Anal Sex

A reference guide for Physicians treating gay men who engage in anal sex

Let’s review the facts around anal sex. Like most people, gay men engage in different sexual activities. Not all engage in anal sex, but most do and find it extremely pleasurable. Be willing and prepared to discuss sex with your patients. And this means more than saying “I hope you are using condoms” and collecting a urine sample to test for gonorrhea and Chlamydia. Avoid vague references like “down there” and “privates”. This clearly signals you are uncomfortable with the conversation. Ask directly, “Do you enjoy sex with men, women or both?”; “Tell me a bit about the sex you are having.”; Do you have one partner or more than one?” And if they indicate they have one partner, clarify if the relationship is exclusive or open. Be sure to know the facts around anal sex so that you can answer questions and address concerns. A comfortable and informed discussion will allow your patient to bring up any issues they have around sex and will result in better physical and sexual health.

Top, Bottom or Versatile

During anal sex, each man can either be the insertive partner (known as “top”) and/or the receptive partner (known as “bottom”). Some men are always tops and some are always bottoms but many enjoy both positions depending on their preference in the moment and the preference of their partner. Preferences can also change over time and from one relationship to another. Men who enjoy being both a top and a bottom are often referred to as “versatile”. Asking your patient if he is top, bottom or versatile is a great way to start a conversation about their sexual experiences.  

Is Anal Intercourse Painful?

No. Just like vaginal sex, receptive anal intercourse can be painful on initial penetration the first few times. This is caused by spasm or contraction of the anal sphincter. If your patient initially experiences pain when bottoming, his partner should withdraw allowing the receptive partner to relax, and then try again. Going slow initially is a good idea. With time, the anal sphincter will relax on its own and anal intercourse will become more pleasurable from the outset. For the beginner, you can suggest digital play and small toys to help train the sphincter to relax. And encourage the patient to always use lubricant, go at their own pace, and have fun!

If men who bottom regularly suddenly start to experience pain during intercourse, something is wrong. Common causes of painful receptive intercourse include anal fissures and thrombosed hemorrhoids. A visual and digital anal exam is in order. If this is unrevealing, anoscopy and/or imaging may be needed.

Does Anal Intercourse Cause Trauma or Bleeding?

No. Anal sex, when consensual and with lubricant, does not cause bleeding. If a patient presents to the clinic with anal bleeding after anal intercourse, this must be investigated. Even benign causes such as hemorrhoids or internal warts should be treated to allow your patient to return to a healthy and pleasurable sex life. More worrisome causes of anal bleeding include dysplasia and anal cancer. Note that with rough sex or nonconsensual sex, injury can occur.

Does Anal Intercourse Cause Incontinence?

No. Over time, patients who engage in regular receptive anal intercourse will have a lower resting anal sphincter tone. However, they maintain full sphincter function and control. 

Is Anal Intercourse Messy?

Not usually, but it can be. Coming into contact with feces depends on the depth of penetration. Many gay men will douche before engaging in anal sex to rinse out the rectum and reduce the chance of encountering fecal matter. If they want to try douching, let your patient know that douches can be purchased commercially. A rubber bulb, that is filled with water, and attached nozzle is the most common type of douche. Patients should use lukewarm water and never soaps or detergents. Remind them to always rinse the bulb after use.

Examining the Anus

A healthy anus is part of good sexual health.

Visual exam – visually inspect the anus and perianal region for fissures, warts, skin tags, hemorrhoids, abrasions, excoriations.

DARE: Digital Anal-Rectal Exam – with a lubricated digit, palpate the full circumference of the anal canal feeling for lumps or bumps and any areas of tenderness.