If anal sex injuries really are on the rise, it’s not a question of anatomy, but of education Kat Ford The Skeptic

Inspiration for an article for The Skeptic can come from the most unlikely places – this one came to me after a conversation with a friend, when she stated with concern that she had read that the rates of young women attending hospital with anal injuries due to anal sex is on the rise, that young women are even developing faecal incontinence, and that it’s all because of pornography.

I was suspicious of the whole claim, but knowing literally nothing about hospital admission rates by age, gender, illness or injury I had nothing to push back with. My initial response was to argue that, if it is indeed true that more people are being injured due to anal sex, it is more likely due to a lack of education around the topic, and that when sex education focuses solely on cisgender, heterosexual, penis in vagina sex for the purpose of procreation it leaves a huge information gap.

The conversation meandered on, but that idea, that there was an increase in women being injured by anal sex, piqued my interest, so I decided to dig around and see where my friend may have gotten this information, and how much of it was true.

The first things I found were news and magazine articles with titles such as “Young women who have anal sex are being ‘put at risk’ because NHS is failing to warn them of the dangers, doctors claim – as a quarter of straight couples have tried it” from The Daily Mail, or The Guardian’s “Rise in popularity of anal sex has led to health problems for women”. Both of these articles make the claim that there has been an increase in women becoming interested in anal sex and, to my eyes, suggest that anal is inherently a health risk to women.

Glamour magazine seemed to take a more sex-positive approach, asking why women are engaging in unsafe sex, stating that bad technique and a lack of education can lead to physical injury. Glamour even includes some advice from Dr Evan Goldstein, anal surgeon, founder of Bespoke Surgical, and seller of lube and anal toys. The inclusion of advice on how to safely engage in anal is great, but, with my skeptical hat firmly on, a man who sells anal toys and lube might also have a biased opinion on the topic of whether anal sex is safe. Further research is needed.      

A bit more googling and link clicking finally took me to what seemed to be the original article, published in the BMJ and written by general and colorectal surgeon Tabitha Gana and consultant surgeon Lesley Hunt. In it, Gana and Hunt argue that by shying away from discussing anal sex, doctors are letting down a whole generation of women and leaving them vulnerable to harm.

The overall message of the paper is reasonable: those working in the medical field, especially those working in colorectal medicine, probably should ask about anal sex and give advice on how to safely enjoy anal sex, if it may be relevant to the complaints the patient is presenting with. But some of the claims in the original article are unsupported, and the emphasis on the danger of anal sex for women specifically also seemed odd.

Evidence for the claim that anal sex is more dangerous for women is mixed at best. Colonoscopies tend to be more difficult on people assigned female at birth as the sigmoid colon tends to be, on average, longer in women but packed into a smaller abdominal cavity so has more twists and turns. That said, the sigmoid colon starts at the top of the rectum, and the rectum itself is 18-20cm long (approximately 7 inches), so in all likelihood, the average penis is unlikely to bother anyone’s sigmoid colon.

The article also suggests that one reason anal sex might be more dangerous for women is that women have lower anal canal pressure. Interestingly, low pressure in the anal canal is actually cited as a risk factor for constipation, which isn’t quite the polar opposite of faecal incontinence but arguably, quite a different problem altogether. If I wanted to be pedantic, long term constipation can in extreme cases lead to faecal incontinence due to internal damage, and constipation and faecal incontinence can coexist in the same patient, but we’re at real risk of going off on a tangent that would ruin the narrative flow of this article.

The original paper also claimed that rates of faecal incontinence is higher among women who have anal sex and references Markland et al. Markland et al does state that, yes, faecal incontinence is more common in women who have anal sex compared to women who do not report having had anal sex. However, what Gana and Hunt fail to mention is that the paper also reports the same for men. In fact, when looking at the data in that article, there is a greater increase in the reports of faecal incontinence among men who report having had anal sex than there is among women who report having had anal sex. So it appears to me that there is no good anatomical reason that anal sex should present more of an injury risk for people assigned female at birth than it would for those assigned male at birth.

There is another issue with the original BMJ article. It is stated as fact that young women are turning up at hospital with injuries caused by anal sex at an increased rate – but no evidence for this claim is offered. The BMJ is written by two doctors who are well placed to be experts on such things, and absence of evidence is not evidence of absence but, without presenting any evidence it is difficult to say whether the increase in rates of young women harmed by anal sex is verifiably true, or just a hunch on the part of the authors.

Some of the points raised in the article just seem plain irrelevant to the overall argument. For example the statement that “anal intercourse is considered a risky sexual behaviour because of its association with alcohol, drug use and multiple sexual partners” doesn’t help us evaluate whether anal, in and of itself, poses a health risk – it merely positions the act as adjacent to other behaviours society tends to frown upon. To me, this seems actively unhelpful when arguing that physicians don’t ask about anal sex enough because of the taboos and stigma around it.

The real issue when it comes to women and sexual pleasure is rooted in sexism, in living in a culture where male pleasure is valued over female comfort and safety. This is not a question of anatomy. It is important to raise awareness of how people, regardless of gender, can safely enjoy and explore their bodies and their sexuality, but this can’t be done while also promoting misinformation.

We need to be focusing on education around consent, and really emphasising the message that anything other than an enthusiastic ‘yes’, ought to be understood as a ‘no’. There is no inherent problem with more people becoming interested in trying, or even regularly engaging in anal sex – as long as it is done consensually, safely, respectfully, with plenty of clear and honest communication… and a lot more lube than you think you’re going to need. 

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Is it really the case that more women are presenting in hospital with injuries caused by anal sex? Or is the media merely continuing to push stigma and taboo?
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