies of anal
sex and vaginal microflora changes are associational. There has been virtually no systematic investigation
oftheindividualandinterpersonalfactorsthatmotivate
Lubricants and other products. A variety of sexual behavioral occurrence and frequency of heterosexual
lubricants is commercially available, although many anal sex. What is currently known is primarily based
womenusesaliva,vaginalfluids,orlubricatedcondoms on retrospective studies. For example, research suggests
(orusenolubricationatall)foranalintercourse(Exner that alcohol and other substance use is associated with
et al., 2008). Commercially available water-based lubri- anal intercourse experience; however, the lack of
cants typically contain glycerin or propylene glycol, as event-leveldatamakesitimpossibletodetermineifalco-
well as one or more parabens, as preservatives. All of hol or substances were used at the time that anal sex
these products are compatible with latex condoms. occurred. Hensel, Fortenberry, and Orr (2008) pub-
Silicone-based lubricants typically do not contain pre- lishedresultsfromadailydiarystudyofsexualbehavior
servatives and are also compatible with latex (but not in adolescent women, including event-level data on het-
with silicone sex toys). Petroleum-based lubricants con- erosexual anal intercourse. The results indicated that
tinue to be in relatively common use, at least among days with both anal intercourse and vaginal intercourse
MSM. The influence of these products on HIV and were associated with younger age, alcohol use, higher
STI transmission is not extensively studied. Some sexual interest, greater negative mood, no coitus in the
commercially available lubricants cause vaginal irrita- previous week, and anal intercourse in the previous
129
MCBRIDEANDFORTENBERRY
week. Days that consisted of analintercourse only were attention to heterosexual anal sex, except in passing
associated with vaginal bleeding, no coitus in the past mention (Bancroft, 2009; Hyde & Delamater, 2008;
week, and days with anal intercourse and coitus in the Strong, Yarber, Sayad, & De Vault, 2006). Because
previous week. These findings suggest that event-level muchoftheresearch,todate,hasbeenconductedwithin
contextual factors may influence the occurrence of an infection risk paradigm, little consideration hasbeen
heterosexual anal intercourse. given not only to anal sexual pleasure, but also to anal
On a broader level, there has been speculation about sexuality. It is known that anal intercourse occurs less
the extent to which social and cultural factors, such as frequently than vaginal intercourse, is associated with
abstinence-based sexuality education and the prolifera- low levels of condom use, and is associated with other
tionofanalseximagesofheterosexualcouplesinporno- behavioralriskcharacteristics.Itisalsoknownthathet-
graphy,havecontributedtotherecentriseinbehavioral erosexual anal intercourse is often reported to occur
prevalence. withinthecontextofacommitted,monogamouspartner-
ship. Researchers have often overlooked the latter
Virginity. Much of the initial interest in under- because the risk for infection is low, although monoga-
standing the relationship between heterosexual anal mouspartnersmayeventuallychangeorextra-relational
intercourse and virginity was sparked by findings from partnersmayaffectrisk.Withinthecontextofarelation-
a study conducted by Sanders and Reinisch (1999). ship,itislikelythatsomeheterosexualsincorporateanal
The researchers found that among a sample of 589 sexualbehaviorsintotheirsexualrepertoiresonaregular
college students, 19% of respondents did not consider basis (McBride et al., 2008). For these individuals and
0
1 anal intercourse to be sex (Sanders & Reinisch, 1999). couples, anal sex may be a part of their sexuality, but
0
2
e Thus, an individual who engages in anal intercourse the meanings associated with it might be distinct from
n
Ju but abstains from vaginal sex may still label herself a those attached to other forms of sexual behavior within

9
2 ‘‘virgin.’’ Few published studies explore virginity as a therepertoire(i.e.,vaginalintercourse).

3
:4 motivating factor for anal sex; however, a study of To better understand feelings toward heterosexual
6
1 urban high school students (N¼2,026) in Grades 9 anal sex and the individual meanings ascribed to the
:
t
A through 12, who identified as virgins, found that 1% behavior, a qualitative analysis of the articles ‘‘The

]
ty of the sample had engaged in heterosexual anal inter- Bottom Line,’’ published in New York Magazine, (EM
i
rs course during the previous year (Schuster, Bell, & & LO, 2007) and ‘‘IsAnalSextheNewDealBreaker,’’
e
v
i Kanouse,1996).Morerecently,afocusgroupstudythat published in Men’s Style (Men’s Style, 2007), was con-
n
U
n evaluated the language and meaning that abstinence- ducted by Kimberly R. McBride in September 2007. In
r
te only-until-marriage program participants (8–17 years addition, a blog that related to the Men’s Style article
s
e
w old) assigned to the term abstinence found that anal was reviewed. Quotations from individuals who were
h
t
or intercourse was only mentioned in one focus group of interviewed for the articles or who posted comments on
N
[ six that were conducted (Goodson, Suther, Pruitt, & the blog were analyzed for themes, and those found to
:
y
B Wilson, 2003). Although the significance of the role of be recurrent were organized into conceptual categories.

d
de virginity as it relates to heterosexual anal intercourse Six broad categories were identified, including inti-
a
lo activities cannot be established based on three studies, macy–trust–gifting, novelty–variety, control–domina-
n
w
o these findings suggest that ‘‘virginity’’ may play a role tion, taboo–forbidden–erotic, pain–pleasure, and
D
intheoccurrenceofanalintercourseamongadolescents. relationship status–context. To confirm themes, chat
roommessagesonanumberofothersiteswerereviewed.
Pornography and erotica. The influence of porno- Sites were diverse in content and audience, but all had
graphy on sexual behaviors is documented in adoles- discussions of anal sexual behaviors—typically, inter-
cents and adults, particularly its effects on aggression course. No new themes arose. Examples of quotations
and risk taking (Brown & L’Engle, 2009; Vega & supportingeachcategoryareasfollows:
Malamuth, 2007; Wosnitzer & Bridges, 2007). The
coupling of prevalent heterosexual anal sex images in
pornography and erotica and the rise inbehavioralpre- . Intimacy–trust–gifting: ‘‘For me, anal sex is very
valencehasledtothesuggestionthatpornographymay intimate,muchmoresothanregularsex.’’(Female
beinfluencingtheactualincidenceofanalsex.Wecould respondent)
notfindanyevidencetosupportorrefutethepossibility. . Novelty–variety: ‘‘Variety is sexy.’’ (Male
respondent)
Anal sexuality. An apparently prevalent assump- . Control–domination:‘‘Formostofmyfriends,it’s
tion (with associated social and legal proscriptions) is sort of a domination thing.’’ (Male respondent)
thatpenile–vaginalintercourseis‘‘normal’’heterosexual . Taboo–forbidden–erotic:‘‘...andbreaking taboos
sexuality.Atbest,heterosexualanalsexualbehaviorsare is sexy.’’ (Female respondent)
treated as marginal corollaries to coitus. For example, . Pain–pleasure: ‘‘I think it can feel good for
three widely cited human sexuality texts give no specific anyone—except if you’re too uptight about it,
130
HETEROSEXUALANALSEXUALITY
meaning, you’re literally tight assed.’’ (Female women found anal sex to be unpleasurable or unerotic.
respondent) However,45%oftheoverallsampleofwomensaidthat
. Relationship status–context:‘‘Ifirstdiditwithmy they had engaged in anal receptive penetration with a
husband. It was a regular part of our married sex fingerorsextoy(e.g.,butt-plug,dildo,orvibrator),sug-
life, and I enjoyed it.’’ (Female respondent) gestingthatpleasuremaybeabehavioralmotivationfor
somewomenwhoengageinanalactivities.JackMorin,
Although not generalizable, the quotations suggest in his 1986 book on anal pleasure and health, wrote:
that for a certain number of heterosexuals, anal inter-
course is pleasurable, exciting, and perhaps considered Thisbriefoverviewrepresentsvirtuallyallthatisknown
more intimate than vaginal sex. Many of the chats that aboutanalsexualityintheUnitedStates,andalsoindi-
werereviewedfocusedontheimportanceofcooperation cates the limited scope of research into other times and
and communication among partners. Anal intercourse societies. Although this information is interesting, per-
haps even provocative, when we compare it with the
was seen as something that had to be worked toward
depth and detail of materials available about other
bybothpartnersinorderforittobeamutuallypleasur-
sensual=sexual behaviors, especially in studies of
able experience. It required more planning than vaginal
Americans, it is clear that we are faced with an ‘‘infor-
intercourse, including proper preparation. A number of
mation gap.’’ For example, we know next to nothing
messages discussed aspects of preparation and gave
aboutpeople’s feelings towardanalpleasure. (p.14)
advice—typically, ‘‘use a lot of lube,’’ ‘‘go very slow,’’
and‘‘incorporateanalplaypriortopenilepenetration.’’ Morin’s passage was written in 1986; over two dec-
0
1 Remarkably,mostoftheadvicewasconsistentwiththat ades later, virtually nothing is known about people’s
0
2
e of professional sexual health educators and therapists. attitudes toward heterosexual anal pleasure and its
n
Ju However, the nature of these data makes it impossible influence on behavioral motivations.

9
2 to determine whether the opinions presented are repre-

3
:4 sentative of anal intercourse experiences for a substan- Gender and sexual agency. The findings from the
6
1 tial number of practitioners or whether they reflect a aforementioned studies raise questions about the role
:
t
A small number of individuals who happen to enjoy or ofgenderandsexualagencyinactsofheterosexualanal

]
ty prefer this form of sexual interaction over vaginal sex. sex. Although prevalence rates of anal intercourse are
i
rs Understanding how anal sex behaviors are introduced roughly the same by sex, these studies suggest that
e
v
i and negotiated, as well as the meanings individuals women’sratingsofpleasurearelowerthanmen’s.Simi-
n
U
n attach to these behaviors, will be important to under- larly,one study found that 47% of their all-female sam-
r
te standing anal sexuality. ple reported anal intercourse experience, with the
s
e
w majority evaluating it as a negative experience (Rogala
h
t
or Sexual pleasure. Few studies have devoted atten- & Tyden, 2003).
N
[ tion to sexual pleasure as a motivating factor for anal Theextenttowhichcoercionorviolenceplayarolein
:
y
B sex. A small number of studies have briefly commented someactsofanalsexmustbeconsidered.Sexualcoercion

d
de on sexual pleasure as one aspect of anal sex; however, andintimatepartnerviolencehavebeenconsistentlylinked
a
lo nonehasclearlyrelatedexperiencesofpleasuretobeha- to the risk for HIV and STIs (Josephs & Abel, 2009;
n
w
o vioralmotivation.Astudythatinvestigatedtheassocia- Kalichman, Williams, Cherry, Belcher, & Nachimson,
D
tions between the pleasurability of various sexual 1998). Typically, studies have assessed risk by measuring
activities and behavioral experiences with the activities condom use and other behavioral risk factors. For
foundgendermaineffectsforanalintercourse,withhet- example, a study investigating intimate partner violence
erosexualmenratinganalintercoursesignificantlymore and HIV risk among methadone-maintained women
pleasurable than women (Pinkerton, Cecil, Bogart, & (n¼416) in New York City found that intimate partner
Abramson, 2003). Among women, higher pleasure rat- violence (sexual or physical) was associated with having
ingswerecorrelatedwithincreasedbehavioralfrequency unprotected anal intercourse (El-Bassel, Gilbert, Wu,
for all behaviors, except anal intercourse. An earlier Go,&Hill,2005).Astudythatinvestigatedtheprevalence
study of gender differences incollegestudents’attitudes andcorrelatesofanalsexamongyoung,inner-citywomen
toward sexual behaviors found that men had signifi- foundthatparticipantswhoreportedhavingamainpart-
cantly more positive attitudes toward anal intercourse ner mostly take the lead ‘‘in deciding what you do when
thanwomendid(Wilson&Medora,1990).Astudythat you have sex’’ was significantly associated with unpro-
explored young women’s motivations for engaging in tected anal intercourse (Friedman et al., 2001). Because
anal intercourse found that 58% of the women in their bothofthestudiesinquiredaboutunprotectedanalinter-
sample who had engaged in anal intercourse reported courseandnotintercourseitself,itisdifficulttodetermine
doing so at the request of their male partner (Flannery whetherintercoursewasunwantedorcoercive.
et al., 2003). These data do not provide information Sociocultural scripts for sexual behavior may contri-
onwhetherthisresultdiffersmarkedlyfrom genderdif- bute to such findings. Dominant sexual scripts are
ferences in coital initiation or whether the 58% of phallocentricandvalue‘‘insertive’’sexualbehaviorover
131