Contextual Factors Surrounding Anal Intercourse in Women: Implications for Sexually Transmitted Infection/HIV Prevention

"You Feel Like Normal Sex is not Enough Anymore": Women's Experiences of Coercive and Unwanted Anal Sex with Men

In this article, we explore the gendered dynamics of coercion described by 18 women we interviewed about their experiences of unwanted and nonconsensual heterosexual anal sex. Several women referred to what they believed to be the normative status of heterosexual anal sex. In many cases, the socially coercive effects of perceived norms intertwined with threads of interpersonal coercion, leaving women feeling pressured to agree to, or little room to refuse, anal sex they did not want. We discuss the ways that new sexual norms can translate into new pressures for women within the gendered framework of heterosexual relationships.

Anal Intercourse among Heterosexual Young Adults: A Population-Based Survey in Switzerland

Anal intercourse (AI) among heterosexuals is an understudied and taboo subject. This 2017 Swiss national study aimed to describe the characteristics and motivations of heterosexual young adults practicing AI. Participants with any same-sex experience, same-sex attraction or non-heterosexual identity were excluded. The Federal Statistical Office provided the initial sample and potential participants were recruited through postal mail inviting them to an online survey (response rate 15.1%). The sample comprised 3892 participants (52% males; 54% of the overall sample, mean age 26.3 years). Overall, 55% of women and 56% of men had never experienced AI, 17% and 12% had done it once and 28% and 32% more than once, respectively. We found that participants engaging in AI had higher odds of practicing intercourse while intoxicated, being younger at first sexual experience, not using a condom at last intercourse and reporting a history of sexual transmitted infections. The main reason reported by both genders for engaging in their first AI was being curious followed by being in love. In conclusion, AI is a widespread practice among heterosexual young adults and health professionals should be especially attentive to it.

Promoting safer sex in the context of heterosexual anal intercourse: A scoping review

AIMS AND OBJECTIVES

To locate and summarise existing literature regarding safer sex practices specific to heterosexual anal intercourse and identify promising health promotion strategies.

BACKGROUND

Much of the literature regarding anal intercourse and safer sex is related to men who have sex with men. However, some studies suggest there are more women than men engaging in unprotected receptive anal intercourse. The risks associated with this sexual practice have been well documented, although many healthcare providers fail to ask about anal intercourse while addressing safer sex in the heterosexual population.

DESIGN

The study was based on Arksey and O'Malley's 2005 five-step methodology.

METHODS

A search was conducted of MEDLINE; CINAHL; PsycInfo; Cochrane; and PubMed. Databases were searched from 1990-2020. The 72 studies selected were classified according to their main area of focus. A grey literature search was also included. This scientific submission has been assessed for accuracy and completeness using the PRISMA-ScR guideline criteria (File S1).

RESULTS

The literature in this area is heterogeneous in terms of method and topic. Prevalence and incidence (n = 26) in addition to sexually transmitted infection risks (n = 26) related to heterosexual anal intercourse are well understood. However, there is limited information on condom use (n = 6), factors that influence heterosexual anal intercourse (n = 10) and health promotion strategies for this population and practice (n = 4). Two websites that mentioned heterosexual anal intercourse risk reduction activities were included.

CONCLUSIONS

Although heterosexual anal intercourse appears to be an increasingly common sexual practice, very little is known about health promotion strategies nurses might use for encouraging safer sex in this population.

RELEVANCE TO CLINICAL PRACTICE

Increased awareness of the prevalence and risks of heterosexual anal intercourse could enhance nurses' harm reduction strategies. Screening for sexually transmitted infections may be based on incorrect assumptions about sexual practices or due to stigma linked with anal intercourse. Reducing unprotected heterosexual anal intercourse will reduce sexually transmitted infections and their long-term sequelae.

Individual and Partnership Factors Associated with Heterosexual Anal Intercourse Among Attendees of Public Sexually Transmitted Disease Clinics in Los Angeles County

Heterosexual anal intercourse (HAI) is an understudied sexual behavior and poses unique challenges to the prevention of sexually transmitted diseases (STDs). This study aimed to explore individual and partnership characteristics associated with HAI. This study used data collected from 243 young people who attended STD clinics in Los Angeles County between April 2012 and May 2014. Participants reported on sexual behaviors with their last three sexual partners. Hierarchical, mixed effects, repeated-measures analyses were used to assess partner-level (demographic) and individual-level (demographic and behavioral) factors associated with recent (past 6 months) HAI. Thirty-two percent of participants (n = 243) reported HAI with at least one recent sex partner, and 49% reported ever having anal intercourse (AI). After adjusting for demographic characteristics, HAI was more than twice as likely to occur in relationships (n = 503) lasting more than a year compared to relationships lasting less than one month. HAI was also more likely to occur in relationships where intimate partner violence (IPV) was reported either as IPV initiated by the respondent (aOR = 2.18, 95% CI 1.08-4.41) or IPV initiated by the partner (aOR = 2.38, 95% CI 1.27-4.47). Among our participants, a substantial proportion reported HAI in the recent past 6 months and nearly half reported lifetime AI. Notably, our results indicate the importance of relationship contexts for people engaging in HAI and highlight the increased risk of STD/HIV transmission in the context of relationships with intimate partner violence victimization and perpetration.

The Anal Sex Stigma Scales: A New Measure of Sexual Stigma Among Cisgender Men Who have Sex with Men

We conducted a series of studies to validate a new scale of stigma toward anal sex, culturally tailored to cisgender men who have sex with men (MSM). In Study 1 we conducted in-depth interviews (N = 35) to generate items. In Study 2, we reduced the item pool through an online survey (N = 268), testing scale performance, dimensionality, and convergent and discriminant validity. For Study 3, we recruited another online sample (N = 1605), randomized to exploratory or confirmatory factor analyses to finalize item reduction, then assessed validity among sexually active MSM (n = 1263). Final subscales encompassed self-stigma (6 items, Cronbach's α = .72), provider stigma (5 items, Cronbach's α = .79), and omission of information (6 items, Cronbach's α = .73; full 3-factor scale = .80). We developed a 17-item measure, grounded in the lived experience of cisgender MSM. Future work should examine associations with health-seeking behavior.

Childhood Traumatic Experiences and Receptive Anal Intercourse Among Women

CONTEXT

Receptive anal intercourse (RAI), which has become increasingly common among U.S. heterosexual women, is associated with STDs, including HIV, when it is unprotected and coercive. Childhood traumatic experiences may increase sexual risk behavior, but the relationship between childhood trauma and RAI among women has not been examined.

METHODS

Data from 4,876 female participants in Waves 1 (1994-1995), 3 (2001-2002) and 4 (2007-2008) of the National Longitudinal Study of Adolescent to Adult Health were used to examine associations between nine self-reported childhood traumas (neglect; emotional, physical and sexual abuse; parental binge drinking and incarceration; and witnessing, being threatened with and experiencing violence) and RAI during adulthood using modified Poisson regression analysis. Whether depression, low self-esteem, drug use, relationship characteristics or sex trade involvement mediated the relationship between trauma and RAI was also explored.

RESULTS

Forty percent of the sample reported having engaged in receptive anal intercourse. After adjustment for sociodemographic characteristics, eight of the nine childhood traumas were associated with increased risk of RAI (adjusted prevalence ratios, 1.2-1.5); the strongest association was with experience of violence. Each unit increase in the number of traumas yielded a 16% increase in RAI prevalence. In mediation analyses, only drug use and relationship factors slightly attenuated the association between childhood trauma and RAI (1.2 for each).

CONCLUSIONS

Women with a history of childhood trauma may be at increased risk of engaging in RAI, highlighting the importance of screening and trauma-informed education in sexual health settings. Pathways linking childhood trauma and RAI among women are complex and warrant further research.

Examining Heterosexual Women's Anal Sexual Health Knowledge and Product Use

Prevalence rates indicate that receptive anal sex is increasingly part of heterosexual women's sexual repertoire. However, there is a body of literature linking this behavior to risk for adverse sexual health outcomes. Women's anal sexual health knowledge and awareness of behaviors associated with elevated risk have received less attention in the research literature. The aim of the current study was to examine anal sexual health knowledge and product use among heterosexual women aged 18 to 30 years. A total of 33 self-identified heterosexual women recruited from the general population participated in one of six focus groups. The results suggest that knowledge was variable. Salient sexual health themes centered on risks of human immunodeficiency virus/sexually transmitted infections (HIV/STIs), other infections, and physical harm/damage. Product-use themes included cleanliness/hygiene, comfort, and product safety. Participants expressed the desire for anal sexual health education. The results have implications for sexual health research, education, and clinical practice.

Heterosexual Anal and Oral Sex in Adolescents and Adults in the United States, 2011-2015

BACKGROUND

Heterosexual anal and oral sex are related to the acquisition and transmission of sexually transmitted diseases (STDs). As common reportable STDs (chlamydia, gonorrhea, and syphilis) in the United States are increasing, it is important to understand recent oral and anal sexual behaviors.

METHODS

We examined the prevalence and correlates of heterosexual anal and oral sex, associated condom use, and having multiple partners among men and women aged 15 to 44 years.

RESULTS

Approximately one third of women and men had ever engaged in anal sex, including 11% of adolescents (15-19 years). Most women and men had ever received or given oral sex (at >75%). Six percent and 7% of women and men, respectively, used a condom at last oral sex compared with 20% and 30% who used a condom at last anal sex. Having multiple sex partners in the past year was most common among adolescents, never or formerly married persons, and those who had a nonmonogamous partner. Less than 10% reported multiple anal sex partners in the past year. A substantial minority had multiple oral or anal sex partners; black women and men had the highest reports of oral sex partners by race/ethnicity.

CONCLUSIONS

Anal and oral sex are common sexual practices. Given the low rates of condom use during these behaviors, it is important that recommendations for sexual risk assessments are followed. Tailored messaging regarding risk for STD and human immunodeficiency virus acquisition during oral and anal sex may benefit adolescents, singles, and divorced individuals. Future discussions regarding the benefits of extragenital STD testing for heterosexuals may be useful.

Heterosexual Women's Anal Sex Attitudes and Motivations: A Focus Group Study

Focus group methods were used to explore heterosexual women's receptive anal sex attitudes and motivations. Behaviors under investigation included penile-anal intercourse (PAI), manual-anal stimulation, oral-anal contact, and the use of sex toys. A total of 33 self-identified heterosexual women ages 18 to 30 recruited from two metropolitan areas in the Midwestern United States participated in one of six focus groups. The findings suggest that women viewed heterosexual anal sex as an emerging norm. Attitudes and motivations were complex and varied by behavior. Dominant themes included curiosity, pain, pleasure, and stigma. Relational factors, including acquiescence, coercion, and consent, were also salient among participants. Factors that influence anal sexual behaviors may not be entirely distinct from those that influence other sexual behaviors; however, factors that influence anal intercourse may be distinct from those that influence nonintercourse anal sex. Improved understanding will allow scientists to better understand the integration of anal sex behaviors into the broader sexual repertoire.

Prevalence and Correlates of Heterosexual Anal Intercourse Among Men and Women, 20 U.S. Cities

Heterosexual anal intercourse (HAI) is not an uncommon behavior and it confers a higher risk of HIV transmission than vaginal intercourse. We examined data from heterosexuals recruited in 20 US cities for the 2013 National HIV Behavioral Surveillance system. We assessed correlates of reporting HAI in the previous year. Then, among people reporting HAI in the past year, we assessed what event-level factors are associated with having HAI at last sex. Thirty percent of women and 35 % of men reported HAI in the past year. Among people who had HAI in the past year, those who had HAI at last sex were more likely to have a partner who was HIV-positive or of unknown status or to have exchanged money or drugs for sex at last sex. Information that highlights the risk of HIV transmission associated with HAI would complement existing HIV prevention messages focused on heterosexuals in the U.S.

Social and psychological correlates of unprotected anal intercourse among Hispanic-American women: implications for STI/HIV prevention

Heterosexual anal intercourse is associated with increased risk for HIV and other sexually transmitted infections. Research on the social and psychological risk factors associated with heterosexual unprotected anal intercourse among Hispanic women in the USA is limited. We examined demographic, mental health, relationship power, sexual self-efficacy, self-esteem, acculturation and HIV knowledge as correlates of unprotected anal intercourse among 514 HIV-negative Hispanic women, 18 to 59 years of age, residing in one urban county in southern Florida. In both unadjusted and adjusted results, the likelihood of engaging in unprotected anal intercourse was associated with food insecurity in the past 30 days (adjusted odds ratio [AOR] = 1.57, 95% confidence interval [CI] 1.03, 2.40) and more interpersonal power attributed to the male partner (AOR = 1.63, 95%CI 1.08, 2.45). Not significant, yet of possible importance, were ever having engaged in exchange sex (AOR = 1.96, 95%CI = 0.97, 3.98) and lower HIV knowledge (AOR = 0.80, 95%CI = 0.63, 1.01). Interventions aimed at reducing heterosexual unprotected anal intercourse risk for HIV infection among Hispanic women may benefit by addressing socioeconomic and interpersonal issues, and assessing HIV knowledge and comprehension.

Anogenital infection by Chlamydia trachomatis and Neisseria gonorrhoeae in HIV-infected men and women in Salvador, Brazil

Background

Infections caused by Chlamydia trachomatis and Neisseria gonorrhoeae are the most common bacterial sexually transmitted infections throughout the world. These sexually transmitted infections are a growing problem in people living with HIV/AIDS. However, the presence of these agents in extra genital sites, remains poorly studied in our country. The objective of this study was to estimate the prevalence of Chlamydia trachomatis and Neisseria gonorrhoeae anal and genital infection in people living with HIV/AIDS followed in a reference center in Salvador, Brazil.

Methods

Cross-sectional study, from June 2013 to June 2015. Proven HIV-infected people attending this reference center were invited. Clinical and epidemiological data were obtained through interview with standardized form. Chlamydia trachomatis and Neisseria gonorrhoeae screening was performed using qPCR (COBAS 4800^® Roche).

Results

The frequency of positive cases of Chlamydia trachomatis and Neisseria gonorrhoeae was 12.3% in total, 9.2% cases amongst women and 17.1% amongst men. We found 14.0% of positive cases in anus and 3.1% in genital region in men, while 5.6% and 3.6%, in women, respectively. Among men, anal infection was associated with age <29 years (p = 0.033), report of anal intercourse (p = 0.029), pain during anal intercourse (p = 0.028). On the other hand, no association between genital infection and other variables were detected in bivariate analysis. Among women, we detected an association between Chlamydia trachomatis genital infection and age <29 years (p < 0.001), younger age at first sexual intercourse (p = 0.048), pregnancy (p < 0.001), viral load >50 copies/mL (p = 0.020), and no antiretroviral use (p = 0.008). Anal infection in women was associated with age <29 years old (p < 0.001) and pregnancy (p = 0.023), and was not associated with report of anal intercourse (p = 0.485).

Conclusion

Missed opportunities for diagnosis in extra genital sites could impact on HIV transmission. The extra genital sites need to be considered to break the HIV and bacterial sexually transmitted infections chain-of-transmission.