Fridae

I told a patient who had never been able to have anal sex to buy a small dildo and practice inserting it. I promised that with time he would get used to putting things in his anus. He came back a month later complaining that my instructions failed and he couldn't even get the small dildo in. I asked to see his dildo. He reached into a shopping bag and pulled out the Jeff Stryker model. I got chest pain looking at it.

Introduction:
The term "anal sex" is most often used to describe sexual intercourse between two men when one partner inserts a penis, sex toy, or fingers into another partner's anal canal. Technically speaking, however, "anal sex" can apply to any form of sexual anal stimulation. For some of us that means only anal intercourse with a penis but for others it includes using toys, fingers, fists, enemas, vegetables, tongues and anything else you can think of. Before we go any further I think we need to clear up two very common misconceptions.

Number one: Not only gay men have anal sex. That outstanding medical journal, Redbook Magazine, surveyed women's sexual practices and found that almost half of all women had tried it at least once, although it was not a lesbian survey. (You go girls!) And now for the number two misconception (better sit down for this one): Not all gay men have anal sex! Anal sex is steeped in all kinds of psychological baggage and it is not right for everyone. Some of us just don't enjoy it and/or have no desire to do it. If that's the way you feel then your partner must respect your wishes. It is rape if a man forces himself on you, regardless of your gender.

Anal sex is also the highest risk sex act two men can perform -- and not just because of HIV. Most STDs can pass between partners during close skin to skin contact when a penis rubs against your anus -- and vice versa. Infections travel both ways.

Recreational drugs are the number one cause of unsafe sex. When you are high, you don't think about putting on that condom. Some men also think that if an HIV viral load is undetectable, there is no risk of HIV transmission. Not true. Most studies show that blood levels of HIV may not accurately predict the amount of HIV in ejaculate. In other words, your semen can have a high viral load even though it's undetectable in your blood. If you have an STD, you are at increased risk of transmitting or becoming infected with HIV.

Physiology
News flash: an anus is not a vagina. Your anus is only 1 to 2 inches long and connects to the rest of your colon. The colon's main function is to absorb water from the liquid waste that leaves your small intestines so that by the time it reaches your anus it is solid material. (And we all know what happens when this doesn't work.) It is this heightened absorptive capacity that makes your rectum so good at trapping STDs.

The anus has two sphincter muscles, the internal sphincter and external sphincter, which control your bowel movements. These muscles are bands that surround your anus and rectum. Your internal sphincter is actually a part of the colon wall and is an involuntary muscle -- which means you can't control it. This is the sphincter that relaxes to let out your bowel movements and gas. Your external sphincter is under the skin of your anus and is a voluntary muscle. You tighten it to keep from having a bowel movement at inopportune times. It also contracts reflexively (and out of your control) when something approaches your anus from the outside. Therefore, no matter how much you want your partner inside you, your muscle will contract to keep him out. But like any muscle, there is a limit to how long it can contract before it has to relax. When this happens, your partner (or toy) can safely enter you.

Another important difference between a vagina and an anus (or "mangina" as some men like to call it) is that it will not self-lubricate; you need to use a water-soluble lubricant (no Crisco, please!). In addition to damaging condoms, oil-based lubricants can block your anal glands and cause infection. Many oils, including hand creams, also contain perfumes which can irritate your skin and cause dermatitis.

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Technique
The receptive partner must be in control. Sex between men; sex between women and men:
Because of the high risk of passing STDs during anal sex and foreplay, place a condom on your partner as soon as his penis is going to come in close contact with your anal area -- even if he isn't going to penetrate you. Put a lot of lubricant on your partner's condom-covered penis and on the outside of your anus. Beware of the "two finger stretch" to get ready for him because this can tear your sphincter muscles easier than his penis. I recommend that you sit down on your partner so that you maintain control while you try to take him. As soon as the head of his penis pushes against your anus, the internal and external sphincter muscles contract. You will feel a sharp pain. Stay there! Within 30 to 60 seconds your muscles will relax. You can then safely sit the rest of the way down on him. Move up and down a few times and by then your muscles will be sufficiently relaxed so you can go to any position you want. Do not stimulate your penis while you are trying to take your partner. This also sets up a strong reflex that contracts your sphincter muscles even tighter.

Sex between women: Lesbians can transmit STDs through anal play with each other if hands or toys aren't cleaned and covered with a latex glove or condom. There isn't anything particularly different for women having anal sex with each other vs. men with men, except for the "No penis parking" sign. The anal canal has the same musculature and it will tense and loosen in a similar manner. So have fun gals, use lots of lubricant-the wetter the better!

Hygiene
No matter how hard you try, your anus will always be an anus. You can't sterilize it. You can, however, gently wash the outer skin with a moist cloth or pad (try Tucks) to remove any fecal residue stuck to your skin. Avoid wet toilet paper or tissues because they flake and leave behind annoying bits of paper. If necessary, try to move your bowels prior to sex. I do not advise enemas or douching, which may increase the risk of HIV transmission. Enemas -- even if they are just plain water -- irritate the lining of your colon and make it easier for HIV to get in or out. The motion of the sex toy, your partner's hand or penis also stimulates colon contractions. Frequently you won't evacuate the entire liquid enema before sex, and the remainder is forced out during sex by increased colon contractions, making a bigger mess than the one you took the enema to avoid. If you feel like there is still some stool in your rectum, try a gentle washout. Fill an ear syringe with warm water and insert it into your rectum. Give a couple of squirts and hopefully you will wash out any remaining feces; the volume you put in won't irritate your colon. This small amount is also more likely to be fully expelled before sex. A towel is probably your best protection for those thousand thread count sheets.

Problems
Some people feel that they are too tight for anal sex and can't seem to relax enough. I am sorry to say that you may never be able to relax enough to enjoy anal sex; it may not be your thing. If you really want to try it, buy a small (finger size) dildo. Lie on your side and gently insert the well lubricated dildo with constant gentle pressure. Again, it is important to wait until you feel your sphincters relax. Once it is in, leave it there and wait until it feels comfortable. With time and practice, your level of comfort should dramatically improve as you gradually learn to enjoy the sensation of penetration and anal stimulation. Once you can easily insert the small dildo, try the next larger size until you gradually work up to something approximating the girth of a normal penis or that mega dildo you've been dreaming about. If all goes well, you're ready for your partner. Use the small dildo as part of foreplay to "pre-stretch" your sphincters. For men, it can be a hot experience for you and your partner as you use the dildo to get ready. When your muscles are suitably relaxed you can safely sit down on him. Just remember boys and girls: You can't always take everything just because you want too! Some men (and some toys) will be too large to fit no matter how hard you try.

Complications:
Bleeding: most often from a hemorrhoid of fissure (tear). If you see blood, stop. Most often the bleeding stops quickly. Do not have anal sex again until you stop bleeding with bowel movements. If you have hemorrhoids, experiment with different positions to see if you can tolerate one better than the other. Many men find that when the receptive partner is on his stomach, his hemorrhoids experience less swelling and bleeding.

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Pain: Pain during anal sex most often results from your sphincter muscles going into spasm or from a tear. You can tear the sphincters or your delicate anal lining (a fissure). If it hurts, stop anal sex. Try treating your fissure conservatively with stool softeners, sitz baths (warm soaks) and hold off having sex until you are healed. STDs can often be present with pain in your anal area but the pain usually doesn't begin until several days after sex. Pain that begins during or immediately after sex usually results from a fissure or sphincter injury.

Perforation: A true tear through your colon wall is a very rare complication of anal sex. A penis is pliable and does not have the strength to rupture your colon. A toy, on the other hand, can cause serious damage - especially if it is long. Your colon makes a sharp bend to the left, approximately eight inches up. A penis can bang against this turn and you might notice a sharp pain in the pit of your stomach. It usually won't push through. A hard toy can push through and when it does, you are in a life and death situation. You feel intense pain and must get right to a hospital. Delay and the bacteria can spread throughout your abdomen. This type of infection (peritonitis) can take your life.

Incontinence: Incontinence is an inability to control your bowels or gas. If your anal sex is pain free, your muscles should be fine and you don't have to worry about this dreaded complication. Those who enjoy fisting or large toys can permanently overstretch their sphincters and are at increased risk for incontinence in later life.

STDs: Anal sex is the highest risk sex act that men who have sex with men can perform. Virtually every STD can pass between partners during anal sex, and for most, penetration isn't necessary and a condom may not protect you. STDs are harder to diagnose when they are inside your anal canal and not on your penis. STDs commonly passed during anal sex include: HIV, herpes simplex, gonorrhea, syphilis, molluscum contagiosum, crabs, human papillomavirus (HPV), hepatitis, and chlamydia. MEN: Put a condom on early -- as soon as you anticipate contact between the anus and penis. Remember that fingers and toys used during foreplay can also carry STDs between partners. A condom doesn't cover the base of your partner's shaft, his scrotum or pubic hair -- these are all places where STDs can lurk or land.

HIV Risk
Anal sex is the highest risk sex act two men can perform. This is also true for a woman if she's the anal receptive partner with a man. Your risk increases dramatically in proportion to the number or partners you have and if your sex is unprotected (whether you are inserting or receiving). One medical study published in 1987 found that anal sex with one partner increased your chances of catching HIV by three times -- five or more partners increased it 18 times.

Although we like to think that a condom is 100 percent effective in preventing HIV, it isn't. Condoms break and can be improperly used. Semen can leak out, especially if you don't pull out while holding onto your condom as soon as you ejaculate. Precum also contains HIV and this can leak into your partner during foreplay if you don't use a condom. A recent medical study examined the risk of catching HIV from various sex acts men perform with each other. It found that unprotected receptive anal sex with a partner with HIV had a 0.82 percent risk of giving you HIV. Unprotected receptive anal sex with a partner whose status was unknown (or believed to be negative) had a 0.27 percent risk of giving you HIV. If you had unprotected insertive anal sex with a partner whose status was positive or unknown you had a 0.06 percent risk of catching HIV. But the numbers are very misleading because there was heterogeneity in per-contact risk. In plain English, that means that some men caught HIV on their first unprotected experience while others were fine after 20. Unprotected anal sex is like Russian Roulette -- you never know which shot has the bullet.

Nonoxynol-9 kills HIV in laboratories but the amount in lubricants is not enough to kill all the HIV in a partner's ejaculate. Nonoxynol-9 has been shown to irritate the delicate lining of your rectum and may actually increase your chances of catching or giving HIV.