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Article Excerpt
Anal intercourse is a highly efficient mode of HIV transmission, and its practice among men who have sex with men has received much scholarly attention. Research on women's experiences of anal sex has been scarce and has been based on limited samples, but evidence suggests that the practice of anal intercourse is widespread among U.S. women. (1-9)
Heterosexual anal intercourse is associated with higher rates of HIV transmission than vaginal intercourse, (10-13) and women who have unprotected anal intercourse with partners who are HIV-positive or whose serostatus is unknown may be at greater risk for acquiring HIV than women who do not engage in 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 HW transmission. (14) Similarly, in a study in Brazil, seronegative women who practiced anal intercourse in addition to vaginal or oral intercourse with seropositive male partners were statistically significantly more likely to acquire HIV than were women who did not practice anal intercourse. (15) Additionally, Halperin (1) found that women 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. This oversight may be due to cultural taboos surrounding anal intercourse, including its association with homosexuality and the perception that it is unhygienic. (1) Several researchers have pointed to the need for increased attention to anal intercourse as a source of HIV transmission from seropositive men to their 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 has focused on the contexts surrounding anal intercourse in South Africa (16,17) and Brazil, (18,19) but research on American women's experiences with anal intercourse is sorely lacking.
To develop effective interventions for HIV prevention, it is important to better understand both women's motivations for engaging in anal intercourse and the circumstances in which they choose to use a condom. Our qualitative study was part of a larger study on rectal microbicide acceptability among individuals who practice anal intercourse. The analysis presented here comes from 28 in-depth, semistructured interviews with women who had recently had unprotected anal intercourse with a partner who was HIV-positive or whose status was unknown. 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 sexual desire, provides the theoretical framework for our analysis. According to Simon and Gagnon, (22) in choosing to practice certain sexual behaviors over others, individuals are guided by cultural scenarios that proscribe specific courses of action. In contemporary American sexual culture, the predominant sexual script is one of male pursuit and female acquiescence. (22) This script may be a disadvantage to women's sexual health (22,23) and has important implications for STD prevention.
Similarly, despite calls for increased attention to the role of female desire in sexuality research, (24-27) pleasure as a potential factor in women's sexual decisions has often been overlooked. In this article, we attempt to partially remedy the "pleasure deficit" (24) in research on anal intercourse by not only examining how women have experienced and responded to pressure from their male partners to have anal sex, but also considering women's sexual pleasure as a motivation to practice unprotected anal intercourse.
METHODS
Study Design
The data for our analysis were collected at a community clinic in Boston as part of a study of rectal microbicide acceptability in 2006. The study design and procedures were approved by the institutional review boards of the New York State Psychiatric Institute and Fenway Community Health, where participants were interviewed.
Investigators sought to recruit 28 women, distributed in approximately equal numbers by race and ethnicity. Women were recruited through flyers; palm cards; outreach at community-based organizations, colleges and community events; Internet and print advertisements; 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 18 or older, were HIV-negative, reported having had unprotected anal intercourse in the prior year with a man who was HIV-positive or whose serostatus was unknown, had not participated in another research protocol within the past year and were comfortable with spoken English.
Eligible potential participants reported to the clinic for a meeting with a female interviewer. They were assigned unique identifier codes, given a brief overview of the procedures, rescreened to ensure eligibility, and asked to review and sign an informed consent form. Those enrolled in the study filled out a demographic questionnaire asking their age, education level, racial and ethnic identity, gender identity, sexual orientation, work or school status and personal income.
The investigators developed an interview guide that contained open-ended questions and follow-up probes to assess the psychological, social and cultural factors associated with anal sex. At the beginning of the interview, the interviewer explained that questions 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?" The interviewer then used the participant's terms throughout the interview. In this analysis, however, we use only the terms "anal intercourse" and "anal sex." Among other topics, the interviewer asked participants to discuss their first, most recent and general experiences with anal sex; their feelings about and attitudes toward anal sex; and their perception of others' views about anal sex. On completion of the interview, women received $50 as compensation for their time.
In this article, we examine topics that the interview...
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