The publisher's final edited version of this article is available at Perspect Sex Reprod Health See other articles in PMC that cite the published article. Nevertheless, there is evidence to suggest that anal intercourse is also widely practiced by women in the US 1 — 4. Given that anal intercourse is associated with higher rates of heterosexual HIV transmission than vaginal intercourse 10 — 13 , women who engage in unprotected anal intercourse with sexual partners of unknown or seropositive status may be at greater risk for acquiring HIV than women who do not practice anal intercourse or who use protection while doing so.
Additionally, Halperin 1 found that women who engaged in anal intercourse 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 in their assessments of coital acts, thus continuing to overlook anal intercourse as a potential source of HIV transmission.
This oversight may be due to cultural taboos surrounding anal intercourse, including its association with homosexuality and its perceived lack of hygiene 1. A number of researchers have already pointed to the need for increased attention to anal intercourse as an understudied source of HIV transmission from seropositive men to their seronegative female partners 1 , 3 , 6 , A topic that has received even scarcer attention is the circumstances under which women engage in anal intercourse.
Our qualitative study was part of a larger study on rectal microbicide acceptability among men who have sex with men MSM and women who practice anal intercourse.
The present analysis comes from 28 in-depth, semi-structured interviews with women with a recent history of unprotected anal intercourse with an HIV-positive or status unknown partner. Sexual scripting theory 21 , which emphasizes the constructed, rather than biological, origins of human 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.
These social scripts are so culturally pervasive that even deviations from the script--as heterosexual anal intercourse is often perceived to be--are still largely confined to and defined by the prevailing cultural scenarios p.
In contemporary American sexual culture, the predominant sexual script is one of male pursuit and female acquiescence METHOD The data for our analysis were collected at a community clinic in the Eastern US [clinic name and location to be specified in the final manuscript] as part of a study of rectal microbicide acceptability in The study design and procedures were approved by the appropriate institutional review boards.
Women were recruited through flyers; palm cards; outreach at community based organizations, colleges, and at community events; Internet and print media advertising; 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 female; 18 years of age or older; HIV-negative; reported having unprotected receptive anal intercourse in the prior year with a man of unknown or seropositive status; had not participated in another research protocol within the past year; and were comfortable with spoken English.
Study Procedures Eligible and interested participants reported to the clinic for a one-time, face-to-face meeting with a female interviewer. Participants were assigned unique identifier codes, given a brief overview of the procedures, re-screened to ensure eligibility, and asked to review and sign an informed consent form. The interview guide consisted of open-ended questions and follow-up probes developed by the co-investigators to assess the psychological, social, and cultural factors associated with anal sex, as per the study objectives.
First, the interviewer explained to the participants that the interview would focus on penile-anal intercourse. To elicit responses, the interviewer first asked participants open-ended questions such as: The interviewer then followed up with more specific probe questions, when appropriate.
Data Analysis The qualitative interviews were tape recorded and transcribed. Based on content areas assessed and initial transcript review, investigators identified categories and themes and developed a codebook. Using the software NVivo, all transcripts were coded independently by staff members who then compared the codes, compared discrepancies, and discussed them until consensus was reached.
Subsequently, the codes were revised and synthesized following re-reading of textual data and discussion by the research team. A grounded theory approach guided the qualitative data analyses 29 , 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 should be thought of as a lower bound in cases when not all participants responded to a given question.
In addition to or instead of these racial categories, seven participants also reported Hispanic ethnicity. The mean age of the participants was Women had unprotected anal intercourse with a wide variety of partners, ranging from friends to casual partners, short-term and long-term boyfriends, husbands, strangers met on the Internet, and fathers of their children.
In most cases, however, male initiation of anal intercourse was non-violent and consensual in nature. Although male partners initiated anal sex more often, the women in our sample did not necessarily lack control over the practice; in fact, because they were the ones who had to consent to a specific behavior in order for it to take place, at times women felt that they, not their partners, were the ones who determined the course of a sexual encounter. The following participant, when asked if she had been pressured to have anal sex by her non-exclusive partner, distinguished between male initiative and male pressure: For example, engaging in an unusual practice with her casual sexual partner made one participant feel more desirable: I love the attention [from anal intercourse].
Far from being uncomfortable with anal intercourse, as we might expect of an activity that is so often stigmatized 1 , this participant took satisfaction in being the object of male desire and, in doing so, reaffirmed her sense of being a beautiful, desirable woman. In acting out this part, she did not so much relinquish her power as assume her scripted role as the pursued.
Non-consensual anal intercourse occurred with a range of partners both familiar and unfamiliar, from former husbands and boyfriends to strangers and men met on the Internet. In the following example, the participant recalls an occasion when she had non-consensual anal sex with a man whom she did not know very well: Among those women who had experienced non-consensual anal intercourse in the past, more than one participant also reported engaging in anal intercourse of her own accord, for non-transactional purposes, on other occasions.
Pain and Discomfort Coercion and violence notwithstanding, many participants reported other sensations of pain and discomfort arising from anal intercourse, including emotional distress. Mild intestinal discomfort was also experienced as an aftereffect of anal intercourse, such as in disrupted bowel movements. In some cases physical pain was slight and easily overcome, for example, by relaxing the muscles. In cases where women expected anal sex to be painful, they listed various reasons for engaging in the practice anyway: Indeed, some participants experienced pain during anal sex as enhancing their sexual pleasure.
The following participant describes having anal sex, while using substances, with the man who would later become 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.
For all but one participant, the last occasions of anal intercourse occurred alongside other forms of sexual activity, such as oral sex and vaginal intercourse. Viewed as a complementary form of sexual expression, anal intercourse took on meaning not only as a site of negotiation and pressure, but as a source of sexual pleasure and eroticism for the women in our study.
Physical Pleasure In considering the motivations for women to engage in high-risk sexual behaviors such as unprotected anal intercourse, it is important not to overlook female desire 24 , 31 , Among our participants, pleasure-seeking behavior, encompassing both physical arousal and emotional desire, emerged as a factor associated with a greater willingness to both engage in and request anal intercourse 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, such as this participant: What has led you to have anal sex [in general]? If I have anal sex, I have orgasms. My body likes it. It feels like vaginal but almost a little better, it seems like. And it feels good. 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 motivating factor for engaging in anal intercourse.
Intimacy and Variety Participants often cited the desire for intimacy or closeness to their partners as either the motivation for anal intercourse, or as the necessary preconditions for anal intercourse to occur. Just [for] something different. And I just found a new part of my body I can enjoy.
In the following example, the participant talks about the first time she had anal sex, with a man that she met on the Internet for the purpose of having sex: Tell me a little bit about your reasons why you did it the first time. I would have to say to please my partner. That would be just about it. And it sounds like you, like you said [earlier], he pleased you so much.
Like the idea of reciprocity. In this sense, anal intercourse was sought not only for the physical pleasure that it afforded women, but also valued as a marker for exceptional sex. By equating exceptional sex with exceptional relationships, women sought to express their love, commitment, and openness towards theirpartners through their willingness to have anal intercourse, as this woman did with her husband: 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 towards others.
Condom Use Infrequent condom use during anal activity 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 of anal intercourse.
Reasons for not using a condom during anal sex were varied, including: In the following example, the participant was asked if she had used condoms with her boyfriend the last time they had had anal intercourse: No, [we did not use condoms]. The reason is that 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. On the other hand, those participants who had used a condom during anal intercourse listed the following reasons for doing so: When describing discrete occasions of anal intercourse, on eight occasions participants reported that they had used a condom for vaginal sex to prevent pregnancy, but had removed the condom prior to anal sex.
Among those who reported using a condom during anal intercourse, on three occasions participants used the same condom for both vaginal and anal intercourse; on another three occasions participants used separate condoms for vaginal and anal intercourse; and on four occasions participants used condoms for anal intercourse but not vaginal intercourse, citing concern about hygiene or pregnancy as motivations. How safe do you think anal sex is when it comes to HIV?
It was with my significant other. He never had done it before. However, another participant Valeria, 41, Hispanic said that she regularly had anal sex with a man whose other partner was HIV-positive. Although nearly all of the participants were aware that unprotected anal intercourse might put them at risk for sexually transmitted infections, this knowledge apparently did not translate into behavioral change, as evidenced by the participant who had unprotected anal intercourse with her HIV-positive partner.
To avoid sounding confrontational, our interviewer did not ask participants why they continued to practice unprotected anal intercourse with partners of unknown or positive HIV status, despite the risks involved.
Following this line of reasoning, at first glance the pattern of male initiative over anal intercourse suggests that women might engage in anal intercourse under pressure, coercion, or persuasion from male partners. Taking sexual scripting theory into account, however, a more complex story emerges from the data. In this context, male initiative alone may not necessarily indicate a lack of female agency, but rather serve as a marker for the presence of a strong sexual script that dictates male pursuit and female acquiescence or rejection of male desire.
Pleasure-Seeking and Sexual Risk Although researchers have documented the relationship between pleasure-seeking behavior and sexual risk-taking in men who have sex with men 36 — 38 , it is not yet clear how pleasure-seeking may be related to sexual risk-taking among women. Nevertheless, as we did not survey a control group of women who engaged in low-risk, protected anal intercourse, it may be difficult to draw conclusions about the relationship between sexual risk-taking and pleasure-seeking behaviors from our sample alone.
Future research is needed to elucidate such relationships.