Abstract
Purpose:
We evaluated the relationship between lifetime receptive anal intercourse (RAI) and the risk of common colorectal and urologic diagnoses.
Methods:
We conducted an internet-based survey on sensations during RAI between July 2022 and March 2023. We used multivariable logistic regression to assess the independent impact of lifetime RAI exposure on the diagnosis of common urologic and colorectal conditions. Participants completed a main survey and were invited to complete randomly assigned patient-reported outcome measures (PROMs), which measured pelvic symptoms, mental health symptoms, and sexual satisfaction.
Results:
In total, 1100 participants completed the main survey and 416 completed the PROMs. Participants of the main survey ranged from 18 to 78 years old and the median age of the sample was 32 years. There was no significant association between lifetime RAI exposure and any medical diagnosis, except for anal fissures, which increased linearly with additional RAI exposure. Both sexual satisfaction and mental health symptoms improved with RAI exposure.
Conclusions:
RAI was not associated with most of the colorectal and urologic diagnoses tested and was associated with fewer mental symptoms and increased sexual satisfaction. Development of anal fissures may be directly related to trauma of the anal canal from penetration.
Keywords: colorectal health, men who have sex with men, sexual health, urology
Introduction
Receptive anal intercourse (RAI) is consensual penetration of the anus by a partner for sexual pleasure. Within the United States, 9.8% of men and 37.3% of women reported having RAI within their lifetime regardless of sexual orientation. 1 The majority of medical literature on RAI has focused on mitigating risk of sexually transmitted infections (STIs) and human immunodeficiency virus (HIV). 2 Early research aimed at understanding the risk profile of RAI suggested an association between fecal incontinence and RAI practices, especially for unconventional “hard practices,” such as fisting. 3,4 Given these findings, RAI may also impact other structures within the pelvis, such as the anal sphincter, pelvic floor, or prostate.
Despite negative stigma, RAI has many positive emotional and physical benefits that are important aspects of relationships and sexual health. In fact, many individuals in our previous qualitative study had practiced RAI for >30 years without any apparent negative health consequences. 5 Outside of infection risk, the long-term safety profile of RAI is not well documented. We use lifetime RAI exposure, a previously validated measure, to assess the impact of RAI on prevalence of colorectal and urologic diagnoses as well as associated patient-reported outcome measures (PROMs). 6
Methods
Study design and survey development
Between July 2022 and March 2023, we conducted an internet-based survey on sensations during RAI among people with prostates (i.e., cisgender men and transgender women). The primary aim of our survey was to validate a measure on sensations experienced during RAI. Data presented here represent a follow-up analysis of the survey results.
Inclusion criteria were anyone born with a prostate who engaged in RAI within the past 6 months, 18 years or older, and able to read English. The survey content was developed based on our research team’s previous qualitative research. All participants who completed the main survey were invited to complete randomly assigned PROMs. Participants were not paid to complete the survey but, as an incentive, were invited to participate voluntarily in a raffle of eight $25 dollar gift cards. Information about the study, such as introduction to the study team, the study aims and protocol, a consent question, and research participation rights, were displayed to all before the survey questions were administered. All individuals in our survey consented to participate. Prior to study enrollment, institutional review board approval was obtained at the University of California, Los Angeles. The full survey can be found in the supplementary materials (Supplementary Appendix SA1).
Gender and sexual orientation definitions
We asked all participants the following two questions before eligibility was assigned: What was your sex assigned at birth? (male, female, other) and What is your current gender? (male, female, nonbinary/genderqueer, prefer not to say). Only individuals assigned male at birth were included. All participants regardless of current gender were included. Sexual orientation was later defined as the response to the following question: What is your sexual orientation? (heterosexual/straight, gay, lesbian, bisexual/pansexual, queer, not listed).
Exposure
We assessed exposure to RAI via a single question: “Over the course of your lifetime , about how many times have you bottomed? (not the number of sexual partners). For reference, 500× is about once a week for 10 years.” Response options included (a) less than 10 times, (b) 11–50 times, (c) 51–200 times, (d) 201–500 times, and (e) >500 times. From our previous research, lifetime exposure to RAI correlates with age, years of RAI activity, and the number of RAI experiences within the past 3 months.
Outcomes
We evaluated several self-reported colorectal and urologic diagnoses. Diagnoses were chosen based on conditions that came up during qualitative patient interviews and those we considered may negatively impact RAI. We asked “has a doctor ever told you that you had one of the following conditions?” These included: benign prostatic hyperplasia, prostate cancer, chronic prostatitis, Crohn’s disease or ulcerative colitis, rectal cancer, anal cancer, hemorrhoids, anal fissure (tear), anal abscess or fistula, and irritable bowel syndrome (IBS). Because very few respondents reported a history of rectal (n = 14) and anal cancers (n = 9), these outcomes were removed in our analyses.
PROMs included measures of sexual satisfaction, urinary health, erectile health, anorectal symptoms, prostatitis symptoms, mental health symptoms, and internalized homophobia. Sexual satisfaction was estimated via the New Sexual Satisfaction Scale-Short (NSSS-S), which is a 12-item survey. 7 Lower urinary tract symptoms were assessed via the American Urological Association (AUA)-symptom score, which is a seven-item survey measuring incomplete emptying, frequency, intermittency, urgency, weak stream, straining, and nocturia. 8 Erectile function was measured via the Sexual Health Inventory for Men, which was only offered to the participant if they had a penis. 9
Anorectal symptoms were measured via the Late Effects Normal Tissue Subjective, Objective, Management, Analytic (LENT-SOMA) scale, which is a survey originally designed to assess rectal symptoms after radiation therapy. 10 This six-item questionnaire was selected as it asks about bowel movement frequency, pain, discharge, bleeding, and fecal incontinence, which we anticipated would correlate with painful RAI and bowel symptoms. Pelvic pain was measured using the National Institutes of Health (NIH) Chronic Prostatitis Symptom Index (NIH CPSI). 11 The Brief Symptom Inventory (BSI) was used to measure mental health symptoms (depression, anxiety, somatization). 12 Finally, internalized homophobia was assessed using a nine-item survey for sexual minority adults. 13
Statistical analysis
We used multivariable logistic regression to assess the independent impact of RAI exposure on the health outcomes listed above. Covariates were chosen a priori based on expert opinion. Covariates were variables thought to both impact lifetime RAI exposure and pelvic health diagnoses/PROMs measured. All covariates in the model were age, education status, number of sexual partners, sexual frequency, relationship status, and race/ethnicity. We converted our logistic regression models to predictive margins for ease of interpretation. The predictive margin is the estimated mean (95% confidence interval) of the dependent variables based on each bin of RAI exposure after covariable adjustment. We calculated a chi-squared statistic for the trend across each RAI exposure category, and p values <0.05 were considered statistically significant. All PROM scores were kept as continuous variables for consistency during analysis. All PROM analyses were only adjusted for age and education status as fewer subjects completed these compared with the main survey.
Results
In total, 1100 individuals completed the main survey, of whom 416 also completed the PROMs. Participants of the main survey ranged from 18 to 78 years old and the median age of the main sample was 32 years (interquartile range 26–43). In our main sample, 92% identified as cisgender men, 3% as transgender women, and 4% as nonbinary/genderqueer. Of the cisgender men, 82% identified as gay, 11% as bisexual/pansexual, and 4% as straight. The sample was 71% White, and 74% had at least a bachelor’s degree. All participants were sexually active within the past 6 months. Table 1 shows the demographics of the study population.
Table 1.
Demographic Characteristics of a Convenience Internet Sample of People Who Engage in Receptive Anal Intercourse, 2022–2023
| n = 1100 | |
|---|---|
| Age, median (IQR; range) | 32 (27–43; 18–79) |
| Gender, n (%) | |
| Cisgender male | 1012 (92) |
| Transgender female | 36 (3) |
| Nonbinary/genderqueer | 45 (4) |
| No answer/missing | 7 (1) |
| Sexual orientation among cisgender men, n (%) | |
| Straight | 44 (4) |
| Gay | 825 (82) |
| Bisexual/pansexual | 111 (11) |
| Queer | 26 (3) |
| No answer/missing | 6 (0.5) |
| Sexual orientation among gender diverse people, n (%) | |
| Straight | 4 (5) |
| Gay | 20 (25) |
| Bisexual/pansexual | 27 (33) |
| Queer | 23 (28) |
| Lesbian | 5 (6) |
| No answer/missing | 2 (2) |
| Race/ethnicity, n (%) | |
| Asian/Pacific Islander | 80 (7) |
| Black or African American | 36 (3) |
| Hispanic/Latino/Spanish origin | 112 (10) |
| Native American/Alaska Native | 4 (0.4) |
| White/Caucasian | 782 (71) |
| Mixed | 29 (3) |
| Other | 55 (5) |
| No answer/missing | 2 (0.2) |
| Education, n (%) | |
| High school graduate or less | 81 (7) |
| Some college or 2-year degree | 204 (19) |
| Bachelor’s degree | 362 (33) |
| Graduate/professional degree | 451 (41) |
| No answer/missing | 2 (1) |
| Relationship status, n (%) | |
| Single | 394 (36) |
| Closed relationship (monogamous) | 422 (39) |
| Open relationship | 280 (26) |
| No answer/missing | 4 (1) |
| Number of sexual partners past 6 months, n (%) | |
| 0 | 12 (1) |
| 1 | 439 (40) |
| 2–5 | 366 (33) |
| 6–10 | 139 (13) |
| >10 | 143 (13) |
| No answer/missing | 1 (0.1) |
| Sexual frequency past 6 months, n (%) | |
| Daily | 60 (5) |
| A few times a week | 272 (25) |
| Weekly | 380 (35) |
| Monthly | 232 (21) |
| Less than monthly | 156 (14) |
| No answer/missing | 0 |
IQR, interquartile range.
Table 2 shows the adjusted prevalence of diagnoses by RAI exposure. Confounding variables chosen were age, education status, number of sexual partners, sexual frequency, relationship status, and race/ethnicity. Among the diagnoses we examined, there was no significant trend between lifetime RAI exposure and benign prostatic hyperplasia (BPH), prostate cancer, chronic prostatitis, inflammatory bowel disease (IBD), hemorrhoids, anal abscess/fistula, or IBS. However, the prevalence of anal fissures increased linearly across lifetime RAI exposure.
Table 2.
Lifetime Receptive Anal Intercourse Exposure and Adjusted Prevalence of Colorectal and Urologic Diagnosis, n = 1100
| RAI exposure history | <10 times n = 90 |
11–50 times n = 292 |
51–200 times n = 351 |
201–500 times n = 178 |
>500 times n = 189 |
p value for trend |
|---|---|---|---|---|---|---|
| Diagnosis, % (95% CI) | ||||||
| Benign prostatic hyperplasia | 12 (6–19) | 9 (5–12) | 12 (9–16) | 11 (7–15) | 8 (1–11) | 0.39 |
| Prostate cancer | 9 (2–15) | 2 (0–4) | 4 (2–7) | 2 (0–5) | 3 (0–4) | 0.09 |
| Chronic prostatitis | 7 (2–12) | 4 (2–7) | 5 (2–7) | 4 (0–6) | 2 (0–4) | 0.05 |
| IBD | 4 (0–8) | 1 (0–3) | 2 (0–4) | 7 (3–11) | 5 (0–8) | 0.25 |
| Hemorrhoids | 38 (26–49) | 34 (28–40) | 41 (36–46) | 40 (32–46) | 39 (31–46) | 0.62 |
| Anal fissure | 21 (11–30) | 19 (14–24) | 24 (19–28) | 27 (20–33) | 34 (27–42) | 0.02 |
| Anal abscess/fistula | 7 (1–12) | 4 (1–6) | 5 (3–7) | 4 (0–7) | 4 (0–7) | 0.50 |
| IBS | 12 (5–19) | 13 (9–17) | 15 (12–19) | 15 (9–20) | 15 (10–21) | 0.42 |
Models adjusted for age, education status, number of sexual partners, sexual frequency, relationship status, and race/ethnicity.
CI, confidence interval; RAI, receptive anal intercourse; IBD, inflammatory bowel disease; IBS, irritable bowel syndrome.
Table 3 shows the relationship between PROM scores and lifetime RAI. Our analysis of the adjusted questionnaire scores for each PROM showed no significant trend between lifetime RAI and urinary symptoms, erectile function, and anorectal symptoms. Sexual satisfaction increased, while chronic prostatitis symptoms, mental health symptoms, and internalized homophobia decreased with greater lifetime RAI exposure.
Table 3.
Lifetime Receptive Anal Intercourse Exposure and Adjusted Patient-Reported Outcome Measures, n = 416
| RAI exposure history | <10 times n = 33 |
11–50 times n = 108 |
51–200 times n = 123 |
201–500 times n = 71 |
>500 times n = 81 |
p value for trend |
|---|---|---|---|---|---|---|
| Questionnaire, score (95% CI) | ||||||
| NSSS | 37 (34–40) | 41 (39–42) | 41 (40–43) | 44 (42–46) | 46 (44–48) | <0.01 |
| AUA-SI | 9 (6–11) | 7 (6–9) | 7 (6–8) | 6 (5–8) | 7 (5–9) | 0.17 |
| SHIM | 18 (16–20) | 18 (16–19) | 18 (17–19) | 20 (19–21) | 19 (18–20) | 0.06 |
| LENT-SOMA | 9 (8–10) | 9 (9–10) | 9 (9–10) | 9 (8–10) | 9 (8–9) | 0.27 |
| NIH/CPSI | 10 (7–12) | 8 (6–9) | 7 (6–8) | 6 (5–8) | 6 (4–7) | <0.01 |
| BSI-18 | 15 (12–18) | 9 (7–11) | 9 (7–10) | 7 (5–9) | 7 (5–9) | <0.01 |
| Internalized homophobia | 19 (16–22) | 18 (16–19) | 16 (15–18) | 16 (14–17) | 15 (13–16) | <0.01 |
Models adjusted for age and education status.
NSSS, New Sexual Satisfaction Scale (higher scores indicate greater satisfaction); AUA-SI, American Urological Association Symptom Index (higher scores indicate greater symptomatology); SHIM, Sexual Health Inventory for Men (higher scores indicate better erectile health); LENT/SOMA, Late Effects Normal Tissue/Subjective, Objective, Management, Analytic (scale that measures anorectal symptoms; higher scores indicate greater symptomatology); NIH/CPSI, National Institutes of Health, Chronic Prostatitis Symptom Index (higher scores indicate greater symptomatology); BSI-18, Brief Symptom Inventory-18 (higher scores indicate greater mental health symptomatology); Internalized Homophobia Scale, higher scores indicate greater internalized homophobia.
Discussion
Overall, long-term exposure to RAI did not correlate with the majority of pelvic health diagnoses tested and was positively associated with sexual satisfaction and mental health scores. However, our results suggest that RAI is a risk factor for the development of anal fissures. As lifetime RAI exposure increased, the prevalence of anal fissures linearly increased as well. Proper lubrication, speed of entry, and communication with one’s partner(s) may be strategies for anal fissure prevention. 5 Given that many anal fissures may be asymptomatic, the absolute prevalence of anal fissures presented in our study should be interpreted with caution. 14
Notably, we did not observe a relationship between hemorrhoids and lifetime RAI experience. Anecdotally, misperceptions among both providers and individuals engaging in RAI that the practice may contribute to hemorrhoid development are common. Although the exact pathogenesis of hemorrhoids remains not well characterized, our results may reiterate that the mechanism underlying hemorrhoid formation is likely related to sliding of the anal cushions and straining with chronic constipation, rather than RAI. 15,16 RAI, however, may exacerbate pain or bleeding within preexisting hemorrhoids.
Our analyses also show that participants who were first engaging in RAI reported the most pelvic symptoms, mental health symptoms, and internalized homophobia. Initiation of RAI may represent a vulnerable stage in sexual development. For reference, normal BSI-18 scores range from 5 to 7. 12,17 Individuals who were first engaging in RAI reported about three times this value. RAI debut also correlates with both race and perceived socioeconomic status, which likely contribute to both mental health symptoms and internalized homophobia. 18 Internalized homophobia was very commonly reported upon initiation of RAI within our qualitative study. Participants noted shame as a barrier to pleasure. 5 Further investigation is needed to determine if the decline in mental health symptoms and internalized homophobia with RAI experience is due to individuals self-selecting out of the practice as a result of negative sequela or because these psychosocial elements naturally improve over time. Longitudinal studies with repeated measures are needed to confirm this finding.
Sexual satisfaction, as measured by the NSSS, increased with RAI exposure. This finding could have several explanatory factors. One, sexual satisfaction may increase because pleasure also increases with RAI experience. 6 Two, sexual satisfaction may increase as one comes to term with preferred sexual roles (i.e., insertive vs. receptive partner). Third, sexual satisfaction may increase as other barriers to sexual intimacy decrease, such as internalized homophobia or mental health symptoms. Pelvic pain symptoms, as measured by the NIH/CPSI, decreased with RAI exposure. RAI lends to regular relaxation and stretching of the pelvic floor musculature, which has been shown to improve pelvic pain. 19 Alternatively, people with pelvic pain opt out of RAI over time due to pain. The relationship between pelvic pain and RAI merits further inquiry.
Limitations
We recognize a few limitations to this study. Although previous reports have correlated RAI with fecal incontinence, this was not a diagnosis explicitly assessed in our study. 3,4 The LENT-SOMA questionnaire, which does have one question regarding urge fecal incontinence, was chosen as a PROM given the breadth of questions probing anorectal quality of life. Very few individuals reported urge fecal incontinence within this survey (n = 5). On the one hand, this provides some evidence that many individuals with longstanding RAI exposure do not experience fecal incontinence. On the other hand, we only studied individuals who were currently sexually active and cannot exclude the possibility that some individuals developed fecal incontinence and discontinued the practice. We deliberately excluded assessment of STIs to focus on global pelvic health. We cannot exclude the possibility of uncontrolled confounding variables. Although the rectum is highly permeable to microbes, risk for STIs has been shown to be more dependent on social factors, such as number of sexual partners and condom usage. 20
Conclusions
Overall, for individuals who practice RAI, these data highlight its impact on general and sexual wellbeing. In our sample, RAI exposure was not associated with increased prevalence of many common high morbidity conditions, including BPH, prostate cancer, chronic prostatitis, IBD, hemorrhoids, anal abscess/fistula, and IBS. Educational campaigns may focus on anal fissure awareness and prevention. Mental health symptoms and internalized homophobia decreased with increasing RAI exposure. Ultimately, we hope these results will contribute to destigmatization of RAI while also promoting healthy practices.
Authors’ Contributions
T.W.G.: Conceptualization, investigation, data curation, formal analysis, writing—original draft. T.S.: Formal analysis, methodology, validation, writing—original draft. N.W.V.: Data curation, methodology, project administration, writing—review and editing. M.R.: Methodology, project administration, validation, writing—review and editing. M.S.L.: Investigation, methodology, resources, supervision, validation, writing—review and editing.
Author Disclosure Statement
The authors have no conflicts of interest or disclosures.
Funding Information
This project received no funding.
Supplementary Material
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