Anal sex

Written by Dr John Dean, specialist in sexual medicine and Dr David Delvin, GP and family planning specialist

What is it?

Anal sex means sexual activity involving the bottom – in particular, the type of intercourse in which the penis goes into the anus. It is often referred to as 'rectal sex'. Anal sex does carry some health risks, so please read our advice carefully.

Other types of sexual activity which involve the anus include:

'postillionage' – which means putting a finger into the partner's bottom.

insertion of 'butt plugs' – which are sex toys that dilate the anal opening and create a sensation of fullness.

use of vibrators on or in the anus (please see cautionary note below).

'rimming' – which is oral-anal contact; this carries a significant risk of infection.

'fisting' – which means putting the hand into the rectum; this activity is rare among heterosexual couples.

Taboos and infection

There are taboos surrounding the various types of anal sex – and particularly anal intercourse.

These may arouse strong feelings of moral indignation, guilt 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.

Research shows that, whether we like it or not, the anal area is equipped with many erotic nerve endings – in both men and women. So it is not surprising that many couples (including a lot of heterosexual ones) derive pleasure from some form of 'bottom stimulation'.

What about infection? 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 still a criminal offence punishable by long custodial sentences, corporal or even capital punishment. It remains forbidden in some states of the USA, and in some former colonies of Britain – including for instance Jamaica.

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 anal sex as a part of their sexual repertoire and that they are sure of the legal position on anal intercourse in the country that they are in.

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. About one third of heterosexual couples try it from time to time.

It is thought that 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 no doubt that anal intercourse carries a greater risk of transmission of HIV - the virus that can cause acquired immunodeficiency syndrome - 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 could perhaps predispose infected individuals to cancer of the anal canal.

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

Hepatitis C: is a cause of progressive and sometimes fatal chronic liver disease. Hepatitis C 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 sometimes cause mild to severe, or even (rarely) fatal, gastroenteritis. It is one of many viruses and bacteria that can be transmitted by oral-anal contact. Some E. coli strains (uropathic E. coli) can also cause urinary tract infections , ranging from cystitis to pyelonephritis - a serious kidney infection. E. coli very readily crosses the short distance between the female anus and the female urinary opening, so causing a urinary infection. Anal intercourse could facilitate this 'transfer' – particularly if it is immediately followed by vaginal intercourse.

Protection

Avoiding anal sex altogether is of course 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 the anal route.

The use of condoms and water-based lubricants, such as K-Y 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 have anal intercourse safely

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 to 'receive' it, 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 risk of the receptive partner passing faeces.

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 the receiving partner to find out whether penetration is comfortable and enjoyable. Having managed to accommodate one finger, you can run the finger around the anal canal - gently stretching it. This must be done delicately so as not to cause pain or injury.

Next, you can, if you wish, try and insert two fingers. If this is successfully achieved, the couple may agree 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.

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