What is it?
Anal sex encompasses a variety of commonly practised sexual activities. Although there is nothing remarkable about them in practical terms, there are taboos surrounding them that may arouse strong feelings of moral indignation and anxiety. It is important to remember that while some people find these activities repugnant, others may find them stimulating, exciting, and a normal part of their sexual intimacy.

Most sexual activities carry a risk of transmission of sexually transmitted diseases (STDs) from gonorrhoea and herpes, to hepatitis B and HIV. There is evidence that anal intercourse carries a higher transmission risk than almost any other sexual activity. Information about these risks is given below.

Consent
What consenting adults enjoy sexually in the privacy of their homes is their own business provided that the law does not prohibit it. The key issues are legality and consent. In the UK, anal intercourse is a legal activity between consenting men and women aged 16 and over, in both heterosexual and homosexual relationships, except in Northern Ireland where it's 17 and over. In some countries it is a criminal offence punishable by long custodial sentences, corporal or even capital punishment.

Consent freely given by both partners is an essential feature of sexual activity in a loving relationship. Many individuals, both men and women, may have secret fantasies involving anal intercourse but feel unable to discuss them with their partner. Some may try and pressurise their partner to have anal intercourse, even though the partner does not share their interest. Some partners will reluctantly acquiesce, others may be pressured or even physically forced to allow it. Forcing or pressurising a partner to submit to an activity that they find distasteful or degrading is completely unacceptable behaviour. Intoxication with drugs or alcohol is associated with lowering inhibitions and experimentation with unusual or unsafe sexual behaviour and can lead to serious consequences. It should be remembered that in the absence of freely given consent, the very serious criminal offences of assault and rape are committed. Therefore, it is essential that both partners agree that they wish to try it as a part of their sexual repertoire and that they are sure of the legal position on anal intercourse in the country of their residence.

What does it involve?
Anal sex may include the following activities:

anal intercourse - penetration of the anus with the penis or, possibly, with a dildo or vibrator.

fisting - insertion of the fingers, hand, or even the forearm, into the anus.

rimming - oral contact with the anus for sexual stimulation.

Who does it?
There is a common misconception that anal sex is practised almost exclusively by gay men. This is certainly not the case. An estimated one third of gay couples do not include anal intercourse in their lovemaking with about one third of heterosexual couples doing so from time to time. About 10 per cent of heterosexual couples have anal intercourse as a regular feature of their lovemaking. In absolute numbers, more heterosexual couples have anal sex than homosexual couples.

Is it safe?
Anal sex, if practised with care, is possible for most couples. It does, however, carry additional health risks and there are safer sexual practices that couples can enjoy. The main health risks, which affect both heterosexual and homosexual couples, are described below.

Human immunodeficiency virus (HIV): there is good research evidence that anal intercourse carries a greater risk of transmission of HIV - the virus that can cause acquired immunodeficiency syndrome (AIDS) than other sexual activities, particularly for the receptive partner.

Human papilloma virus (HPV, wart virus): can be transmitted during anal intercourse and lead to anal warts, which in turn can predispose infected individuals to cancer of the anal canal.

Hepatitis A (infectious hepatitis): is a viral infection that can cause jaundice and abdominal pain. It is not usually a serious illness, although sufferers can feel very ill. It can be transmitted by oral-anal contact.

Hepatitis C: is a cause of progressive and sometimes fatal chronic liver disease. It may be transmitted by anal intercourse, although this seems to be a rare occurrence. Sharing of equipment for intravenous drug use is a far more important risk for transmission.

Escherichia Coli (E. Coli): may cause mild to severe, or even fatal, gastroenteritis. It is one of many bacteria and viruses that can be transmitted by oral-anal contact. Some E. coli strains (uropathic E. coli), probably transmitted during anal intercourse, can also cause urinary tract infections, ranging from cystitis to pyelonephritis - a serious kidney infection.

Protection
Avoiding anal sex altogether is the best way of avoiding these risks. There are other, safer sexual practices that can be exciting and rewarding, but many couples may still wish to try it. The use of condoms and water-based lubricants, such as KY Jelly, will offer some protection. Other lubricants may cause condoms to split, as will over-energetic thrusting without adequate lubrication. Specially toughened condoms designed for anal intercourse may offer more protection.

How to safely perform anal intercourse
Anal intercourse involves the penetration of the anus and rectum with the erect penis for the purpose of sexual stimulation. It is possible for both men and women, although care is needed for it to be safe and comfortable.

Ensure the anal area is clean and the bowel is empty. This is important both aesthetically and practically. If the bowel is empty, there is no more risk of the receptive partner passing faeces during anal sex than there is of the insertive partner passing urine.

The 'receptive' partner must be able to relax their anal sphincter in order to accommodate the erect penis. The anal sphincter is a ring of muscle that can be contracted or relaxed under voluntary control. Forced penetration may result in tearing of the sensitive skin around the anus or the sphincter itself. This may result in severe anal pain or even faecal incontinence.

Try gently inserting a lubricated finger perhaps covered by a condom or glove into the anus first. This will enable them to find out whether penetration is comfortable and enjoyable. Having managed to accommodate one finger they should run the finger around the anal canal gently stretching it. This must be done gently so as not to cause pain or injury.

Next they should try and insert two fingers. If this is successfully achieved they may wish to try with a well-lubricated penis or with a butt plug (a broad-based anal dilator), dildo or vibrator (see below about the risks of sex aids and anal sex).

Gentleness, care, adequate lubrication and anal relaxation are required, not the insertive partner pushing harder! If condoms are used for penile penetration, which is advisable to reduce the risk of sexually transmitted disease, it is important to use a water-based lubricant. The insertive partner must control their thrusting, so as to give the receptive partner time to allow their sphincter to relax. With time and practice, this will become easier.

Drugs and anal sex

Muscle relaxant drugs (amyl nitrate, butyl nitrate, glyceryl trinitrate) have been tried to make anal intercourse easier or more comfortable. Amyl nitrate 'poppers' sold in small bottles for inhalation, are popular in the gay community and have a reputation both for enhancing the intensity of orgasm and helping relax the anal sphincter. There is no real evidence to support these assertions and its use is NOT recommended. It is important to remember that amyl nitrate is a potent drug with several side effects, including facial flushing, headaches, dizziness and low blood pressure, which may lead to faintness and loss of consciousness. Amyl nitrate, when taken with sildenafil (Viagra), may cause a catastrophic drop in blood pressure with potentially fatal consequences. These drugs must NEVER be taken together.

Local anaesthetics, such as lignocaine (Lidocaine) cream or even locally applied cocaine, have been used to reduce anal pain during intercourse. By numbing the anal skin there is a real risk of causing serious injury to the anal sphincter through over-vigorous thrusting. By following the steps above it is possible to gently dilate the sphincter for comfortable intercourse. The purpose of pain is to make us aware that we are causing injury and, therefore, local anaesthetics should be avoided. Another problem with local anaesthetics is that they may make the penis of the insertive partner numb. This may lead to problems with erection, orgasm and ejaculation.

Fisting
This involves the insertion of the whole hand or forearm into the anus or vagina for sexual stimulation. With adequate relaxation it is physically possible and may be acceptable and enjoyable for some couples. But the diameter of the hand or forearm is so much greater than that of the penis there is an increased risk of anal injury. Good anal relaxation in the receptive partner and care by the insertive partner are essential.

Rimming
Rimming involves oral contact with the anus for sexual stimulation. In order to reduce the risk of transmission of infection, good anal hygiene before sex and good oral hygiene after sex is essential.

Sex aids and anal sex
Some couples will prefer to use some form of sex aid for insertion into the anus or individuals may use them for solitary sexual stimulation. The same principles apply as for genital insertion in that anal relaxation is more important than pushing. Sex aids must be kept clean and cleaned between use by each partner. Condoms may be placed over sex aids as an additional precaution.

One additional risk from the use of sex aids in anal sex is that of losing the aid into the rectum. Most medical school pathology museums have a wide selection of novel foreign bodies recovered from the rectums of both men and women, ranging from vibrators to milk bottles. Human ingenuity seems to know no bounds in this area, but it is incredibly foolish to insert potentially breakable objects into the anus and terrible injuries may result. If you do lose a sex aid into the rectum you should attend the Accident and Emergency department of your local hospital as soon as possible, however embarrassing it may be. The situation will only get worse if it is neglected and the object may break or become more difficult to recover.

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