Women’s Experiences with Anal Sex: Motivations and Implications for STD Prevention
CONTEXT: Heterosexual anal intercourse is a highly efficient mode of HIV transmission, yet little is known about the contexts in which women engage in it, or when and with whom they use condoms. Similarly, sexuality and reproductive health research has paid little attention to female desire and pleasure-seeking.
METHODS: In-depth interviews were conducted in Boston in 2006 with 28 women who reported having had unprotected anal intercourse in the last year with a man who was HIV-positive or whose serostatus was unknown. Sexual scripting theory guided analyses of their experiences with and motivations to practice anal intercourse.
RESULTS: Participants engaged in anal intercourse for a wide variety of reasons: to experience physical pleasure, enhance emotional intimacy, please their male partners or avoid violence. Male partners usually initiated anal sex. Anal intercourse often occurred in the context of vaginal and oral sex. Among reasons women cited for not using condoms were familiarity with their partner and feeling that condoms made anal sex less pleasurable. Knowledge of HIV and STD risks did not appear to encourage condom use.
CONCLUSIONS: Women who perceive condom use during anal sex as limiting their pleasure or intimacy may be at increased risk for acquiring HIV. Consequently, interventions to promote safer anal intercourse must find a way to increase the use of barrier methods without decreasing pleasure or perceived intimacy between sexual partners.
Perspectives on Sexual and Reproductive Health, 2009, 41(3):142–149
Anal intercourse is a highly efficient mode of HIV transmission, and its practice among men who have sex with men has received much scholarly attention. Research on women's experiences of anal sex has been scarce and has been based on limited samples, but evidence suggests that the practice of anal intercourse is widespread among U.S. women.1–9
Heterosexual anal intercourse is associated with higher rates of HIV transmission than vaginal intercourse,10–13 and women who have unprotected anal intercourse with partners who are HIV-positive or whose serostatus is unknown may be at greater risk for acquiring HIV than women who do not engage in anal intercourse or who use protection while doing so. For example, a New York study of initially serodiscordant heterosexual couples found that a history of anal intercourse was one of the strongest predictors of eventual HIV transmission.14 Similarly, in a study in Brazil, seronegative women who practiced anal intercourse in addition to vaginal or oral intercourse with seropositive male partners were statistically significantly more likely to acquire HIV than were women who did not practice anal intercourse.15 Additionally, Halperin1 found that women were less likely to use condoms during anal intercourse than during vaginal intercourse.
Most studies of heterosexual HIV transmission fail to distinguish between vaginal and anal intercourse. This oversight may be due to cultural taboos surrounding anal intercourse, including its association with homosexuality and the perception that it is unhygienic.1 Several researchers have pointed to the need for increased attention to anal intercourse as a source of HIV transmission from seropositive men to their female partners.1,3,6,13 A topic that has received even scarcer attention is the circumstances under which women engage in anal intercourse. Qualitative research has focused on the contexts surrounding anal intercourse in South Africa16,17 and Brazil,18,19 but research on American women's experiences with anal intercourse is sorely lacking.
To develop effective interventions for HIV prevention, it is important to better understand both women's motivations for engaging in anal intercourse and the circumstances in which they choose to use a condom. Our qualitative study was part of a larger study on rectal microbicide acceptability among individuals who practice anal intercourse. The analysis presented here comes from 28 in-depth, semistructured interviews with women who had recently had unprotected anal intercourse with a partner who was HIV-positive or whose status was unknown. Previously, we have used these data to examine the implications of women's anal sex practices for the formulation and promotion of rectal microbicides.20
Sexual scripting theory,21 which emphasizes the constructed, rather than biological, origins of sexual desire, provides the theoretical framework for our analysis. According to Simon and Gagnon,21 in choosing to practice certain sexual behaviors over others, individuals are guided by cultural scenarios that proscribe specific courses of action. In contemporary American sexual culture, the predominant sexual script is one of male pursuit and female acquiescence.22 This script may be a disadvantage to women's sexual health22,23 and has important implications for STD prevention.
Similarly, despite calls for increased attention to the role of female desire in sexuality research,24–27 pleasure as a potential factor in women's sexual decisions has often been overlooked. In this article, we attempt to partially remedy the “pleasure deficit”24 in research on anal intercourse by not only examining how women have experienced and responded to pressure from their male partners to have anal sex, but also considering women's sexual pleasure as a motivation to practice unprotected anal intercourse.
The data for our analysis were collected at a community clinic in Boston as part of a study of rectal microbicide acceptability in 2006. The study design and procedures were approved by the institutional review boards of the New York State Psychiatric Institute and Fenway Community Health, where participants were interviewed.
Investigators sought to recruit 28 women, distributed in approximately equal numbers by race and ethnicity. Women were recruited through flyers; palm cards; outreach at community-based organizations, colleges and community events; Internet and print advertisements; referrals through other studies or staff at the community clinic; and word of mouth.
Women were initially screened for eligibility over the phone and were invited to participate in the study if they were 18 or older, were HIV-negative, reported having had unprotected anal intercourse in the prior year with a man who was HIV-positive or whose serostatus was unknown, had not participated in another research protocol within the past year and were comfortable with spoken English.
Eligible potential participants reported to the clinic for a meeting with a female interviewer. They were assigned unique identifier codes, given a brief overview of the procedures, rescreened to ensure eligibility, and asked to review and sign an informed consent form. Those enrolled in the study filled out a demographic questionnaire asking their age, education level, racial and ethnic identity, gender identity, sexual orientation, work or school status and personal income.
The investigators developed an interview guide that contained open-ended questions and follow-up probes to assess the psychological, social and cultural factors associated with anal sex. At the beginning of the interview, the interviewer explained that questions would focus on penile-anal intercourse. To both clarify the topic of discussion and assess the participant's use of terms, the interviewer asked, “What do you call it when a man puts his penis in your anus?” The interviewer then used the participant's terms throughout the interview. In this analysis, however, we use only the terms “anal intercourse” and “anal sex.” Among other topics, the interviewer asked participants to discuss their first, most recent and general experiences with anal sex; their feelings about and attitudes toward anal sex; and their perception of others' views about anal sex. On completion of the interview, women received $50 as compensation for their time.
In this article, we examine topics that the interview was designed to assess, as well as topics that emerged from the participants' responses.28
The interviews were audiotaped and transcribed by a commercial transcription service. The investigators developed a codebook that was based on the interview guide, but they also incorporated themes that emerged from the interviews. Two staff members independently coded all transcripts using NVivo, a software program for qualitative data analysis. Concurrent codes and discrepancies were identified and were discussed by the investigators until consensus was reached. The codebook was then revised, and one staff member coded the transcripts a second time. A grounded theory approach guided the analyses.29,30
Because participants were not required to answer every question, and because the degree to which each participant responded to a given question varied, it was not appropriate to perform statistical analyses on responses to interview questions. Instead, when talking about the frequency of certain behaviors, we refer to the percentage of participants who responded affirmatively. These percentages represent lower bounds in cases when not all participants responded to a given question.
Twenty-eight women participated in the study. Ten identified themselves as black, seven as white, two as Asian or Pacific Islander, and nine as belonging to other racial groups. Seven participants reported Hispanic ethnicity. Participants' ages ranged from 18 to 55 and averaged about 30 years (standard deviation, 7); 68% of women had at least some postsecondary education, and 61% had an annual income of less than $20,000. Women had had unprotected anal intercourse with a variety of partners, ranging from friends to casual partners, short-term and long-term boyfriends, husbands and strangers met on the Internet. One woman reported having had unprotected anal intercourse with an HIV-positive partner; others either failed to disclose their partners' serostatus or said that they did not know.
Participants' accounts suggest that their male partners overwhelmingly took the initiative when it came to anal intercourse, consistent with the conventional sexual script.23 Overall, 82% of our sample reported that their male partners had initiated their first occasion of anal intercourse; only 11% had taken the initiative themselves (the remaining 7% are unaccounted for). When asked about their most recent occasion of anal intercourse, 68% reported that their male partners had initiated the behavior. Twenty-five percent of women told of having been forced into having anal intercourse at least once. In most cases, however, male initiation of anal intercourse was nonviolent, and the behavior was consensual.
Although the women in our sample initiated anal sex less often than their male partners, they did not necessarily lack control over the practice. In fact, because women had to consent, they sometimes felt that they, not their partners, determined the course of a sexual encounter. For example, when asked if her nonexclusive partner had pressured her to have anal sex, one participant distinguished between male initiative and male pressure:
“I really enjoy anal sex, and I can say that he initiated it in that he initiates everything that happens. But if I hadn't wanted him to do it, all I had to do was put his penis somewhere else.”—27-year-old white woman
In other cases, women recognized that permitting or withholding anal intercourse allowed them greater power in other areas of their relationships. One woman explained that engaging in an unusual practice with her casual sexual partner made her feel more desirable:
“I love the attention [from anal intercourse]. I love the spotlight, I love the attention afterwards, the phone calls, even though they're obsessed with me, it makes me feel needed and wanted, and it just makes me feel like a woman.”—36-year-old black, Hispanic woman
For this participant, anal intercourse reinforced, rather than undermined, the gendered norms of sexual conduct, whereby men “take possession of the object of desire” and women are “the object of desire.”21 Far from being uncomfortable with anal intercourse, as we might expect with an activity that is so often stigmatized,1 she took satisfaction in being the object of male desire and, in doing so, reaffirmed her sense of being a beautiful, desirable woman.
Nonconsensual Anal Sex
Seven women reported having had nonconsensual anal intercourse at least once. Nonconsensual anal intercourse occurred with a range of partners, from former husbands and boyfriends to strangers, including men met on the Internet. One participant offered the following recollection of an occasion on which she had nonconsensual anal sex with a man whom she did not know very well:
“The first time I had anal sex with him, he just said, ‘Turn over,’ like a demand, and I was very uncomfortable. It felt like he was doing it to hurt me purposely…. He loved it. He wanted me to be in pain, because during it I was asking him, ‘Please take it out. You’re hurting [me]. Please, please, take it out.” And he was going, ‘Shut up, bitch. Shut up, bitch.’”—41-year-old black, non-Hispanic woman
Two women who had experienced nonconsensual anal intercourse also reported having had anal intercourse during transactional sex at least once, suggesting, for these women, a history of limited sexual agency. However, given our sample size, we cannot draw conclusions about the relationship between nonconsensual anal intercourse and transactional sex.
Among women who had experienced nonconsensual anal intercourse, more than one also reported engaging in anal intercourse of her own accord, for nontransactional purposes, on other occasions. This variation in experience, not only among participants but across a woman's sexual history, suggests that women's motivations to practice anal intercourse were fluid, dependent not so much on the behavior itself, but on the social context in which anal intercourse occurred. For example, one participant (a 19-year-old black, non-Hispanic woman) had first had anal intercourse with a stranger who forced her to do so, but more recently had had consensual anal sex with the man she had been seeing for a few months.
Pain, Discomfort and Pleasure
Coercion and violence notwithstanding, many participants reported pain and discomfort, including emotional distress, during anal intercourse. Some also said they had mild intestinal discomfort (for example, disrupted bowel movements) afterward.
In some cases, physical pain during anal intercourse was slight and easily overcome—for example, by relaxing the muscles. In other cases, pain was extreme, as in the situation described by one participant, when her on-again, off-again boyfriend initiated anal sex:
“At first I thought, okay, I could deal with this. But then when I realized he was trying to go harder and harder with it, then I'm like, okay, that's enough. It just felt like it couldn't go any further than what he was trying to push it, so it felt like I was ending up in a lot more pain.”—18-year-old black, non-Hispanic woman
Given the frequent mentions of pain during consensual anal intercourse, we were interested in understanding why and how women participated in the behavior. Women who expected anal sex to be painful listed various reasons for engaging in it anyway: to try something new, to please their partners or to experience sexual pleasure. Indeed, some participants said that pain during anal sex enhanced their sexual pleasure. One related the following about having had anal sex, while using substances, with the man who later became her husband:
“I let him do it. And we did it in the big recliner chair. It hurt and it felt good at the same time. Because I know it was hurting me, but I wouldn't let him stop…. It was hurting, but it was hurting good. So I didn't consider stopping or anything.”—41-year-old Hispanic woman
Some participants experience anal intercourse as both pleasurable and painful, either at the same time or on different occasions. The variability in responses suggests that participants viewed anal intercourse as a complex emotional and physiological event that could not be easily categorized.
In considering women's motivations for engaging in high-risk sexual behaviors, such as unprotected anal intercourse, it is important not to overlook female desire.24,31,32 Among our participants, pleasure-seeking, encompassing both physical arousal and emotional desire, emerged as a factor associated with a greater willingness to both engage in and request anal sex from male partners. Regardless of who initiated it, many women in our study reported enjoying anal intercourse and the physical sensations related to the practice. When asked what had led her to have anal sex, one participant replied:
Pleasure-seeking… emerged as a factor associated with a greater willingness to both engage in and request anal sex.
“Wanting it. I like it. If I have anal sex, I have orgasms. So it's just like I'm having the regular—missionary sex. It's just like that. My body likes it.”—32-year-old black, non-Hispanic woman
In terms of the physical sensations produced by anal intercourse, participants often referred to vaginal or oral sex as standards of comparison. Some women compared anal sex favorably with vaginal sex, as one woman did when she spoke about having had anal sex with her baby's father:
“It feels like vaginal but almost a little better, it seems like. I like it. It feels like you're in another world somewhere. Ohh! It feels like you're getting massaged. And it feels good.”—20-year-old black, non-Hispanic woman
While not complaining of reduced pleasure per se, a few women compared anal sex unfavorably with vaginal sex, which they considered “real sex.” Some repeated the catchphrase that the rectum is “an exit, not an entrance,” suggesting that anal sex was not easily equated with vaginal intercourse. However, just as the sensation of physical pleasure during anal intercourse varied among participants, so did the importance that participants placed on physical pleasure alone as a motivation for engaging in anal intercourse.
Intimacy and Variety
Participants often cited the desire for intimacy or closeness to their partners as either the motivation or the precondition for anal intercourse. Some women tried anal intercourse out of curiosity, or because they saw it as a way of bringing variety into their sexual relationships. For example, one participant described the practice this way:
“[I've had anal sex] just for excitement. Just [for] something different, something added, because a lot of people don't do that. And I just found a new part of my body I can enjoy. I like it.”—46-year-old white woman
Because gender norms encourage women to view themselves in relation to other persons, particularly men,33 and women are expected to meet others' needs (including sexual needs) before their own,23 it is not surprising that women often reported that they practiced anal intercourse to please their partners. In these cases, a woman's pleasure was contingent upon male satisfaction, insofar as she fulfilled her sexual role (and thus reinforced her sense of being a woman) by ensuring that the man was satisfied first. In one very telling exchange, the interviewer asked a woman why she had had anal sex for the first time, and she replied:
“I would have to say to please my partner. That would be just about it.”—20-year-old woman, member of “other” racial group
When the interviewer reminded her that she had previously mentioned enjoying anal sex with this partner (a man she had met on the Internet for the purpose of having sex), she said, “Yeah. Exactly. Like the idea of reciprocity.”
Thus, in reconstructing her rationale for having anal sex, the participant overlooked her own pleasure and emphasized that it was “to please [her] partner.”
The importance placed on intimacy, variety and the sense of taking sex to a “different level” (in the words of a 27-year-old white participant) revealed that women sought anal intercourse not only for its physical pleasure, but as a marker for exceptional sex. By equating exceptional sex with exceptional relationships, women sought to express their love, commitment and openness toward their partners through their willingness to have anal intercourse, as this woman did with her husband:
“Anal sex? … I think it's more about the intimacy, feeling comfortable. Just getting to know someone's body and like being with them long enough and starting to explore other areas than what you're going to explore with someone you've known a week.”—27-year-old white woman
Infrequent condom use during anal sex was to be expected among participants, given the eligibility requirements. Eighty-two percent of the sample indicated that they had not used condoms during the first occasion of anal intercourse, and the same proportion (though not necessarily the same participants) reported no condom use during the last occasion. When asked about their most recent occasion of anal intercourse, most women (86%) reported having had vaginal intercourse on the same occasion.
Participants had not used condoms consistently during anal or vaginal intercourse. Eight women said that they had used a condom for vaginal intercourse to prevent pregnancy, but had removed the condom before having anal intercourse. Four participants reported having used condoms for anal intercourse but not for vaginal intercourse. Three women had used the same condom for vaginal and anal intercourse; another three had used different condoms for vaginal and anal intercourse.
Reasons for not using a condom during anal sex were varied. Some reflected characteristics of the relationship or the sexual encounter: The woman was very familiar with her partner, anal sex was unanticipated or nonconsen-sual, or the partner preferred not to use a condom. Others reflected women's attitudes toward or experiences with condoms: They increased discomfort or pain, made anal sex less pleasurable or were inconvenient. One woman was trying to get pregnant, and others reported that they used different forms of birth control or that their partner practiced withdrawal. In the following excerpt, one participant explains why she and her boyfriend had not used condoms the last time they had had anal intercourse:
“We mostly used the condoms in order not to get pregnant. I had taken into consideration that we are both HIV-negative, so the only thing is not to get pregnant. So if you can't get pregnant having anal sex … there was no use in having condoms.”—21-year-old white woman
This response was typical in that condom use was usually not motivated by fear of HIV or other STDs among this sample. In an extreme case, the one participant who reported having an HIV-positive partner said that she preferred to have anal intercourse without a condom because it “felt better,” even though her partner worried about passing the virus on to her and was reluctant to give up using condoms.
On the other hand, participants who had used a condom during anal intercourse said they had done so because they were concerned about hygiene, they believed that one could get pregnant through anal sex or their partner had not removed a condom that had been used for vaginal sex.
Anal Sex and STD Risk
Participants' responses suggest that STD prevention was not the primary motivation for condom use during anal intercourse. When queried about condom use, only 25% of participants spontaneously mentioned prevention of HIV or other STDs as a concern; none consistently relied upon condoms for disease prevention during anal intercourse. Nevertheless, when probed directly, 96% acknowledged that unprotected anal intercourse put them at risk for STDs. For example, when asked how safe she considers anal sex in terms of HIV, one woman responded:
“[Anal sex] is probably the unsafest [kind of sex] you could ever have.”—20-year-old Hispanic woman
Apart from asking women about their partners' HIV status to establish their eligibility for study participation, we did not raise the topic. However, it sometimes came up in the course of the interview, as in the following remarks:
“[My significant other] never had done it before. And he was very much concerned about the fact that he was HIV-positive and I wasn't, and I didn't want a condom on because it doesn't feel the same to me. [So] I convinced him to do it.”—41-year-old black, non-Hispanic woman
This was the only report of unprotected anal intercourse with a seropositive partner, but another participant (a 41-year-old Hispanic woman) said that she regularly had anal sex with a man whose other partner was HIV-positive. Because most participants did not mention seropositive partners, it is likely that they did not know their partners' serostatus. One participant explained:
“It's hard enough to bring it [HIV status] up, and then if they say, ‘Oh, yeah, I tested, and I was negative,’ then you don't really know where to go. Because it was so hard to even mention it, that you feel like if you say, ‘Could you get that on paper?’ or ‘When was the last time?’ or ‘And how much sex have you had since?’ that then you're questioning, … and they become defensive.”—29-year-old white woman
As this quote illustrates, participants' intentions to ascertain their partners' HIV status may have seemed incompatible with their desire to experience emotional intimacy and trust through anal sex.
Although nearly all participants knew that unprotected anal intercourse might put them at risk for STDs, this knowledge apparently did not translate into behavioral change. To avoid sounding confrontational, our interviewer did not ask participants why they continued to practice unprotected anal intercourse with partners who were HIV-positive or of unknown serostatus, despite the risks involved. Nevertheless, we hypothesize that among these women, other motivations for engaging in unprotected anal intercourse—such as pleasure, intimacy, partner's pleasure, curiosity—outweighed the motivation to stay free of HIV and other STDs.
Because our participants tended to follow traditional gender scripts when it came to initiating anal intercourse, and because anal intercourse emerged as a behavior that complemented vaginal and oral sex, it may be useful to view heterosexual anal intercourse not so much as a deviant behavior, but as an example of how sexual decisions are negotiated between men and women. In this respect, women's decisions to practice anal intercourse may reflect power dynamics at work in heterosexual relationships, in which women usually have less power than men.34,35
At first glance, the pattern of male initiative over anal intercourse suggests that women might engage in this behavior because of pressure, coercion or persuasion from male partners. Taking sexual scripting theory into account, however, a more complex story emerges from the data. According to Simon and Gagnon,21 prevailing sexual scripts dictate that men act as sexual pursuers and women as the pursued. Therefore, women who initiate anal intercourse may be perceived as “breaking the rules,” and this may account for why so few women initiated anal intercourse—not so much because anal intercourse is a stigmatized behavior, but because women are supposed to allow their male partners to take the lead in determining the course of their sexual activity. In this context, male initiative may indicate not a lack of female agency, but rather the presence of a strong sexual script that dictates male pursuit and female acquiescence or rejection of male desire.
By interpreting anal sex as a more intimate form of sexual activity than vaginal or oral sex, women represented themselves not so much as sexual rule breakers, but as the enforcers of the notion that sex should heighten intimacy and build relationships, rather than satisfy one's own desire. This notion of sexuality does not so much uphold the masculine model of the autonomous sexual actor seeking his own satisfaction, but instead identifies women—and by extension, their male partners—as sexual beings by virtue of their relational stance toward others.
Pleasure-Seeking and Sexual Risk
Although researchers have documented the relationship between pleasure-seeking and sexual risk-taking among men who have sex with men,36–38 it is not clear how pleasure-seeking may be related to sexual risk-taking among women. Because our study recruited women who reported having engaged in unprotected anal intercourse, we had the opportunity to examine women's pleasure-seeking behaviors in the context of high sexual risk. Nevertheless, as we did not survey a control group of women who engaged in low-risk, protected anal intercourse, we cannot draw conclusions about the relationship between sexual risk-taking and pleasure-seeking behaviors. Future research is needed to elucidate such relationships.
Among our sample, women's practice of unprotected anal intercourse was motivated by the following factors: the desire to experience pleasure or intimacy through an exotic sexual practice; the desire to please one's partner; the desire to engage in a sexual behavior carrying no risk of pregnancy; and the desire to increase sexual pleasure by not using condoms. Thus, unprotected anal sex seemed to offer women a way to please their partners, to please themselves and to avoid pregnancy. Unfortunately, missing from their decision-making process was a consideration of STD risk.
Unprotected anal sex seemed to offer women a way to please their partners, to please themselves and to avoid pregnancy.
The fact that many of our participants were confused about the various risks presented by vaginal and anal intercourse may suggest the need for comprehensive sex education that addresses the differences between pregnancy prevention and STD prevention. Larger societal discourses that focus on the pleasures and risks of penile-vaginal intercourse may also have contributed to participants' tendency to view anal intercourse as less risky than vaginal intercourse. As long as some women view having anal sex as a risk-free way to bypass pregnancy concerns while maintaining intimacy and sexual pleasure, the failure to educate this population on STD prevention may lead to increased infection.
Regarding men who have sex with men, Blais39 has written about how the “social coding of intimacy” may make men reluctant to speak honestly about their sexual activity outside of a given relationship. As long as unprotected sex is equated with emotional intimacy, argues Blais, men who have sex with men may be at increased risk for STDs, including HIV. A similar dynamic may be at work among women who engage in unprotected anal intercourse to achieve a greater degree of intimacy with their male partners. Interventions to promote safer anal sex must find a way to increase the use of barrier methods without decreasing perceived intimacy between partners. This may be done by emphasizing the intimate nature of anal intercourse, even when accompanied by condom use.
Too often, note Gupta and Weiss,40 interventions to address high-risk sexual practices collude with existing hierarchies, rather than challenge the underlying structures that contribute to economic and sexual marginalization. In designing interventions to address unprotected anal intercourse among women, we must balance the immediate need to work within the status quo—to meet participants “where they are”41—with the desire for broader social change that will eventually empower women to make safer choices regarding their own bodies.42 To meet women where they are, interventions to increase condom use or to promote rectal microbicide use during heterosexual anal intercourse should consider the ways in which a woman might use a barrier method without straying too far from her scripted role as the acquiescent partner if that is the role she prefers. Although microbicides are often promoted within the research community as being “female-controlled,” marketing them as such may have the opposite effect of what is intended, as long as some women prefer to be the less assertive partner in their sexual relationships. Therefore, vaginal and rectal microbicides should be marketed as products that will enhance women's sexual desirability.
On the other hand, STD interventions geared toward women who have unprotected anal intercourse must not lose sight of societal factors that disadvantage women. Women's vulnerability to STDs is strongly influenced by gender-based power differentials.23,35,40 Future studies should seek to identify the factors that put women at risk for nonconsensual, unprotected anal intercourse.
Nonconsensual anal sex—although uncommon in our sample—increases women's risk of acquiring HIV because of the low likelihood that they can negotiate condom use in this situation, their increased possibility of experiencing rectal tearing or bleeding, and their lack of control over partner choice. To be successful, interventions must take into account the ways in which violence directed toward women can impact their ability to negotiate safer vaginal and anal sex. Given that the need for female-controlled alternatives to condoms encompasses products that can be used rectally as well as vaginally, once rectal microbicides become available, they should be marketed to women as well as to men who have sex with men.
Our findings must be interpreted within the limitations of this study. Although the sample was ethnically and racially diverse, participation was limited to English-speaking women, and participants were predominantly low-income women. Additionally, as participants were women who were willing to be interviewed about a highly stigmatized practice, we know little about the experiences of women who may feel uncomfortable discussing anal intercourse.20 Furthermore, participants had recently engaged in unprotected anal intercourse with a partner who was HIV-positive or whose serostatus was unknown. Undoubtedly, numerous women practice anal intercourse with minimal risk (e.g., by consistently using condoms, knowing their partner's serostatus or having few partners), but their motivations for engaging in anal intercourse are yet to be addressed and are outside the scope of this study. Future studies should seek to quantitatively assess HIV and STD risk among a larger and more representative sample of women who engage in anal intercourse.
Furthermore, notwithstanding that this may have been a highly motivated group of women who welcomed the opportunity to talk about their anal sex experiences, social constraints or norms about what is socially appropriate may have influenced women's interview responses. Stadler et al.,16 for example, conducted focus groups examining anal sex among South African women, and emphasized that in that context, women may have been more disposed to express ambivalence toward anal intercourse than to report desire. Similarly, although our interviewer made every effort to establish rapport, ensure confidentiality and make participants feel comfortable, it is difficult to know the extent to which the interviewer, a young woman trained in sexual interviewing, influenced participants' narratives. Despite the limitations of the study, the findings presented here have important implications for HIV interventions aimed at heterosexual women.
Anal intercourse is both risky and pleasurable for heterosexual women. As behavioral researchers and health educators continue to investigate the ways in which sexual attitudes influence sexual behavior, it behooves them to explore both aspects of this experience for women, to help guide efforts to assist women in achieving the intimacy they desire in their sexual relationships while safeguarding their health.
The research on which this article is based was supported by grant R01 046060–01 from the National Institute of Child Health and Human Development. The authors thank Jackie Correale for performing the initial coding of the data; the members of the HIV Center Manuscript Workshop, led by Susie Hoffman, and A. Jordan Wright for their generous feedback; and the participants, who shared their time and experiences.
1. Halperin DT, Heterosexual anal intercourse: prevalence, cultural factors, and HIV infection and other health risks: part I, AIDS Patient Care and STDs, 1999, 13(12):717–730.
2. Erickson PI et al., Prevalence of anal sex among heterosexuals in California and its relationship to other AIDS risk behaviors, AIDS Education and Prevention, 1995, 7(6):477–493.
3. Baldwin JI and Baldwin JD, Heterosexual anal intercourse: an understudied, high-risk sexual behavior, Archives of Sexual Behavior, 2000, 29(4):357–373.
4. Voeller B, AIDS and heterosexual anal intercourse, Archives of Sexual Behavior, 1991, 20(3):233–276.
5. Cunningham I, An innovative HIV/AIDS research and education program in Puerto Rico, SIECUS Report, 1998, 26(3):18–20.
6. Misegades L et al., Anal intercourse among young low-income women in California: an overlooked risk factor for HIV? AIDS, 2001, 15(4):534–535.
7. Reinisch JM et al., High-risk sexual behavior among heterosexual undergraduates at a Midwestern university, Family Planning Perspectives, 1992, 24(3):116–121 & 145.
8. Friedman SR et al., Prevalence and correlates of anal sex with men among young adult women in an inner city minority neighborhood, AIDS, 2001, 15(15):2057–2060.
9. Gross M et al., Anal sex among HIV-seronegative women at high risk of HIV exposure, Journal of Acquired Immune Deficiency Syndromes, 2000, 24(4):393–398.
10. Leynaert B, Downs AM and De Vincenzi I, Heterosexual transmission of human immunodeficiency virus: variability of infectivity throughout the course of infection, American Journal of Epidemiology, 1998, 148(1):88–96.
11. Vernazza PL et al., Sexual transmission of HIV: infectiousness and prevention, AIDS, 1999, 13(2):155–166.
12. Mastro TD and De Vincenzi I, Probabilities of sexual HIV-1 transmission, AIDS, 1996, 10(Suppl. A):S75–S82.
13. Padian NS et al., Heterosexual transmission of human immunodeficiency virus (HIV) in Northern California: results from a 10-year study, American Journal of Epidemiology, 1997, 146(4):350–357.
14. Seidlin M et al., Heterosexual transmission of HIV in a cohort of couples in New York City, AIDS, 1993, 7(9):1247–1254.
15. Guimarães MDC et al., HIV-infection among female partners of seropositive men in Brazil, American Journal of Epidemiology, 1995, 142(5):538–547.
16. Stadler JJ, Delany S and Mntambo M, Sexual coercion and sexual desire: ambivalent meanings of heterosexual anal sex in Soweto, South Africa, AIDS Care, 2007, 19(10):1189–1193.
17. Ndinda C et al., Perceptions of anal sex in rural South Africa, Culture, Health & Sexuality, 2008, 10(2):205–212.
18. Halperin DT, HIV, STDs, anal sex and AIDS prevention policy in a northeastern Brazilian city, International Journal of STD & AIDS, 1998, 9(5):294–298.
19. Goldstein DM, AIDS and women in Brazil—the emerging problem, Social Science & Medicine, 1994, 39(7):919–929.
20. Exner TM et al., Women's anal sex practices: implications for formulation and promotion of a rectal microbicide, AIDS Education and Prevention, 2008, 20(2):148–159.
21. Simon W and Gagnon JH, Sexual scripts: permanence and change, Archives of Sexual Behavior, 1986, 15(2):97–120.
22. Tolman DL and Diamond LM, Desegregating sexuality research: cultural and biological perspectives on gender and desire, Annual Review of Sex Research, 2001, 12(1):33–74.
23. Tolman DL, Femininity as a barrier to positive sexual health for adolescent girls, Journal of the American Medical Women's Association, 1999, 54(3):133–138.
24. Higgins JA and Hirsch JS, The pleasure deficit: revisiting the “sexuality connection” in reproductive health, International Family Planning Perspectives, 2007, 33(3):133–139.
25. Knerr W and Philpott A, Putting the sexy back into safer sex: the Pleasure Project, Institute of Development Studies Bulletin, 2006, 37(5):105–109.
26. Philpott A, Knerr W and Boydell V, Pleasure and prevention: when good sex is safer sex, Reproductive Health Matters, 2006, 14(28):23–31.
27. Wood JM, Koch PB and Mansfield PK, Women's sexual desire: a feminist critique, Journal of Sex Research, 2006, 43(3):236–244.
28. Patton MQ, Qualitative Research and Evaluation Methods, Thousand Oaks, CA: Sage, 2002.
29. Glaser BG and Strauss AL, The Discovery of Grounded Theory: Strategies for Grounded Research, New York: Aldine de Gruyter, 1967.
30. Strauss AL and Corbin J, Basics of Qualitative Research: Grounded Theory Procedures and Techniques, Newbury Park, CA: Sage, 1990.
31. Philpott A, Knerr W and Maher D, Promoting protection and pleasure: amplifying the effectiveness of barriers against sexually transmitted infections and pregnancy, Lancet, 2006, 368(9551):2028–2031.
32. Holland J et al., Risk, power, and the possibility of pleasure: young women and safer sex, AIDS Care: Psychological and Socio-Medical Aspects of AIDS/HIV, 1992, 4(3):273–283.
33. Gilligan C, In a Different Voice: Psychological Theory and Women's Development, Cambridge, MA: Harvard University Press, 1993.
34. Blanc AK, The effect of power in sexual relationships on sexual and reproductive health: an examination of the evidence, Studies in Family Planning, 2001, 32(3):189–213.
35. Pulerwitz J et al., Relationship power, condom use and HIV risk among women in the USA, AIDS Care, 2002, 14(6):789–800.
36. Dudley MG et al., Correlates of high-risk sexual behavior among young men who have sex with men, AIDS Education and Prevention, 2004, 16(4):328–340.
37. Parsons JT and Halkitis PN, Sexual and drug-using practices of HIV-positive men who frequent public and commercial sex environments, AIDS Care, 2002, 14(6):815–826.
38. Gutierrez-Martinez O et al., Sexual sensation-seeking and worry about sexually transmitted diseases (STD) and human immunodeficiency virus (HIV) infection among Spanish adolescents, Psicothema, 2007, 19(4):661–666.
39. Blais M, Vulnerability to HIV among regular male partners and the social coding of intimacy in modern societies, Culture, Health & Sexuality, 2006, 8(1):31–44.
40. Gupta GR and Weiss E, Women's lives and sex: implications for AIDS prevention, Culture, Medicine and Psychiatry, 1993, 17(4):399–412.
41. Nyswander D, Education for health: some principles and their application, Health Education Monographs, 1956, No. 14, pp. 65–70.
42. Rappaport J, Studies in empowerment: introduction to the issue, Prevention in Human Services, 1984, 3(2–3):1–7.