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Contextual Factors Surrounding Anal Intercourse in Women

Implications for Sexually Transmitted Infection/HIV Prevention

Stahlman, Shauna MPH, PhD*; Hirz, Alanna E. MSPH; Stirland, Ali MBChB, MSc; Guerry, Sarah MD; Gorbach, Pamina M. DrPH*; Javanbakht, Marjan MPH, PhD*

Sexually Transmitted Diseases: July 2015 - Volume 42 - Issue 7 - p 364–368
doi: 10.1097/OLQ.0000000000000303
Original Study
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Background Our objectives were to describe women's reasons for engaging in anal intercourse (AI), contextual factors surrounding AI, and how these vary by current rectal sexually transmitted infection (STI) status, and to assess women's knowledge and concerns about rectal infections.

Methods Between January 2011 and June 2013, we conducted semistructured, qualitative interviews among 40 women attending public sexually transmitted disease clinics in Los Angeles County, California. Women were eligible if they were at least 18 years of age, reported AI in the past 90 days, and were tested for rectal Chlamydia trachomatis and Neisseria gonorrhoeae. Interviews, which were guided by the theory of gender and power, were transcribed and coded to explore contextual factors surrounding AI.

Results On average, participants reported having 3 AI partners in their lifetime and most (n = 30) reported being in a serious relationship with a main/regular sex partner at the time of the interview. Motivations for engaging in AI and feelings about AI varied by rectal STI status. Women with a rectal STI more prominently conveyed the idea that AI was intended to please their sexual partner, whereas those who did not have a rectal STI reported AI more as a way to increase intimacy and personal sexual gratification. Almost all women (regardless of rectal STI status) reported limited to no knowledge about the risk of rectal STIs.

Conclusions Among women, risk of acquiring rectal STIs may vary by reason for engaging in unprotected AI as well as other contextual factors. Providers should consider addressing these contextual factors to reduce risk.

A qualitative study of women attending sexually transmitted disease clinics in Los Angeles County, California, identified contextual factors surrounding unprotected anal intercourse that could increase risk of acquiring rectal sexually transmitted infections. Supplemental Digital Content is available in the article.

From the *Department of Epidemiology and †Community Health Sciences, Fielding School of Public Health, University of California, Los Angeles, Los Angeles CA; and ‡Los Angeles County Department of Public Health, Los Angeles, CA

Conflicts of Interest and Sources of Funding: This research was supported by funds from the California HIV/AIDS Research Grants Program Office of the University of California, Grant No. ID09-LA-012. No conflicts of interest have been declared.

Correspondence: Shauna Stahlman, MPH, PhD, Department of Epidemiology, University of California, Los Angeles, Box 951772, Los Angeles, CA 90095-1772. E-mail: sstahlman@ucla.edu.

Received for publication February 28, 2015, and accepted May 5, 2015.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal’s Web site (http://www.stdjournal.com).

Unprotected receptive anal intercourse (AI) represents one of the most efficient modes of sexual transmission of HIV1 and is an important risk factor for the transmission of other sexually transmitted infections (STIs). In addition, there is growing evidence suggesting that a large number of heterosexual couples engage in AI.2–9 In a recent national survey in the United States, up to 46% of women reported ever having AI,10 with estimates of recent experience with AI among women ranging from 10% to 22% among clients attending sexually transmitted disease (STD) clinics and 5% to 42% of substance using women.6,8,9,11,12 In one study, up to 18% of women responding to a population-based survey reported AI a few times per year to monthly, with 4% reporting AI a few times per month.13 Factors found to be positively associated with AI among women include substance use, injection drug use, number of sex partners, exchanging drugs or money for sex, and lack of condom use.2,4,5,8,11,14

However, there are limited data available on the contextual factors surrounding unprotected AI and subsequent risk for STIs.15–17 Maynard et al.15 and Carter et al.18 identified physical pleasure, emotional intimacy, and partner pleasure as key motivating factors for women to engage in AI. Exner et al.14 identified additional contextual factors associated with AI, such as infrequent condom use with reasons ranging from not having a condom on hand to never using condoms with a primary partner. However, because these studies did not measure rectal STI status, it remains uncertain how and which of these contextual factors, such as relationship dynamics, can influence risk for rectal STIs. The limited findings prompted us to gain a better understanding of the important interpersonal and contextual factors that influence AI and the acquisition of rectal STIs among women. Specifically, our objectives were as follows: (1) to report women's reasons for engaging in unprotected AI; (2) to describe the contextual factors surrounding AI, such as feelings about AI and perceptions of control during AI, use of alcohol/substances, condoms, and lubrication, and how these vary by current rectal STI status; and (3) to assess women's knowledge and concerns about rectal infections.

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METHODS

Study Setting and Participants

Between January 2011 and June 2013, we conducted semistructured, qualitative interviews among 40 women attending public STD clinics in Los Angeles County, California. The 12 public STD clinics serve approximately 10,000 women per year, with 10% reporting AI and, among whom a prevalence of 5% for rectal gonorrhea and 15% for rectal chlamydia has been noted.7,12 Women were eligible for inclusion in this study if they were 18 years or older, reported AI in the past 90 days, and were tested for rectal Chlamydia trachomatis and Neisseria gonorrhoeae. Based on existing protocols in place at the clinics, only women who reported AI in the past 90 days (or longer if rectal symptoms were present) were tested for rectal STIs. By design, we selected both women with and without rectal STIs and interviewed 19 women who tested positive for rectal C. trachomatis and/or N. gonorrhoeae and 21 women who tested negative for rectal C. trachomatis and/or N. gonorrhoeae.

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Data Collection and Analysis

Recruitment was based on provider referral with potentially eligible and interested participants referred to a trained female research assistant who was of similar age and race/ethnicity. The research assistant met with participants to verify eligibility, obtain written informed consent for all study related procedures, and conduct the study interview. The 50- to 60-minute face-to-face interviews were scheduled at the participants' earliest convenience, with 18 of the interviews taking place on the same day of the clinic visit (i.e., day of STI testing). Although it is unlikely that those interviewed on the same day as testing would have known their STI status, it is possible that some of the remaining 22 participants knew their rectal STI status at the time of the interview. The interviews took place in private offices or examination rooms at the clinic and were audio-recorded. We used a semistructured, open-ended script, which began with general questions and led into questions focusing on the participant's sexual behaviors. The interview guide was informed by the “Theory of Gender and Power (TGP).”19,20 The TGP proposes that 3 major structures characterize the gendered relationships between men and women: (1) the sexual division of labor, (2) the sexual division of power, and (3) the structure of social norms and affective attachments. Interviews combined open-ended questions based on established ethnographic interview methodology21 as well as structured probes to explore factors in each of the 3 TGP domains. Participants provided written informed consent and received $30 for their time. The study was approved by institutional review boards at the University of California Los Angeles and the Los Angeles County Department of Public Health.

Interviews were transcribed verbatim and checked for accuracy to enable reliable analysis of responses.22 The response text was searched, labeled, extracted, and categorized for each topic of interest using content analysis. The themes were then analyzed for content pertaining to our research objectives. The interviews were independently coded by 2 study investigators and discrepancies compared with standardize code definitions. All data were analyzed using ATLAS.ti 7 (ATLAS.ti GmbH, Berlin, Germany).

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RESULTS

Sample Demographics

Most respondents identified as either Hispanic (n = 18) or black (n = 18), with 4 identifying as white. The mean age was 28 years (range, 18–49 years). On average, participants reported having 3 (range, 1–30) AI partners in their lifetime and most (n = 30) reported being in a serious relationship with a main or regular sex partner at the time of the interview.

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Reasons for Engaging in AI and Feelings about AI

Anal intercourse had varied meaning for women with 3 major themes emerging from our analysis: (1) a need to please her partner, (2) to express deeper intimacy, and (3) to increase sexual gratification (Table 1). However, reasons for engaging in AI and feelings about AI varied by rectal STI status (Table 2). Specifically, the idea that AI served as a strategy to please sexual partners was more prominent among women with a rectal STI, whereas those who did not have a rectal STI were more likely to report AI as a way to increase intimacy and personal sexual gratification.

TABLE 1

TABLE 1

TABLE 2

TABLE 2

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%).

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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.

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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).

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Substance Use

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).

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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).

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DISCUSSION

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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