“Back Door” Shenanigans: Yes, this blog is on anal intercourse (finally!)

What a journey our attitude towards anal intercourse has had over the last few years. From twerking, to Kim Kardashian's epic glistening behind on the cover of Paper Magazine, to 2014 being named the “Year of the Booty” all things ass-related have taken on a mainstream edge. Once considered hardcore taboo, anal intercourse now appears to be a popular, even commonplace, act in the heterosexual bedroom. In fact, 36% of women and 44% of men aged 25-44 in the US have had heterosexual anal intercourse (HAI) at least once (Chandra, Mosher, Copen, & Sionean, 2011). Is this new? No. HAI has been in vogue since at least the Age of Antiquity dating back to the Ancient Greeks (McBridge & Fortenberry, 2010). But, research on HAI typically uses self-report measures, like questionnaires, so it’s hard to determine if the frequency of anal s is actually increasing, or if respondents are simply more comfortable admitting they’ve had it over the years (Reynolds, Fisher, & Rogala, 2015).

Just so that we’re all on the same page, anal intercourse has been defined as a partnered sexual act involving the insertion and thrusting of one partner’s penis into the anus of the other (Merriam-Webster Dictionary Online, 2009). Anal play, though, includes anything from finger or sex toy insertion into, or oral sex on, the butt. So what’s the big deal going down about asses then? Well, for starters, there’s a large crack in the research. The majority of research is devoted to gay men, thus largely ignoring heterosexual women’s (and men’s) experiences (Fahs, Swank & Clevenger, 2014). Further, sexual risk-taking, increased risk of anal cancer among women, contraction of HIV, and low rates of condom use have been the focus of the anal intercourse literature, leaving connections between anal intercourse, power and pleasure largely neglected (Benson, Gilmore, Micks, McCoy, & Prager, 2019). So, by framing anal intercourse as just a health concern, we really don’t know much about whether heterosexual women (or men) derive pleasure from anal intercourse—or really anything about their experience with it (Benson et al., 2019). In the end then, more facts are crucial for heterosexual women to determine if they want to give their man the green light to their backdoor. 

A recent groundbreaking study by Benson et al. (2019) sought to address this gap in the HAI literature and found that the majority of women had a negative first experience with anal intercourse due to physical pain and/or feeling coerced. This finding appears to be consistent with previous findings, as women tend to have significantly less positive attitudes toward anal intercourse compared to men. In fact, 60% of young heterosexual men reported that they liked past experiences of anal intercourse but only 13% of heterosexual women had the same response (Fahs, Swank, & Clevenger, 2014). When asked why women engaged in HAI, minor motivators such as pregnancy prevention, maintaining perceived virginity status for religious reasons, and avoiding vaginal intercourse during menstruation were common. However, the researchers found that primary motivator behind women engaging in HAI was *cue the drum roll* to please their partner (Benson et al., 2019).

Cultural norms and media appear to be the primary culprits of this unfortunate reality. Cultural beliefs about gender and heterosexuality typically frame men as sexually assertive and women as sexually passive. Accordingly, sexuality scripts often place men in the directive role of initiating and determining the nature of the sexual interaction while women are expected to submit to men’s wishes (Fahs et al., 2014). Men’s pleasure is central in terms of our cultural understanding of sex (Murphy, 2017). Speaking of, there is a social norm called “rape culture,” wherein men coerce, convince, and pester women into various sex acts (Murphy, 2017). And, not only is this the norm, but men are often lauded when they succeed at this “game” as “players” (Murphy, 2017). Feminists argue that getting a woman to engage in anal intercourse is something men brag to their friends about; and not just because they enjoy the experience, physically, but because they know women don’t want to do it, that it is uncomfortable or even painful for women, and that it equates to a show of power (Murphy, 2017). In a recent GQ article (2017) in which men were asked why they sought anal intercourse, the majority said it was because it was “a harder-to-reach goal than old-fashioned intercourse” and the “ultimate final barrier” (Rubin, 2007). For other men, the appeal of anal penetration is less about the novelty and more about the psychology. For example, a respondent in the GQ interview said, "For most of my friends, it's sort of a domination thing…it’s basically getting someone in a position where they're most vulnerable” (Rubin, 2007). Thus, from the minimal research we have, it appears that anal intercourse is a complex negotiation that involves gendered understandings of pleasure as well as power (McBridge & Fortenberry, 2010). 

Ass-backwardly, another motivator of anal intercourse is that it increases relationship intimacy, which explains why the majority of anal intercourse occurs in monogamous relationships rather than with casual partners (McBridge & Fortenberry, 2010). When reviewing online blogs about anal intercourse, writers focused on the importance of cooperation and communication among partners. Anal intercourse was seen as something that had to be worked toward by both partners for it to be mutually pleasurable (McBridge & Fortenberry, 2010). Those who practice anal intercourse also said it required more planning than vaginal intercourse, including proper preparation and the building of trust with their partner (McBridge & Fortenberry, 2010). These bloggers are not wrong. The anus is not as flexible as a vagina - it’s tight, and its thin tissues can be easily damaged (Engle, 2018). So, feeling relaxed, working up to anal intercourse through inserting fingers and butt plugs first, leaving time for foreplay, using protection, and lots of lube as well as going slowly are essential for safe and enjoyable anal intercourse. Indeed, with proper preparation, a pro-anal mindset among both partners, and a strong relationship dynamic, anal intercourse can be pleasurable for both parties with the dual benefit of broadening a couple’s sexual repertoire and keeping the spiciness in the bedroom alive.

All in all, although there is a dearth of research on the health implications of HAI, there is an even greater paucity of research on anal intercourse and women’s sexual satisfaction. In order for women, and people in general, to avoid anal intercourse when they don't want to have it, and to have good anal intercourse when they do, we have to provide clear-cut, pleasure-based intercourse education in schools and at home. It would also be nice if media gave anal intercourse/play a more realistic tone as well; right now, it is simply sensationalized by media. Just because media are all about anal intercourse/play or just because we know how to do butt stuff safely now doesn’t mean anal intercourse/play is a given when you hook up. Anal intercourse is an area of sexual exploration where consent is also essential; so much can go wrong, and research shows that many heterosexual women feel coerced into doing it. Without comprehensive research and education, people will likely engage in anal intercourse in ways that can lead to pain, feeling coerced, and perhaps feelings of inequality within a partnership (even if brief). Let’s foster a generation of sexually mature and self-aware adults who have the freedom to explore their own sexuality and make informed choices. Without such awareness, it’s better for people to be safe than sorry and keep their backdoor shut.

 

Kaitlin Derbyshire

4th Year BAH Psychology, Queen’s University

 References

Benson, L.S., Gilmore, K., Micks, E., McCoy, E.L., & Prager, S.W. (2019). Perceptions of Anal Intercourse Among Heterosexual Women: A Pilot Qualitative Study. Sexual Medicine. 7(2): 198-206.

Chandra, A., Mosher, W., Copen, C., & Sionean, C. (2011). Sexual behavior, sexual, and sexual identity in the United States: Data from the 2006-2008 national survey of family growth. National health statistics reports, 1(36).

Engle, G. (2018, May). Anal Sex: What you need to know. Retrieved from https://www.teenvogue.com/story/anal-sex-what-you-need-to-know

Engle, G. (2017, August). How the normalization of anal sex has shifted the conversation about consent. Retrieved from https://www.marieclaire.com/sex-love/a5489/rise-in-anal-sex-statistics/

Fahs, B., Swank, E., & Clevenger, L. (2014). Troubling Anal Sex: Gender, Power, and Sexual Compliance in Heterosexual Experiences of Anal Intercourse. Gender Issues, 32(1): 19-38.

McBridge, K.R., & Fortenberry, J.D. (2010). Heterosexual anal sexuality and anal sex behaviors: a review. The Journal of Sex Research, 47(2): 123-136.

Murphy, M. (2017, July). No, Teen Vogue, the backlash to your anal sex article was not rooted in homophobia. Retrieved from https://www.feministcurrent.com/2017/07/20/no-teen-vogue-backlash-anal-sex-article-not-rooted-homophobia/

Reynolds, G., Fisher, D., & Rogala, B. (2015). Why Women Engage in Anal Intercourse: Results from a Qualitative Study. Archives of Sexual Behavior, 44(4): 983-95.

Rubin, P. (2007, July). Is anal sex the new deal breaker? Details. Retrieved from http://          www.details.com/sex-relationships/sex-and-other-releases/200707/anal-sex-new-deal-breaker

My genitals are always ‘in the mood’ but I’m not, and it’s putting a strain on my relationship.

Some of you might be reading this and be confused. “You can’t have too much of a good thing” … right? How can feeling too turned on “down there” be a bad thing? And how can it be bad for my relationship if I feel, or my partner feels, this way? If my partner experienced this, it would probably mean that they would always be “in the mood”, right? How could that be bad? 

From the outside looking in, having genitals being always “turned on” might not seem that bad. But, it is actually an extremely distressing and poorly understood condition that often has a negative impact on well-being and day-to-day functioning. The condition is called persistent genital arousal disorder (or PGAD, for short; see our blog on PGAD for more information). One of the most distressing parts of PGAD is that there is a mismatch between the sensations experienced in your genitals and what’s going on inside your head. In other words, your genitals are in the mood but your mind is not. It is thought that PGAD affects approximately 1% of the population[1, 2], and those with PGAD report experiencing high levels of depression, anxiety, and even suicidal ideation [3-9]. Despite the negative impact of this condition on mood and well-being, surprisingly little research has focused on it.

One area that, until recently, had not been studied is how this condition affects romantic relationships. People with other sexual difficulties (like genital pain conditions (see our blog on Vulvodynia), low sexual desire/interest, or erectile difficulties) often report feeling less satisfied with their romantic and sexual relationships than others who don’t have these sexual difficulties[10-19]. When studying a sample of individuals with distressing symptoms of persistent genital arousal (PGA), we found the exact same trend: people with PGA experience lower relationship and sexual satisfaction, higher levels of sexual distress, and more symptoms of anxiety and depression compared to those who do not have this condition. In addition, people with this condition report that it negatively affects their relationship in a number of ways. For example, in this recent study, many participants felt that aspects of their physical, emotional, and sexual intimacy were either ‘somewhat’ or ‘much’ worse as a result of their persistent genital arousal symptoms. These findings make sense, because nearly 2/3 of the sample also said that they avoid sexual activities with their partner in order to prevent their symptoms from being triggered.

So, even though it might seem like having persistent genital sensations could be a positive thing, data from this recent research study strongly suggests otherwise.

Another topic missing from PGAD research is predictors of better relationship adjustment among those with PGA. Once again, research from other sexual difficulties suggest that a number of factors can either improve or hinder relationship satisfaction among those with sexual difficulties; things like the way a partner responds when you’re experiencing symptoms, your level of sexual communication with your partner, and the degree to which you catastrophize about your symptoms (side note: symptom catastrophizing is a pattern of thinking about pain or genital sensations that could involve ruminating over symptoms, and feeling helpless in response) [20-24]. In this same recent sample of those with distressing symptoms of PGA, we also found that having a romantic partner that responds in a supportive way (for example, by encouraging adaptive coping with the symptoms) was associated with better relationship adjustment, and that having lower levels of catastrophizing was also associated with better overall relationship adjustment.

This research is important for several reasons:

First, we still don’t have a go-to, agreed upon treatment for PGAD. Researchers and clinicians are still trying to figure out effective treatments for this condition that both (1) improve symptoms, and (2) decrease distress and level of impairment. There is a clear need to continue research into areas that could help develop these treatments. The results of this recent research provide some initial support to suggest that catastrophizing and supportive partner responses may be two avenues to direct attention to help improve relationship outcomes among those with PGA.

Second, PGAD is just beginning to be recognized by diagnostic classification systems. Having a condition and its symptoms included in a diagnostic manual can make it easier for healthcare providers to take a condition seriously, can facilitate communication within medical and healthcare communities, and can help formulate plans of care. Research in this area is continuously needed in order to increase the likelihood that this condition will be recognized in future diagnostic manuals. Some good news is that the International Society for the study of Women’s Sexual Health (also called ISSWSH) put together an expert panel of researchers in the field of women’s sexual dysfunctions; this expert panel came up with a formal definition for PGAD (see article here) [25]. In addition, the term “persistent genital arousal in women” will be added to the forthcoming version of the International Classification of Diseases, 11th Revision (ICD-11; World Health Organization, forthcoming), which is scheduled to be released in January of 2022. We hope that men and other gender identities will also be included, and we look forward to seeing if any diagnostic symptoms are added to the term in the ICD-11.

Finally, the stigma surrounding this condition, and the levels of shame that patients experience, is very high. Many individuals – including healthcare providers26 – don’t fully understand the condition, or even know what it is. This lack of knowledge and misinformation can lead people to make unwelcome jokes about the condition26, which only serves to invalidate patient experiences and perpetuates the shame. Shedding more light on poorly understood conditions (like PGAD), and on the ways that they can impact various aspects of well-being, can further validate patient experiences and – hopefully – bring about more social awareness into debilitating and distressing conditions.

 

For more information, visit our PGAD Frequently Asked Questions page.

 

Kayla Mooney, MSc

This blog is a summary of Kayla Mooney’s Master’s thesis research. Kayla is a first-year PhD student in the Sexual Health Research Lab.

1 Garvey, L. J., West, C., Latch, N., Leiblum, S., & Goldmeier, D. (2009). Report of spontaneous and persistent genital arousal in women attending a sexual health clinic. International Journal of STD & AIDS, 20, 519 - 521. doi:10.1258/ijsa.2008.008492

2. Jackowich, R. A., & Pukall, C. (submitted). Prevalence of Persistent Genital Arousal Disorder in a Cross-Sectional Sample of Canadian Undergraduate Students. Journal of Sexual Medicine.

3. Hiller, J., & Hekster, B. (2007). Couple therapy with cognitive behavioural techniques for persistent sexual arousal syndrome2007. Sexual and Relationship Therapy, 22, 91 - 96. doi:10.1080/14681990600815285

4. Leiblum, S. R., & Nathan, S. G. (2001). Persistent sexual arousal syndrome: A newly discovered pattern of female sexuality. Journal of Sex & Marital Therapy, 27, 365 - 380.

5. Leiblum, S. R., & Chivers, M. L. (2007). Normal and persistent genital arousal in women: New perspectives. Journal of Sex & Marital Therapy, 33, 357 - 373. doi:10.1080/00926230701385605

6. Leiblum, S. R., Seehuus, M., Goldmeier, D., & Brown, C. (2007). Psychological, medical, and pharmacological correlates of persistent genital arousal disorder. Journal of Sexual Medicine, 4, 1358 - 1366. doi:10.1111/j.1743-6109.2007.00575.x

7. Freed, L. (2005). Persistent sexual arousal sundrome [Letter to the editor]. Journal of Sexual Medicine, 2, 743. doi:10.1111/j.1743-6109.2005.00122.x

8. Jackowich, R. A., Poirier, É., & Pukall, C. F. (submitted). A comparison of medical comorbidities, psychosocial, and sexual well-being in an online cross-sectional sample of women experiencing persistent genital arousal symptoms and control group. Journal of Sexual Medicine.

9. Yero, S. A., McKinney, T., Petrides, G., Goldstein, I., & Kellner, C. H. (2006). Successful use of electroconvulsive therapy in 2 cases of persistent sexual arousal syndrome and bipolar disorder. The Journal of ECT, 22, 274 - 275. doi:10.1097/01.yct.0000244247.33038.26

10. Smith, K. B., & Pukall, C. F. (2011). A systematic review of relationship adjustment and sexual satisfaction among women with provoked vestibulodynia. Journal of Sex Research, 48, 166 - 191. doi:10.1080/00224499.2011.555016

11. Rosen, N. O., Santos-Iglesias, P., & Byers, E. S. (2017). Understanding the sexual satisfaction of women with provoked vestibulodynia and their partners: Comparison with matched controls. Journal of Sex & Marital Therapy, 43, 747 - 759. doi:10.1080/0092623X.2016.1263705

12. Smith, K. B., & Pukall, C. F. (2014). Sexual function, relationship adjustment, and the relational impact of pain in male partners of women with provoked vulvar pain. Journal of Sexual Medicine, 11, 1283 - 1293. doi:10.111/jsm.12484

13. Rosen, N. O., Dubé, J. P., Corsini-Munt, S., & Muise, A. (2019). Partners experience consequences, too: A comparison of the sexual, relational, and psychological adjustment of women with sexual interest/arousal disorder and their partners to control couples. Journal of Sexual Medicine, 16, 83 - 95. doi:10.1016/j.jsxm.2018.10.018

14. Parish, S. J., & Hahn, S. R. (2016). Hypoactive sexual desire disorder: A review of epidemiology, biopsychology, diagnosis, and treatment. Sexual Medicine Reviews, 4, 103 - 120. doi:10.1016/j.sxmr.2016.11.009

15. Sarin, S., Amsel, R., & Binik, Y. M. (2016). A streetcar named “derousal”? A psychophysiological examination of the desire-arousal distinction in sexually-functional and dysfunctional women. Journal of Sex Research, 53, 711 - 729. doi:10.1080/00224499.2015.1052360

16. Althof, S. (2002). Quality of life and erectile dysfunction. Urology, 59, 803 - 810.

17. Fugl-Meyer, A. R., Lodnert, G., Bränholm, I.-B., & Fugl-Meyer, K. S. (1997). On life satisfaction in male erective dysfunction. International Journal of Impotence Research, 9, 141 – 148.

18. Leiblum, S. R. (2002). After sildenafil: Bridging the gap between pharmacologic treatment and satisfying sexual relationships. Journal Of Clinical Psychiatry, 63 Suppl, 17.

19. McCabe, M. P., & Matic, H. (2008). Erectile dysfunction and relationships: Views of men with erectile dysfunction and their partners. Sexual and Relationship Therapy, 23, 51 - 60. doi:10.1080/14681990701705559

20. Anderson, A. B., Rosen, N. O., Price, L., & Bergeron, S. (2016). Associations between penetration cognitions, genital pain, and sexual well-being in women with provoked vestibulodynia. Journal of Sexual Medicine, 13, 444 - 452. doi:10.1016/j.jsxm.2015.12.024

21. Merwin, K. E., O’Sullivan, L. F., & Rosen, N. O. (2017). We need to talk: Disclosure of sexual problems is associated with depression, sexual functioning, and relationship satisfaction in women. Journal of Sex & Marital Therapy, 43, 786 - 800. doi:10.1080/0092623X.2017.1283378

22. Rosen, N. O., Bergeron, S., Glowacka, M., Delisle, I., & Baxter, M.-L. (2012). Harmful or helpful: Perceived solicitous and facilitative partner responses are differentially associated with pain and sexual satisfaction in women with provoked vestibulodynia. Journal of Sexual Medicine, 9, 2351 - 2360. doi:10.1111/j.1743-6109.2012.02851.x

23. Rosen, N. O., Muise, A., Bergeron, S., Delisle, I., & Baxter, M.-L. (2015). Daily associations between partner responses and sexual and relationship satisfaction in couples coping with provoked vestibulodynia. Journal of Sexual Medicine, 12, 1028 - 1039. doi:10.1111/jsm.12840

24. Sullivan, M. J. L., Bishop, S. R., & Pivik, J. (1995). The pain catastrophizing scale: Development and validation. Psychological Assessment, 7, 524 - 532.

25. Parish, S. J., Goldstein, A. T., Goldstein, S. W., Goldstein, I., Pfaus, J., Clayton, A. H., . . . Whipple, B. (2016). Toward a more evidence-based nosology and nomenclature for female sexual dysfunctions – part II. Journal of Sexual Medicine, 13, 1888 - 1906. doi:10.1016/j.jsxm.2016.09.020

26. Jackowich, R. A., Bienias, S., Chamberlain, S., & Pukall, C. F. (in preparation). Healthcare experiences of individuals with persistent genital arousal disorder.