Intended for healthcare professionals

Editorials

Young women and anal sex

BMJ 2022; 378 doi: https://doi.org/10.1136/bmj.o1975 (Published 11 August 2022) Cite this as: BMJ 2022;378:o1975
  1. Tabitha Gana, ST8 general and colorectal surgery,
  2. Lesley M Hunt, consultant surgeon
  1. Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Sheffield, UK
  1. Correspondence to: L M Hunt lesley.hunt3{at}nhs.net

Clinicians’ reluctance to discuss possible harms is letting down a generation of women

Anal intercourse is becoming more common among heterosexual couples. Within popular culture it has moved from the world of pornography to mainstream media.1 It is no longer considered an extreme behaviour but increasingly portrayed as a prized and pleasurable experience.2 In Britain, the National Survey of Sexual Attitudes and Lifestyle shows participation in heterosexual anal intercourse among 16 to 24 year olds rose from 12.5% to 28.5% over the past few decades.3 Similar trends are seen in the US, where 30-44% of men and women report experience of anal sex.4

Individual motivation varies. Young women cite pleasure, curiosity, pleasing male partners, and coercion as factors.56 Up to 25% of women with experience of anal sex report they have been pressured into it at least once.7 Hit television shows such as Sex and the City and Fleabag may unwittingly add to the pressure, as they seem to normalise anal sex in heterosexual relationships or make it appear racy and daring.

Health risks

Anal intercourse is considered a risky sexual behaviour because of its association with alcohol, drug use, and multiple sex partners.8 But it is also associated with specific health concerns. The absence of vaginal secretions, increased traumatic abrasions, and less common use of condoms increase the risk of sexually transmitted disease and anal malignancy.9 Anal pain, bleeding, and fissures also occur as a result of anal intercourse.1011

Increased rates of faecal incontinence and anal sphincter injury have been reported in women who have anal intercourse.12 Women are at a higher risk of incontinence than men because of their different anatomy and the effects of hormones, pregnancy, and childbirth on the pelvic floor. Women have less robust anal sphincters and lower anal canal pressures than men,13 and damage caused by anal penetration is therefore more consequential. The pain and bleeding women report after anal sex is indicative of trauma, and risks may be increased if anal sex is coerced.

Effective management of anorectal disorders requires understanding of the underlying risk factors, and good history taking is key. Without it, patients are likely to present repeatedly with the same symptoms. Asking about anal sex is standard practice in genitourinary medicine clinics14 but less common in general practice and colorectal clinics. Clinicians may shy away from these discussions, influenced by society’s taboos. However, with such a high proportion of young women now having anal sex, failure to discuss it when they present with anorectal symptoms exposes women to missed diagnoses, futile treatments, and further harm arising from a lack of medical advice.

Lack of awareness

More widely, public health education is lacking.1516 NHS patient information on anal sex considers only sexually transmitted diseases, making no mention of anal trauma, incontinence, or the psychological aftermath of the coercion young women report in relation to this activity.17 A plethora of non-medical or pseudomedical websites fill the health information void. Rather than helping young women make informed decisions, some sites may increase societal pressure to try anal sex.

It may not be just avoidance or stigma that prevents health professionals talking to young women about the risks of anal sex. There is genuine concern that the message may be seen as judgmental or even misconstrued as homophobic. However, by avoiding these discussions, we may be failing a generation of young women, who are unaware of the risks. With better information, women who want anal sex would be able to protect themselves more effectively from possible harm, and those who agree to anal sex reluctantly to meet society’s expectations or please partners, may feel better empowered to say no.

Reluctance to discuss anal sex is not confined to healthcare. The Scottish government attracted criticism for proposing that questions about it should be included in the schools’ health and wellbeing census, prompting first minister Nicola Sturgeon to respond: Either we can bury our heads in the sand and pretend that young people are not exposed to the issues or the pressures that we know they are exposed to. Or we can seek to properly understand the reality that young people face and provide them with the guidance, the advice, and the services they need to make safe, healthy, and positive decisions.”18

Healthcare professionals, particularly those in general practice, gastroenterology, and colorectal surgery, have a duty to acknowledge changes in society around anal sex in young women, and to meet these changes with open neutral and non-judgmental conversations to ensure that all women have the information they need to make informed choices about sex.

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References

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