Half the women (n = 20) reported partner pleasure or a need to “satisfy” their partner as the reason for engaging in AI, with this theme more prevailing among women with a rectal STI. One woman who tested positive for a rectal STI stated that her main reason for engaging in AI was to satisfy her partner (quote 1). Others felt pressured into doing it, explaining that they felt “obligated” (quote 5), whereas some even felt like they had to participate in AI in order for their partner to remain faithful, as one woman described, “I felt if I didn't do it he was going to have to find someone else to do it.” (Hispanic, age 19 years, no rectal STI).
Most women reported AI in the context of a serious relationship (n = 30) and considered it “something that should only be for the deserving.” (white, age 23, no rectal STI). One woman exclaimed that she would never have AI with anyone else other than her current partner (quote 11). Feelings of deeper intimacy and positive regard for one's partner also varied by rectal STI status. For example, one STI-positive woman described her experience with AI, “I wasn't okay with it. He didn't ask me if I was comfortable.” (Hispanic, age 21 years, rectal STI). In contrast, an STI-negative woman explained, “And this guy really makes love and I really love it. And I will not trade it for nothing in the world.” (black, age 49 years, no rectal STI).
Regardless of the motivation for engaging in AI, most women reported disliking it, with only 8 reporting AI as a pleasurable experience. Even those who considered AI a pleasurable experience attached negative connotations to it and were either reluctant to tell their partner that they enjoyed it or felt shame in admitting their pleasure. One woman explained she enjoyed AI but was too embarrassed to ask her partner “… it has to be him [to initiate] because I would be ashamed to ask him.” (Hispanic, age 30 years, no rectal STI). Another was afraid to tell her partner that she enjoyed AI, out of fear that her partner would repeatedly ask her for it (black, age 23 years, no rectal STI). Only one woman reported feeling comfortable initiating AI, although she referred to herself as “…just one of those freaky white girls” for enjoying it, although she was having AI with a long-term partner (quote 12).
Most women felt they could refuse AI if they so desired and felt in control of the situation while it was happening. However, the absence or lack of control was more pronounced among women with a rectal STI, and in fact, all but one of the women who reported never feeling in control had a rectal STI. One woman described, “I hardly took control of it. I was hardly able to and even when I said stop he kept continuing and I just, just didn't think about it.” (Hispanic, age 21 years, rectal STI). In contrast, a high proportion of women reported feeling in control among those who reported sexual gratification as a reason for engaging in AI (75%) as compared with deeper intimacy (71%) or partner pleasure (45%).
Sequence of Sex Acts
During a single sexual encounter, women predominantly reported having AI last, after oral or vaginal sex. However, women also reported having AI without any other types of sex. One woman stated that she never engaged in any other type of sex when she practiced AI because, “I can't get into anything else if this is, because it takes a minute to get me to just bear with it.” (black, age 30 years, no rectal STI). Among the 6 women who reported AI as the only sexual activity in a given encounter, 3 screened positive for a rectal STI.
Condom and Lubricant Use
The majority reported not using condoms for AI, and partner trust was a commonly mentioned reason for lack of condom use. One woman explained her partner's reason for not wanting to use condoms for AI, “Because he says since we're not having sex with nobody else but each other.” (black, age 27 years, no rectal STI). Others noted condom use as a strategy to improve “cleanliness” (i.e., reduce the spread of fecal matter) or reduce physical discomfort. One woman explained how condoms could reduce discomfort during AI, “Because condoms are smoother in certain situations than an actual penis.” (black, age 26 years, no rectal STI). Most women also reported use of lubricants as a strategy to reduce discomfort with AI, although most reported using oil-based lubricants. Commonly mentioned types of lubricants included baby oil, massage oil, Vaseline, or spit. One woman described that her method of lubricant use to reduce discomfort was, “KY jelly and petroleum jelly mixed together. That's the only way he'd be able to do it. 'Cause otherwise that's just torture on my anus.” (black, age 30 years, no rectal STI).
Alcohol use with AI was common (n = 25), with some reporting alcohol as a way to relax and potentially mitigate pain associated with AI. One woman stated, “I can only do anal sex when I drink. It hurts too much. I never did it sober.” (black, age 35 years, rectal STI). Another woman explained, “When we first started with the anal sex, alcohol was something that I would use to have to say, well I need to be drunk if we're gonna do this.” (black, age 30 years, no rectal STI). Report of illicit substance use with AI was less frequent than report of alcohol use (marijuana, n = 11; ecstasy, n = 2; methamphetamine, n = 2), although one respondent mentioned that she grew to like AI more after using methamphetamine, “As I got older and I got a little bit freakier, maybe using meth a little bit more [I started to like it more].” (white, age 39 years, rectal STI).
Concerns about Rectal STIs/HIV
Very few women were concerned about rectal STIs resulting from AI, and knowledge of rectal STI/HIV risk was limited. When asked if she ever worried about getting infections from AI one woman stated, “I never thought you could.” (Hispanic, age 28 years, rectal STI). Another said she only associated STIs such as gonorrhea and chlamydia with vaginal sex. In addition, one participant mentioned that she and her partner viewed condoms as a pregnancy prevention strategy unrelated to STIs. She explained, “They're [the male partner] not really thinking about STDs. And so when they want to have anal sex it's like, well you can't get pregnant if I come inside your ass.” (Hispanic, age 28 years, no rectal STI).
These findings highlight that women tend to practice AI within the context of serious relationships, with reasons for engaging in AI and feelings about AI varying by risk for rectal STIs. The 3 themes that emerged from our data as motivations for engaging in AI were partner's pleasure, deeper intimacy, and sexual gratification. These primary motivations are in agreement with those reported by previous studies.15,18 However, our study analyzed these themes according to current rectal STI status, which helps to contextualize factors that have the greatest risk for infection.
Given that most of the women interviewed reported experience with AI in the context of a serious relationship, it is not surprising that AI was frequently reported as an expression of deeper intimacy. We suggest, in concordance with TGP, that by reserving AI for only their “deserving” partners, women attempt to increase their interpersonal sexual division of power.19 In particular, those who feel they lack security within the relationship can control their partner's access to AI and potentially increase security. In contrast, those who note sexual gratification as the primary reason for engaging in AI may have more equal division of sexual power within their relationship and therefore have the freedom to engage in AI for self-pleasure. This power differential has been associated with sexual risk behaviors and urogenital STIs23,24 as well as with AI and intimate partner violence.25 Power differential may also help to explain our findings, which showed a relatively low frequency of rectal STIs among those who cited sexual gratification as a motivating factor for AI (33%) as compared with deeper intimacy (41%) or partner pleasure (55%). In addition, a higher proportion of women felt in control during AI among those who cited sexual gratification as a motivator. Further research should investigate methods of negotiating AI that could potentially be taught as a risk-reduction strategy among women not wanting to engage in AI or lacking power within their relationship.
As with vaginal intercourse,26 women in serious or “main” partnerships were less likely to use condoms for AI. These findings are supported by a number of other studies, which have found that reported rates of condom use are lower for heterosexual AI when compared with vaginal intercourse.5,12,27 The use of anal lubricating products not specifically designed for intercourse was reported frequently. Although condom use was not common, the commonly reported types of lubricants used for AI were oil based, such as baby oil, Vaseline, and massage oils, which can damage latex condoms.28 Therefore, even if the participant reported condom use, she may not be adequately protected against rectal STIs.
Based on quantitative, aggregate level data, almost all women who reported AI also reported engaging in vaginal intercourse.12,29 Although these data suggest that most women practice AI on the same event or occasion as vaginal sex, our event-level data suggest “AI only” episodes may also be common. Screening for rectal STIs may be particularly important among these women because STIs may not be identified through urogenital screening. In addition, most women reported AI after vaginal intercourse during the same sexual encounter, coupled with low condom use. This supports the findings of a recent quantitative study29 and suggests the need for STI/HIV prevention strategies that encompass AI as well as vaginal intercourse.
Another emergent theme to our analysis was the attachment of stigma and negative connotations to AI, even among women who reported enjoying it. Unfortunately, this stigma may contribute to the lack of knowledge about the risk for STIs, because women may be too embarrassed to talk to providers. As a result, they may fail to associate STIs such as chlamydia and gonorrhea with AI as they would with vaginal intercourse. Many of these women could benefit from STD clinic interventions to increase knowledge about rectal STIs as well as risk reduction counseling emphasizing condom and lubrication use. Knowledge of STI risk could also provide negotiating power for condom use, specifically for those women or partners who only believed that condoms were for pregnancy prevention.19,30
There are limitations of this study to consider. We conducted face-to-face interviews with a small number of women within Los Angeles County, and the discussion of sensitive topics such as AI may have resulted in reluctance to disclose certain thoughts or behaviors. In particular, our results reflect only the attitudes and experiences of those who were willing to share this sensitive information and to disclose their recent AI experiences. Approximately half of the interviews (n = 18) took place on the day of testing so it is unlikely that these participants knew their rectal STI status. However, the remaining 22 respondents (n = 9 positive; n = 13 negative) may have received their STI results from the clinic prior to the interview, which could have influenced their responses. To understand the potential influence of knowledge of STI status on attitudes surrounding AI, we examined differences between those who may have known their STI status and those who likely did not know their status. We found similar patterns of rectal STI prevalence by reason for engaging in AI as well as feelings of control during AI within the 2 subgroups, which suggests that potential knowledge of STI result played a minimal role in influencing responses (“Appendix 1”, at http://links.lww.com/OLQ/A107).
These findings suggest a need to reframe AI as a commonly practiced sexual risk behavior among women, and particularly among women in serious relationships. Although being in a serious relationship may not indicate to providers an increased risk for STIS/HIV, our results suggest that risk may be influenced by the contextual factors surrounding AI and reasons for engaging in AI, even among those in a serious relationship. One example is that high rates of drug/alcohol use during AI may impair condom negotiation and women may be susceptible to rectal STIs if their partner has multiple concurrent partnerships. Therefore, it may behoove providers to incorporate AI into discussions about sexual health to normalize these discussions and address risk for rectal STIs and HIV. Sexually transmitted disease prevention programs may also consider including comprehensive information about AI risk for women.
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