Complications from anal penetration

This is a list of "complications" due to anal penetration excerpted from an article written by Jeremy Agnew in 1985:

Agnew, J. (1985, Fall). Some anatomical and physiological aspects of anal sexual practices. J Homosexuality. 12(1):90-94.

You'll notice, at the very end of this excerpt, that Agnew waffles on what causes AIDS, saying AIDS "may possibly be induced by anal activity" -- even though HIV had been identified in 1984, as had anal penetration as the primary mode of its transmission among gay-identified males:

Melbye M, Biggar RJ, Ebbesen P, et al. Seroepidemiology of HTLV-III antibody in Danish homosexual men: prevalence, transmission, and disease outcome. BMJ. 1984;289:573-575

Goudsmit J, Miedema F, Wijngaardendubois RJGJ, Roos M, Schellekens H, Coutinho RA, Vandernoorda J, Melief CJM. Serological evidence of transmission of HTLV in a Dutch homosexual male after anal intercourse with an AIDS patient. Aids. 101 - 109, 1984.

(For more such references, please consult our Man2Man Alliance MSM HIV Timeline.)

But Agnew's waffling isn't surprising in someone whose published work includes a book titled The Enema: A Textbook and Reference Manual; nor does it invalidate his list of "complications."

Here's Jeremy Agnew:


Due to the delicate nature of the lining of the anal canal and the rectum, there are numerous problems that can arise from practices associated with anal erotic activity (Owen, 1983).

1. Rectal Irritation. Frequent anorectal sexual activity, whether it is repeated anal intercourse, frequent enemas, or continued insertion of objects into the rectum, may cause irritation of the rectal mucosa and produce a variety of anorectal problems. Symptoms may include anorectal pain, diarrhea, overproduction of mucus, flatus, purulent discharge, intestinal cramps, painful defecation, fecal leakage, hemorrhoids, anal or rectal ulceration and fissures, pruritus ani, or varying degrees of rectal prolapse. Any irritations of the colonic mucosa, for example colitis, will trigger mass movements in the terminal colonic segments. Collectively, many of these symptoms have been termed the "Gay Bowel" Syndrome (Sohn & Robilotti, 1977). Furthermore, abrasion of the rectal wall due to the insertion of foreign objects may allow penetration of the mucosa by normal colonic organisms and create secondary infection.

Unlike the mucosal layer of the vagina, which is lined with sratified squamous epithelium and is capable of protecting against abrasion during intercourse or the insertion of objects such as vibrators or douche nozzles, the lining of the rectum consists of a single layer of columnar epithelium with numerous goblet cells. The function of this thin layer is to promote the absorption of water and electrolytes. In spite of the limited protective capacity of secreted mucus from the goblet cells, the mucosa is incapable of much mechanical protection against abrasion. Various potentially harmful bacteria inhabit the colon, living in harmony with their host as long as they are not allowed to invade other tissues. These organisms include cocci of various types and highly toxic organisms such as gas gangrene bacilli (Ganong, 1981). If organisms such as these penetrate other tissues through abraded mucosa, very serious infections can result.

2. Anal Laceration. One of the commonest problems associated with anal sexual activity is tearing of the anal canal. The external anal sphincter is biologically intended to have material pass through it out of the body. The sudden or forceful insertion of objects in the "reverse" direction stimulates the anal reflex and produces a natural tendency of the sphincter to contract to prevent insertion. Unlike the vagina, the anus and rectum lack a natural lubricating function, and insertion of unlubricated objects or inadequate dilation prior to the insertion of large objects can result in the tearing of perianal and anal canal tissue.

3. Perforation of the Rectal Wall. The vagina is surrounded by thick muscular tissue which distends and changes shape to accomodate the erect penis during intercourse. The rectum, by contrast, is not biologically intended for the reception of the miscellaneous objects that are pushed into it for erotic stimulation. Thus it is relatively easy to either damage the rectal mucosa or, in extreme cases, to produce perforation of the rectal wall (Barone, Sohn, & Nealon, 1977). Even use of the standard plastic enema nozzle supplied with fountain syringes has been known to cause mucosal abrasions of the anterior rectal wall or to perforate the rectal wall itself (Agnew, 1980).

The rectum beyond the anal sphincters is generally insensitive to pain, thus perforation may occur without the individual being aware of it. Peritonitis and generalized infection will follow rapidly, due to the release of intestinal micro-organisms into the abdominal cavity. As an example, some erotic enema devotees will attempt the full insertion (18" to 24") of a rubber colon tube. While this can be done by medical personnel, it is an inadvisable procedure for recreational use due to the difficulty in rounding the sharp curves of the sigmoid colon. It is typical for the tube either to coil up in the rectum or to be pushed through the rectal wall if attempts are made to force insertion while the distal end of the catheter is trapped in a blind pouch of intestine. Another danger source from enemas is the possibility of colonic rupture due to the use of large volume enemas or those administered under high pressure. Large volume tap-water enemas may cause serious electrolyte depletion or can lead to water intoxication, which can result in symptoms ranging from simple weakness or sweating to shock, convulsions, and even death (Agnew, 1980).

4. Captive Objects. It is extremely easy to lose control of small objects inserted into the anus. They can vanish into the rectum and become lodged there, especially if the objects are well-Iubricated and the individual is in a state of sexual euphoria. As discussed above, some of the objects described in the literature are not small and can be difficult to remove transanally. Some of these objects may cause abrasion or may perforate the rectal wall, requiring extensive surgical procedures to correct the damage.

5. Recreational Drugs. Sex of all types is frequently associated with the use of recreational drugs. When associated with anal insertion and manipulation, the use of drugs such as alcohol, barbiturates, psychedelics, or cocaine can impair judgment, allowing insertion of inappropriate or overly large objects that can easily lead to anal or rectal trauma or perforation. Drugs may also be used for sedative or stimulative purposes while engaging in fist fornication. For example, amyl nitrite ("poppers" or "aroma") is a drug used medicinally in inhalant form to produce vasodilation, particularly for heart stimulation and relief from circulatory inadequacy in cases of angina pectoris. Amyl nitrite is popular with male homosexuals to produce heightened sensations during orgasm (Hyde, 1982). The drug increases sensory awareness in the genitals, probably due to vasodilation in the urinary tract and smooth muscle relaxation (McCary, 1978). Side effects of the drug may include headaches, dizziness, fainting, and even death.

6. Diseases. Many diseases, including anal warts and hepatitis B virus, may be transmitted by way of anal sexual activity (Marino & Mancini, 1978). Among the common transmitted diseases:

(a) Rectal gonorrhea may be contracted both by women involved in heterosexual anal activity and, more commonly, by men involved in homosexual relations. Autoinfection or cross-infection from rectum to vagina or vice-versa may occur in women with gonorrhea from the use of contaminated syringes for douching and enemas, or may result from the direct spread of the bacterial organisms from vagina to rectum. Further complications in women result in various pelvic inflammatory diseases. The gonococci can spread as far as the surface of the liver by direct transmission through the peritoneal cavity from the Fallopian tubes and result in gonococcal perihepatitis, the symptoms of which may include pelvic pain and vaginal discharge. Symptoms of rectal gonorrhea may include rectal discharge and perianal burning or itching, but the disease can also be asymptomatic. Asymptomatic individuals with multiple sexual partners may cause widespread dissemination of the disease before the infection is discovered and treated.

(b) Syphilis can occur following anal intercourse with an infected person. The spirochete may invade the mucus membrane of the rectum, and the syphilitic chancre may appear around the anus.

(c) Anogenital herpes, usually caused by the Type II Herpes Simplex virus, may cause the infected person to develop small painful bumps or blisters around the anus. Autoinfection in women with genital herpes may result from the direct spread of the virus to the anus from labial lesions.

(d) Gastrointestinal infections due to pathogens such as Giardia lamblia, Entamoeba histolytica, or streptococcal infections can be transmitted by an inadequately washed penis following anal intercourse or by inadequately cleaned rectal dildoes or enema syringes. One specific example is the transmission of amebiasis from the ingestion of amebic cysts during oral-anal contact or from inadvertent transport of the cysts from anus to mouth on the fingers. Infection may also be transmitted from the mouth to the rectum following the use of saliva as a lubricant during homosexual or heterosexual anal intercourse. It should be noted that some intestinal disorders may take several days, weeks, or even months following sexual contact to produce symptoms. For example, symptoms of Giardia lamblia infection take several days to appear; thus, anal activity and the resulting pathology may not be associated in the patient's mind. Secondly, this delay in the appearance of symptoms may allow the unknowing infection of multiple sexual partners. The symptoms of many of these infections are variable, non-specific, and often difficult to assign to a particular organism. Also, since they can be contracted from other sources, the diseases may not be directly attributed to sexual activity.

(e) Acquired Immunity Deficiency Syndrome (AIDS) may possibly be induced by anal activity. Symptoms of AIDS include autoimmune disturbances, opportunistic infections, Kaposi's sarcoma, chronic lymphadenomegaly, non-Hodgkin's lymphoma, or squamous cell carcinoma (Sonnabend, Witkin, & Purtilo, 1983). Recently the presence of semen in the colon and subsequent penetration into the vascular bed of the rectal mucosa following anal intercourse in male homosexuals has been implicated as a possible source of the Human T-cell Lymphotropic virus (HTLV III), the probable cause of AIDS.

AIDS is probably caused by multiple factors, with recurrent cytomegalovirus (CMV) infections and depressed immune response to sperm as the most likely causative factors. Repeated anal sexual involvement with multiple partners exposes homosexual men to the immunosuppressive impact of CMV and allogenic semen (Sonnabend, Witkin, & Purtilo, 1983). Semen appears to reach the blood and lymphatic system as a result of abrasion of the rectal mucosa. As discussed above, the single layer of columnar epithelium lining the rectum does not protect against abrasion; it promotes the absorption of sperm antigens, thus enhancing exposure of the recipient's immune system (Mavligit, Talpaz, Hsia, Wong, Lichtiger, Mansell & Mumford, 1984). Immune dysregulation has also been noted in heterosexual women engaging in routine anal intercourse (Mavligit et al., 1984; Masur et al., 1982), though AIDS is not necessarily transmitted via anal intercourse between heterosexual men and women (Harris, Butkus-Small, Klein et al., 1983).

[End of excerpt from Jeremy Agnew.]

It should be noted that Agnew's denial around anal and HIV is not unusual among proponents of anal penetration.

In his work he cites studies by Joseph Sonnabend, the New York City physician who told the gay press, in 1985, that

The rectum is a sexual organ, and it deserves the respect a penis gets and a vagina gets. Anal intercourse has been the central activity for gay men and some women for all of history. ... We have to recognize what's hazardous, but we shouldn't undermine an act that's important to celebrate.

~ quoted by Rotello, Sexual Ecology: AIDS and the Destiny of Gay Men

None of what Sonnabend says is correct.

Note that Sonnabend starts by saying "the rectum is a sexual organ," even though Agnew himself characterizes the rectum as "insensitive."

But Sonnabend's sort of thinking became the foundation for "AIDS prevention efforts" among gay-identified males in the US.

To learn more about that, interested readers can consult my article The Dutch Experiment.

While readers who wish to better understand the role of anal penetration in the concurrent epidemics of sexually transmitted disease which afflict the gay male community may refer to our Man2Man Alliance policy paper, an anus is not a vagina, Part 1: The Biology of Anal Penetration.

And for more about the history of anal penetration among gay-identified males and the cultural forces which currently support anal penetration, see our Man2Man Alliance policy paper Multipartnered Pansexualism or Heroic Love.

See also Anal penetration; Dominant culture of anal penetration.

© Copyright 2011 by Bill Weintraub.
All rights reserved.