Women who have anal sex: Pleasure or pressure? Implications for HIV prevention

CONTEXT

Anal intercourse is a highly efficient mode of HIV transmission. Although much scholarly attention has been paid to anal intercourse between men who have sex with men, research on women’s experiences of anal sex has been scarce. Nevertheless, there is evidence to suggest that anal intercourse is also widely practiced by women in the US (1–4). Prior studies that examined the prevalence of sexual behaviors among women and included anal intercourse found that 20–30% of US women reported lifetime rates of anal intercourse (3, 5–7) and 19%–32% of US women reported having had anal sex in the last 6–12 months (8, 9).

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. For example, a New York study of initially serodiscordant, heterosexual couples found that a history of anal intercourse was one of the strongest predictors of eventual HIV transmission, adjusted OR = 10.81, 95% CI = 2.78–42.0 (14). Similarly, in Brazil, researchers found that seronegative women who practiced anal intercourse in addition to vaginal and/or oral intercourse with seropositive male partners were approximately four times as likely to acquire HIV than women who did not practice anal intercourse (15). 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, 13). A topic that has received even scarcer attention is the circumstances under which women engage in anal intercourse. Qualitative research to date has focused on the contexts surrounding anal intercourse in South Africa (16, 17) and Brazil (18, 19), but there is a dearth of research on American women’s experiences with anal intercourse.

In order to develop effective interventions for HIV prevention, it is important to better understand both women’s motivations for engaging in anal intercourse, and in which circumstances and with whom they chose to use a condom. 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. Previously, we have used these data to examine the implications of women’s anal sex practices for the formulation and promotion of rectal microbicides (20).

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. 105). In contemporary American sexual culture, the predominant sexual script is one of male pursuit and female acquiescence (22). Simon and Gagnon, for example, note that “women have rarely been ‘selected’ for sexual roles on the basis of their own interest in sexual pleasure” (p. 107). This script of female acquiescence may be a barrier to women’s sexual health (Tolman) (22, 23) and has important implications for HIV and STI prevention.

Similarly, despite calls for increased attention to the role of female desire in human sexuality research (24–27), pleasure as a potential motivating factor in women’s sexual decisions has often been overlooked. In this article we will attempt to partially remedy the “pleasure deficit” (24) in research on anal intercourse by not only examining how women experienced and responded to pressure from their male partners to have anal sex, but by also considering how women were motivated by their own sexual desire to practice unprotected anal intercourse.

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 2006. The study design and procedures were approved by the appropriate institutional review boards.

Participants

Investigators sought to recruit 28 women distributed in approximately equal numbers by race/ethnicity. 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. Participants filled out a demographic questionnaire asking their age, education level, racial/ethnic identity, gender identity, sexual orientation, work/student status, and personal income.

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 both clarify the topic of discussion and assess the participant’s use of terms, the interviewer asked “What do you call it when a man puts his penis in your anus?” Following the participant’s response, the interviewer used the participant’s terms throughout the interview. In this analysis, however, “anal intercourse” and “anal sex” refer to penile-anal intercourse, rather than other forms of anal stimulation. Among other topics, the interviewer asked participants to discuss their first, most recent, and general experiences with anal sex; their feelings and attitudes about anal sex; and their perception of others’ views about anal sex. On completion of the interview, women were given $50 as compensation for their time.

This report examines topics that the interview was designed to assess -- such as initiative of sexual behavior, non-consensual sex, condom use, and HIV/STI risk-- as well as indigenous typologies that emerged from the participants’ responses (28), such as pain and discomfort, physical pleasure, intimacy, and sexual variety. To elicit responses, the interviewer first asked participants open-ended questions such as: “How did anal sex come about most recently?” and “Let’s talk about feelings about anal sex”. 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, 30).

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.

RESULTS

Sample Description

Twenty-eight women participated in the study. Ten women identified their race as African American (Black), seven as European American (White), two as Asian/Pacific Islander and nine as “Other” race. In addition to or instead of these racial categories, seven participants also reported Hispanic ethnicity. The mean age of the participants was 29.5 years (SD = 6.62, range = 18–55), 68% had a partial college education or higher, and 61% had an annual income of less than $20,000. 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. One woman reported having had unprotected anal intercourse with a seropositive partner; other women either failed to disclose their partners’ serostatuses or said that they did not know.

When we refer to participants’ responses, we will note their age and race/ethnicity in order to illustrate the diversity of the sample. Participants’ names have been replaced with aliases.

Sexual Initiative

We examined the initiating patterns of heterosexual anal intercourse in order to better understand women’s decision-making surrounding anal intercourse. Participants’ accounts suggest that their male partners overwhelmingly took the initiative when it came to anal intercourse, consistent with theconventional sexual script in which men are the pursuers and women acquiesce to male desire (23). Overall, 82% of our sample reported that their male partners initiated their first occasion of anal intercourse, while only 11% took the initiative themselves (the remaining 7% is unaccounted for). When asked about their most recent occasion of anal intercourse, similar proportions reported that their male partners had initiated the behavior (68%). A considerable proportion of women (25%) told of having been forced, without their consent, into having anal intercourse on at least one occasion. 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:

Sarah: I really enjoy anal sex and I can say that he initiated it in that he initiates everything that happens, but if I hadn’t wanted him to do it all I had to do was put his penis somewhere else. (27, White)

In other cases, women recognized that permitting or withholding anal intercourse from their male partners allowed them greater power in other areas of their relationships. For example, engaging in an unusual practice with her casual sexual partner made one participant feel more desirable:

Isabella: I love the attention [from anal intercourse]. I love the spotlight, I love the attention afterwards, the phone calls, even though they’re obsessed with me, it makes me feel needed and wanted and it just makes me feel like awoman. (36, Black Hispanic)

Contrary to its usual portrayal as a deviant or uncommon sexual behavior, here anal intercourse reinforced, rather than undermined, the usual gendered norms of sexual conduct, whereby men “take possession of the object of desire” and women are supposed to “be the object of desire” (21). 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 Sex

Twenty-five percent of the sample (n=7) reported having non-consensual anal intercourse on at least one occasion. 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:

Alyssa: The first time I had anal sex with him he just said “Turn over,” like a demand, and I was very uncomfortable. It felt like he was doing it to hurt me purposely…He loved it, he wanted me to be in pain, because during it I was asking him “Please take it out, you’re hurting, please, please, take it out?” And he was going “Shut up bitch, shut up bitch.” (41, Black, non-Hispanic)

Among the seven women who experienced non-consensual anal intercourse, two of them also reported having had anal intercourse during transactional sex on at least one occasion, suggesting, for these women, a history of limited sexual agency. However, as this subgroup was so small (7% of the sample), it is difficult to draw conclusions about the relationship between early experiences with non-consensual anal intercourse and later experiences with transactional sex.

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. This variation in experience, not only among participants but across a woman’s sexual history, suggests that women’s motivations to practice anal intercourse were fluid, dependent not so much on the behavior itself, but on the social context in which anal intercourse occurred. For example, whereas Ashley’s (19, Black, non-Hispanic) first experience with anal intercourse was with a stranger who forced her to have anal sex, more recently she reported having consensual anal sex with the man that she had been seeing for a few months; her experience with anal sex varied by partner familiarity. The majority of the sample reported an annual income of less than $20,000, but all but one of the participants who experienced non-consensual anal intercourse had an annual income of less than $10,000; although we did not test for statistical significance, this group might compose an especially disadvantaged subgroup.

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 other cases, pain during anal intercourse was extreme, as in the following instance, when this participant’s on-again, off-again boyfriend initiated anal sex:

Chelsea: At first I thought OK, I could deal with this, but then when I realized he was trying to go harder and harder with it then I’m like “OK, that’s enough.” It just felt like it couldn’t go any further than what he was trying to push it, so it felt like I was ending up in a lot more pain than I already was if I would have kept going with it. (18, Black, non-Hispanic)

Given the frequent mentions of pain during consensual anal intercourse, we were interested in understanding why and how women engaged in anal sex in spite of these unpleasant sensations. In cases where women expected anal sex to be painful, they listed various reasons for engaging in the practice anyway: to try something new, to please their partners, or to experience sexual pleasure. 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:

Valeria: I let him do it. And we did it in the big recliner chair. It hurt and it felt good at the same time. Because I know it was hurting me, but I wouldn’t let him stop… it was hurting, but it was hurting good. So I didn’t consider stopping or anything. (41, Hispanic)

That some participants experienced anal intercourse as simultaneously pleasurable and painful supports our view that anal intercourse usually occurred as a complex emotional and physiological event for our participants, and cannot be easily categorized as entirely pleasurable or entirely painful, even for the same individual. Additionally, sometimes the same participant experienced anal intercourse as being pleasurable in some occasions and painful in others, suggesting that a woman’s ability to enjoy and initiate anal sex was not a static trait, but rather a dynamic process that varied depending on the intimacy of the sexual relationship, prior experiences with anal sex, and comfort with taking sexual initiative, among other factors.

Participants’ accounts of anal intercourse treated it not so much as a separate, unique sexual behavior, but as part and parcel of their larger experience as sexual actors. 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, 32). 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:

Interviewer: What has led you to have anal sex [in general]?

Jada: Wanting it. I like it. If I have anal sex, I have orgasms. So it’s just like I’m having the regular -- missionary sex. It’s just like that. My body likes it. (32, Black, non-Hispanic)

In terms of the physical sensations produced by anal intercourse, participants often referred to vaginal sex and/or oral sex as standards of comparison, thereby somewhat equating the behaviors. Some women compared anal sex favorably to vaginal sex, as this woman did when she spoke about having anal sex with her baby’s father:

Madison: There’s real pleasurable like. It feels like vaginal but almost a little better, it seems like. I like it. It feels like you’re in another world somewhere. Ohh! It feels like you’re getting massaged. And it feels good. (20, Black, non-Hispanic)

While not complaining of reduced pleasure per se, a few women compared anal sex unfavorably to vaginal sex, which they considered “real sex,” or repeated the catchphrase “It’s an exit, not an entrance” when referring to the rectum, suggesting that for some participants, anal sex was not easily equated with vaginal intercourse. 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. Some women tried anal intercourse out of curiosity, or because they saw anal intercourse as a way of bringing variety or “spice” into their sexual relationships, as the following participant, who occasionally had anal sex during transactional sex work, but here refers to the practice in the context of her romantic relationships:

Sophia: [I’ve had anal sex] just for excitement. Just [for] something different. Something added, because a lot of people don’t do that. And I just found a new part of my body I can enjoy. I like it. (46, White)

Because gender norms encourage women to view themselves in relation to other persons, particularly men, (33), and women are expected to meet others’ needs (including sexual needs) before their own (23), it should not be surprising that women often reported that they practiced anal intercourse to please their male partners. In these cases, women’s pleasure was contingent upon male satisfaction, insomuch as women fulfilled their sexual roles (and thus reinforcedtheir sense of being a woman) by ensuring that men were satisfied first. 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:

Interviewer: Tell me a little bit about your reasons why you did it the first time.

Nicole: I would have to say to please my partner. That would be just about it.

Interviewer: And it sounds like you, like you said [earlier], he pleased you so much.

Nicole: Yeah. Exactly. Like the idea of reciprocity. (20, “Other” race)

Here, the interviewer had to remind the participant that she had previously mentioned enjoying anal sex with her partner; tellingly, in reconstructing her rationale for having anal sex, the participant overlooked her own pleasure and emphasized that it was “to please [her] partner.”

The importance placed on intimacy, variety, and the sense of taking sex to a “different level,” in the words of one participant (Julia, 27, White), revealed that anal intercourse took on an important relational significance for some women. 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:

Sarah: Anal sex?…I think it’s more about the intimacy, feeling comfortable. Just getting to know someone’s body and like being with them long enough and starting to explore other areas than what you’re going to explore with some one you’ve known a week. (27, White)

By interpreting anal sex as a more intimate form of sexual activity than vaginal or oral sex, women represented themselves not so much as sexual rule-breakers, but as the enforcers of the notion that sex should serve to heighten intimacy and build relationships, rather than satisfy one’s own desire. 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. Similarly, 18% said that they had used a condom during their first occasion of anal intercourse, and another 18% said that they had used a condom during their last occasion of anal intercourse.

Reasons for not using a condom during anal sex were varied, including: familiarity with partner; physical discomfort or pain; partner’s preference; anal sex was unanticipated; anal sex was non-consensual; one participant was trying to get pregnant and doesn’t use condoms anymore; the male partner removed his penis before ejaculating and thus condoms were not needed; anal sex was more pleasurable without a condom; inconvenience; and because the participant used another form of birth control. In the following example, the participant was asked if she had used condoms with her boyfriend the last time they had had anal intercourse:

Emma: 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. So if you can’t get pregnant having anal sex…there was no use in having condoms. (21, White)

This participant’s response was typical in that condom use was usually not motivated by fear of HIV or STIs among this sample. In an extreme case, the one participant who reported having an HIV-positive partner said that she preferred to have anal intercourse without a condom because it “felt better,” even though her partner worried about passing the virus on to her and was reluctant to give up using a condom.

On the other hand, those participants who had used a condom during anal intercourse listed the following reasons for doing so: a concern regarding hygiene; the erroneous belief that one could get pregnant through anal sex; and the condom that had been used for vaginal sex was kept on during anal sex. 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.

Anal Sex and HIV/STI Risk

Participant’s responses regarding condom use suggest that many participants failed to distinguish between birth control and STI prevention in relation to anal sex, often mistaking one for the other. When queried about condom use, only 25% of participants spontaneously mentioned HIV/STI prevention as a concern, but none consistently relied upon condoms as a form of HIV/STI prevention during anal intercourse. Nevertheless, when probed directly, 96% acknowledged that unprotected anal intercourse was a sexual activity that put them at risk for HIV and other STIs, as in the following exchange:

Interviewer: How safe do you think anal sex is when it comes to HIV?

Kimberly: Not at all. That’s probably the un-safest one you could ever have. (20, Hispanic)

Apart from establishing eligibility criteria, we did not ask participants about their partners’ HIV status, unless the topic spontaneously came up in the course of the interview, as in the following case:

Alyssa: It was with my significant other. He never had done it before. And he was very much concerned about the fact that he was HIV-positive and I wasn’t and I didn’t want a condom on because it doesn’t feel the same to me, [so] I convinced him to do it. (41, Black, non-Hispanic)

Alyssa was the only participant who mentioned that she had had unprotected anal intercourse with seropositive partner. However, another participant (Valeria, 41, Hispanic) said that she regularly had anal sex with a man whose other partner was HIV-positive. Because most participants did not mention seropositive partners, it is likely that they either had not been told their partners’ serostatus, or did not want to ask, as this participant explains:

Esther: It’s hard enough to bring it [HIV status] up, and then if they say, “Oh yeah, I tested and I was negative,” then you don’t really know where to go. Because it was so hard to even mention it, that you feel like if you say, “Could you get that on paper?” or “When was the last time?” or “And how much sex have you had since?” that then you’re questioning…and they become defensive. (29, White)

As this quote illustrates, participants’ intentions to ascertain their partners’ HIV status may have seemed incompatible with their desire to experience emotional intimacy and trust through anal sex.

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. Nevertheless, we can hypothesize that other motivations for engaging in unprotected anal intercourse – such as pleasure, intimacy, to please one’s partner, curiosity -- were greater, in sum, than the motivation to stay free of HIV or other sexually transmitted infections among these participants.

CONCLUSIONS

Because our participants tended to follow traditional gender roles when it came to initiating anal intercourse, and because anal intercourse emerged in our interviews as a sexual behavior that complemented vaginal and oral sex, it may be useful to view heterosexual anal intercourse not so much as a deviant behavior, but as an intensified example of how sexual decisions are negotiated between men and women. In this respect, women’s decisions to practice anal intercourse may be reflective of larger power dynamics at work in heterosexual relationships, in which women usually have less power than men (34, 35).

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. According to Simon and Gagnon (21), men are supposed to act as sexual pursuers and women as the pursued; therefore, women who initiate anal intercourse may be perceived as “breaking the rules” (which may account for why so few women initiated anal intercourse)--not so much because anal intercourse is a stigmatized behavior, but because, as women, they are supposed to allow their male partners to take the lead in determining thecourse of their sexual activity. 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. Because our study recruited women who reported having engaged in unprotected anal intercourse--a high-risk behavior in terms of the potential to transmit HIV and other STIs--we had the unique opportunity to examine women’s pleasure-seeking behaviors in the context of high sexual risk. 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.

Among our sample, women’s motivations to practice unprotected anal intercourse emerged as a convergence of the following factors: 1) the desire to experience pleasure and/or intimacy through an exotic sexual practice; 2) the desire to please one’s partner; 3) the reduced risk of pregnancy compared to vaginal intercourse; and 4) the increased sexual pleasure from condomless intercourse. When taken together, unprotected anal intercourse seemed to offer women a way to please their partners, to please themselves, and to avoid pregnancy. Unfortunately, missing from this heuristic was a consideration of HIV and STI risk.

The fact that many of our participants were confused about the various risks presented by vaginal and anal intercourse may suggest the need for comprehensive sexual education that addresses the differences between pregnancy prevention and HIV/STI prevention. Larger societal discourses which privilege penile-vaginal intercourse as the site of both pleasure and risk may also have contributed to participants’ tendency to view anal intercourse as complementary to, not distinct from, vaginal intercourse. As long as some women view anal sex as a way to bypass pregnancy concerns while maintaining intimacy and sexual pleasure, the failure to educate this population on HIV and STI prevention may lead to increased infection.

HIV and STI Prevention

Regarding men who have sex with men, Blais (39) has written about how the “social coding of intimacy” may make men reluctant to speak honesty about their sexual activity outside of a given relationship. As long as condomless sex is equated with emotional intimacy, argues Blais, MSM may be at increased risk for STIs, including HIV. A similar dynamic may be at work among women who engage in unprotected anal intercourse in order to achieve a greater degree of intimacy with their male partners, as in the case of some of our participants. Interventions to promote safer anal sex must find a way to increase the use of barrier methods without decreasing perceived intimacy between sexual partners. This may be done by emphasizing the intimate nature of anal intercourse, even when accompanied by condom use.

Too often, note Gupta and Weiss (40), interventions to address high-risk sexual practices collude with existing hierarchies, rather than challenge the underlying structures that contribute to economic and sexual marginalization. In designing interventions to address unprotected anal intercourse among women, we must balance the immediate need to work within the status quo--to meet participants “where they are” (41)--with the desire for broader social change that will eventually empower women to make safer choices regarding their own bodies, as per Rappaport (42). In order to meet women “where they are,” interventions to increase condom use or to promote rectal microbicide use during heterosexual anal intercourse should consider the ways in which a woman might use a barrier method without straying too far from her scripted role as the acquiescent partner. Although microbicides are often promoted within the research community as a “female-controlled” method, marketing them as such to consumers may have the opposite effect of what is intended, as long as some women prefer to take the less assertive role in their sexual relationships. Therefore, if part of what makes a woman feel like a woman is being desired by her male partner, vaginal and rectal microbicides should be marketed to women as products that will enhance their sexual desirability.

On the other hand, HIV and STI interventions geared towards women who have unprotected anal intercourse must not lose sight of societal factors that disadvantage women. Prior work has indicated that women’s vulnerability to STIs, including HIV/AIDS, is highly influenced by gender-based power differentials (23, 35, 40). Indeed, even in our small sample, the subgroup of women who had experienced non-consensual anal sex tended to report lower annual incomes than those who had not, though we did not test for statistical significance. Future studies should seek to identify the specific factors that put women at risk for non-consensual, unprotected anal intercourse.

Although its prevalence across the sample was small, non-consensual sex increases women’s risk of HIV transmission due to: 1) the unlikelihood that women would be able to negotiate condom use during non-consensual sex; 2) the higher possibility of rectal tearing or bleeding, and thus increased rate of transmission of HIV; and 3) loss of control over partner choice. To be successful, interventions must take into account the ways in which violence directed towards women can impact their ability to negotiate safe vaginal and anal sex. Given that the need for female-controlled alternatives to condoms encompasses products that can be used intrarectally as well as vaginally, rectal microbicides should be marketed to women as well as to MSM.

Limitations

Our findings must be interpreted within the limitations of this study. Although the sample was ethnically and racially diverse, participation was limited to English-speaking women, and more low-income women were interviewed than middle- and upper-income women. Additionally, as the participants included only those women who were willing to be interviewed about a highly-stigmatized practice, we know little about the experiences of women who may feel uncomfortable discussing anal intercourse with a stranger (20). In terms of the generalizability of our discussion on condom use and HIV and STI prevention, we must emphasize that our sample only consisted of women who had recently engaged in unprotected anal intercourse with a partner of unknown or seropositive HIV status. There are undoubtedly numerous women who practice anal intercourse with minimal risk (e.g. by consistently using condoms, knowing their partner’s serostatus, having fewer partners, etc.), but their motivations for engaging in anal intercourse are yet to be comprehensively addressed and are outside the scope of the present study. Future studies should seek to quantitatively assess HIV and STI risk among a larger and more representative sample of women who engage in anal intercourse.

Furthermore, notwithstanding that this may have been a highly-motivated group of women who welcomed the opportunity to talk about their anal sex experiences, it is important not to overlook how social constraints or norms about what is socially appropriate situated within the interview itself may have influenced how and what may have been discussed during the course of the interview. Stadler et al. (16), for example, in examining anal sex among South African women, emphasized that ambivalence toward anal intercourse may have been more socially appropriate within the context of a focus group than desire. Similarly, although every effort was made on the part of our interviewer to establish rapport, ensure confidentiality, and make participants feel comfortable, it is difficult to know explicitly the extent to which the interviewer, a young woman trained in sexual interviewing, confined or influenced participants’ narratives. Despite the limitations of the study, the findings presented here have important implications for HIV interventions aimed at heterosexual women.