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Archives of Sexual Behavior
The Official Publication of the
International Academy of Sex Research
ISSN 0004-0002
Arch Sex Behav
DOI 10.1007/s10508-012-0068-7
A Mixed-Methods Exploration of Women’s
Experiences of Anal Intercourse: Meanings
Related to Pain and Pleasure
Aleksandar Štulhofer & Dea Ajduković
1 23
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ORIGINAL PAPER
A Mixed-Methods Exploration of Women’s Experiences of Anal
Intercourse: Meanings Related to Pain and Pleasure
Aleksandar S
ˇtulhofer •Dea Ajdukovic
´
Received: 19 June 2012 / Revised: 22 November 2012 / Accepted: 2 December 2012
Springer Science+Business Media New York 2013
Abstract The aim of this mixed-methods study was to doc-
ument and analyze the dimensions and meanings of anore-
ceptive pain and pleasure among heterosexual women. An
online survey was carried out on a convenience sample of
1,893 women aged 18–60 years. Qualitative data were col-
lected using open-ended questions mailed to women who
expressed interest in continuing participation in the study;
narratives from 68 women who had experienced anal inter-
course were collected and analyzed for pain themes. Most
surveyed women had experienced anoreceptive intercourse.
A majority of women (79.1 %) reported their first anal inter-
course to be painful, but for most of them the intensity and
duration of pain/discomfort substantially diminished over
time. Less than a third (27.7 %) of participants who regularly
engaged in anoreceptive intercourse in the past 12 months
stated that they rarely or never experience pain/discomfort
with the practice. Nevertheless, most women who continued
to practice anal intercourse (58.1 %) reported it to be very
arousing and pleasurable. The pleasure associated with ano-
receptive intercourse was best predicted by masturbatory
frequency and orgasmic ability (with sexual intercourse). The
qualitative assessment pointed to a wide range of personal
experiences with and meanings attached to pain/discomfort
associated with anoreceptive intercourse. Three broad pain
themes emerged: (1) pain as insurmountable obstacle, (2)
strategic management of pain, and (3) pain eroticization. The
study findings suggested that the successful inclusion of anal
intercourse into a couple’s sex life is often dependent on a
specific learning process.
Keywords Anal intercourse Pain Sexual pleasure
Women
Introduction
Heterosexual anal intercourse has attracted attention among
sex researchers and epidemiologists due to the combination
of its association with sexual risks and seemingly increasing
popularity (Baldwin & Baldwin, 2000; Herbenick et al., 2010;
Johnson et al., 2001; Lewin, 2000; McBride & Fortenberry,
2010; Satterwhite et al., 2007;S
ˇtulhofer & Bac
´ak, 2011). The
experience of pain associated with anoreceptive intercourse,
although often present in everyday conversation and narra-
tives, has received almost no research attention—aside from a
few exploratory studies carried out among men who have sex
with men (Damon & Rosser, 2005; Hollows, 2007; Rosser,
Short, Thurmes, & Coleman, 1998). Considering anecdotal evi-
dence and a growing number of teach-yourself-pain-free-anal-
sex popular books (e.g., Herbenick, 2011; Morin, 1998), this
lack of a more rigorous, empirical assessment seems unfor-
tunate. In our view, a better understanding of pain at anore-
ceptive intercourse is not only needed from a public health
point of view,
1
but also for educational and, possibly, clinical
purposes.
A. S
ˇtulhofer (&)
Sexology Unit, Department of Sociology, Faculty of Humanities
and Social Sciences, University of Zagreb, I. Luc
ˇic
´a, 10000 Zagreb,
Croatia
e-mail: astulhof@ffzg.hr
D. Ajdukovic
´
Unit for Psychological Medicine, Merkur Teaching Hospital,
University of Zagreb, Zagreb, Croatia
1
Similarly to the experience of pain associated with anal intercourse,
abrasions and fissures of the rectal tissue (which facilitate STI trans-
mission) are more likely when anal sphincters are not relaxed and anal
penetration is attempted without adequate lubrication.
123
Arch Sex Behav
DOI 10.1007/s10508-012-0068-7
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Until recently, there has been no systematic research focus-
ing on pain at heterosexual anal intercourse (Hollows, 2007;
McBride & Fortenberry, 2010). A large-scale online survey
carried out among women from Southeastern Europe sug-
gested that a considerable proportion of women (48.8 %) who
attempted anal intercourse had to stop because it was too pain-
ful to continue, while an additional 17.3 % of participants
persisted in spite of intense pain (S
ˇtulhofer & Ajdukovic
´,
2011). As a likely consequence, over one-third of women who
tried anal intercourse reportedly discontinued the sexual
practice. The study, however, did not provide a more detailed
account of painful sensations (quality and duration of pain)
nor did it attempt to explain an interesting finding that about
9 % of the women continued to practice anal sex in spite of
strong pain. In a multivariate analysis, these women were
found to score significantly lower on sexual assertiveness than
other participants. It was concluded that female anodyspa-
reunia or chronic pain atanoreceptive intercourse—a concept
that has been developed in a few studies on gay men (cf.
Damon & Rosser, 2005;Hollows,2007)—‘‘seems to be a rela-
tively rare phenomenon that may substantially affect per-
sonal sexual well-being’’(S
ˇtulhofer & Ajdukovic
´,2011). As
no qualitative data were collected in the study, the questions
of possible eroticization of pain, its association with intimacy, or
prioritizing the partner’s pleasure were impossible to explore.
The issue of female sexual agency is highly pertinent to
this discussion. Although very little is known about women’s
motivation for engaging in anal sex, it seems to be far from
uniform (Maynard, Carballo-Dieguez, Venteneac, Exner, &
Mayer, 2009). Concerns have been raised, for example, that
pornography has contributed to a (predominantly) negative
experience that women have with anal sex (Rogala & Tyde
´n,
2003). Certainly, if pain or discomfort accompanies anal sex,
the assumptions aboutgendered dynamicsof power and claims
related to female submissiveness portrayed in hardcore por-
nography are bound to provoke morally laden questions.
According to a recent review, women’s motivation for engag-
ing in anal intercourse ranges from intoxication to partner
pressure to preserving virginity to substituting vaginal sex
during menstruation to experimenting and pleasure seeking
(McBride & Fortenberry, 2010). However, the more positive
reasons for having anal sex are often marginalized due to
traditional taboos (shame about body parts) and the stigma-
tizing association of anal eroticism with homosexual prac-
tice. In addition, discussions about heterosexual anal sex are
often framed in public health or gender equality terms (Bald-
win & Baldwin, 2000; Brody & Potterat, 2003; Flannery,
Ellingson, Votaw, & Schaefer, 2003; Hensel, Fortenberry, &
Orr, 2008;S
ˇtulhofer & Bac
´ak, 2011).
Building on our earlier findings (S
ˇtulhofer & Ajdukovic
´,
2011), this study attempted to explore quantitatively the inten-
sity, quality, and retrospectively-assessed dynamics of pain at
anoreceptive heterosexual intercourse more comprehensively.
In addition, the study provided a detailed qualitative analysis
of a multitude of women’s experiences of pain and pleasure
associatedwith anal intercourse,togetherwithsymbolicmean-
ings attachedto these experiences. In additionto these descrip-
tive tasks, we address three research questions: (1) What are
the strategies employed to reduce pain/discomfort with anal
intercourse? (2) What could be the explanation(s) of the find-
ing that a substantial number of women continue with the
practice of anal intercourse despite pain or discomfort (are
they trying hard to please their partners or is the rationale
more complex and varied)? (3) Finally, what are the predic-
tors and correlates of pleasure associated with anoreceptive
intercourse?
Method
Participants
In October 2011, a generic e-mail message was sent to a num-
ber of online forums, a large dating Web site, and the mailing
list of the Croatian edition of Cosmopolitan magazine.
2
The
message contained a brief explanation of the research study
(stating that it focuses on experiences with anal sex among
women of legal age who had one or more male sexual partners
in the past 12 months) and a link to an on-line questionnaire. It
also asked the recipient to forward the message to their female
friends and acquaintances or post it on their Facebook page.
In the period between October 19 and November 23, 2,274
individuals accessed the questionnaire. After removing the
participants who identified as men or failed to provide answers
to 10 % or more of thesurvey question, thesample was reduced
to 1,893 participants.
Procedure and Measures
The questionnaire application included 52 items (including a
number of skip patterns) and required less than 10 min to
complete. It was hosted on a commercial site dedicated to
online surveying tools. To ensure anonymity, participants’ IP
addresses were not permanently recorded. On the first screen
of the application, prospective participants were asked to
confirm that they consent to participating in the study and that
they are of legal age. The questionnaire asked about sociode-
mographic characteristics, sexual behaviors and satisfaction,
2
A majority (70 %) of the Cosmopolitan magazine readership in
Croatia, which is almost exclusively female, are between 15 and 34 years
of age and live in an urban setting (75 %). Over a half of the readers are
employed (55 %). In regard to their educational status, most readers have
high school education (64 %), followed by college (20 %). In comparison
to the general population, the cohort is younger, more urban, and better
educated.
Arch Sex Behav
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sexual assertiveness, and experiences with anal intercourse—
which was defined as‘‘analsex or penis in the anus.’’A detailed
account of personal experiences with anal intercourse, as well
as some other forms of anal eroticism, spanned from the very
first attempt at anal intercourse (if applicable) to present expe-
riences.
All study procedures were approved by the Ethical Review
Board of the Department of Sociology, Faculty of Humanities
and Social Sciences, University of Zagreb.
Experience of Anal Intercourse
Lifetime experience of anal intercourse was assessed with the
following question: ‘‘Have you ever tried anal intercourse
(i.e., anal sex or penis in the anus)?’’ Participants were also
asked if they continued this sexual practice (‘‘After this first
experience, have you tried anal sex again?’’). The answers
were: no, one more time only, and yes, more than once. Fre-
quency of anal intercourse in the past year was measured with
the following item:‘‘During the last 12 months, how often did
you have anal intercourse?’’ A 7-point scale (ranging from
1=never to 7 =several times a week or more often) was
provided to anchor answers.
Discomfort/Pain with Anoreceptive Intercourse
Discomfort and pain during anal intercourse was assessed by
a number of items used in our previous study (S
ˇtulhofer &
Ajdukovic
´,2011), with the addition of four items exploring
the quality of pain in more detail (in case respondents reported
a painful experience), which were adapted from the Pain
Quality Assessment Scale (PQAS) (Jenssen, 2008). The fol-
lowing questions were used:‘‘How often do you feel discom-
fort during anal intercourse (being penetrated anally), even if
only during the initial phase?’’ (responses ranged from 1 =
every time to 5 =never); ‘‘How often do you feel pain during
anal intercourse (being penetrated anally) even if only during
the initial phase?’’(from 1 =every time to 5 =never)
3
;‘‘How
would you describe the level of pain that you experience
during anal intercourse?’’ (1 =pain is unbearable, I have to
stop, 2 =pain is strong, but somehow I bear it, 3 =pain is
moderate, 4 =pain is mild, 5 =pain is barely present, 6 =
discomfort rather than pain, 7 =there is no pain); ‘‘How
would you describe the intensity of pain that you experience
during anal intercourse?’’(from 1 =pain is barely noticeable
to 7 =pain is unbearable);‘‘Is the pain you experience sharp,
i.e. piercing?’’(from 1 =pain is not sharp to 7 =the sharpest
pain imaginable; 8 =can’t say),‘‘Could the pain you experience
be described as hot, i.e. burning?’’(from 1 =Pain is not burn-
ing to 7 =the most burning pain imaginable; 8 =can’t say);
‘‘Would you say that the pain you experience is dull?’’(from
1=pain is not dull to 7 =the dullest pain imaginable;
8=can’t say). Pain at penile-vaginal intercourse was not
assessed in this study.
Women who had anal intercourse once a month or more
frequently in the past year and who reported experiencing either
unbearableor strong pain during thissexual practice wereclas-
sifiedasexperiencingstrongchronicpain at anoreceptiveinter-
course.
Participants who reported pain at anoreceptive intercourse
were also asked to identify the causes of the pain:‘‘When you
think about the pain you experience during anal intercourse,
how do you explain it?’’The following reasons were listed: (1)
insufficient sexual arousal, (2) lack of anal foreplay (mas-
saging the anus, fingering, etc.), (3) partner is inexperienced,
(4) penetration is too abrupt or rough, (5) lubricant is not used,
(6) size of partner’s penis, (7) depth or angle of penetration,
and (8) I am unable to relax. Multiple answers were possible.
Finally, to assess the dynamics of the experience of painful
anal intercourse, the following question was asked: ‘‘From
your first experience with anal sex, has anything changed in
regard to your pain associated with anal intercourse?’’ Six
response options were offered: 1 =pain remained unchanged,
2=pain is lower in intensity, 3 =pain is of shorter duration,
4=pain islower inintensity andof shorterduration, 5 =painis
gone (I no longer feel pain), and 6 =pain increased over time.
Pleasure Associated with Anoreceptive Intercourse
Pleasurable aspects of anal sex were assessed by the follow-
ing items:‘‘How much do you enjoy anal intercourse?’’(from
1=not at all to 5 =a great deal), ‘‘How arousing do you find
anal intercourse?’’(from 1 =not at all to 5 =a great deal),‘‘If
you were to compare the levels of your arousal during the first
and the most recent anal intercourse, what would you say has
changed?’’(1 =it is more arousing, 2 =nothing has changed,
3=it is less arousing, 4 =it does not arous e me anymore), and
‘‘If you were to compare the levels of pleasure during the first
and the most recent anal intercourse, what would you say has
changed?’’ (1 =I started to enjoy it, 2 =I enjoy it more than
before, 3 =nothing has changed, 4 =I enjoy it less than
before, 5 =I do not enjoy it anymore).
Sexual Satisfaction
Sexual satisfaction was measured with three items (‘‘I am
content with the way my sexual needs are met’’;‘‘I am content
with the current degree of my sexual satisfaction’’;‘‘Nothing
is missing in my sexual life at the moment’’) that used a
5-point Likert-type scale (1 =dissatisfied, 5 =very satisfied)
3
As the two indicators were strongly correlated (r=.71, p\.001), this
suggests that participant were not able to clearly distinguish the two con-
cepts; thus, only the latter measure was used in the following analyses.
Arch Sex Behav
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for anchoring answers. Th e additive measure had excellent reli-
ability (Cronbach’s a=.89). Higher scores denoted higher
sexual satisfaction.
Sexual Assertiveness
Three itemswith the average inter-correlation of .48 were used
to measure participants’ sexual assertiveness: ‘‘If I am not
interested inhaving sex, I will make it clear to my partner,’’‘‘In
sex, I never do things I don’t like,’’ and‘‘It is me who decides
when to start having sex with a new partner.’’A summed com-
posite scale had acceptable reliability; Cronbach’s awas .66.
Responses were given using a 5-point Likert-type scale, so
higher scores indicated higher sexual assertiveness.
Qualitative Assessment
Data for the qualitative part of the study were collected using a
brief online questionnaire with four open-ended questions
that focused on pain and pleasure associated with anal inter-
course. In preparation of the qualitative part of the study, nine
in-depth, face-to-face semi-structured interviews were con-
ducted by the female researcher. The interview schedule
encompassed three broad themes: reasons and preconditions
for engaging in anal sex, the experience of anal intercourse,
and the personal and relational consequences of the practice.
For each of the themes, a series of probe questions were
prepared in order to gain a detailed account of the partici-
pants’ experiences. Each interview lasted approximately
90 min. Participants were recruited informally, through the
female researcher’s informal social network of friends and
acquaintances. Although we initially planned to conduct
20–30 interviews, this proved impossible because the women
who did not belong to the researcher’s social circle and were
contacted using the snowball technique were invariably unwill-
ing to discuss the subject. The nine preliminary interviews were
analyzed with the goal of developing a concise set of open
questions that would address painful and pleasurable aspects of
anoreceptive intercourse.
In addition to the open-ended questions that focused on
reasons for trying out anal intercourse, personal feelings and
sensations related to the experience, the meaning of anal sex
in the context of one’s sexual self-perception, and the assess-
ment of reasons behind the seeming popularity of anal sex
among youngheterosexual adults, the questionnaire contained
questions about participants’ age, relationship status, frequency
of anal intercourse in the past 3 months, and the experience of
pain and/or discomfort at anoreceptive intercourse.
During January 2012, this brief questionnaire was com-
pleted by 68 women who reported a lifetime experience of
anal intercourse in the previously described quantitative part
of the study and who expressed their interest in continued
participation in the study by providing their e-mail address at
the end of the questionnaire. All women who entered their
e-mail address, regardless of whether they experienced anal
intercourse or not, were sent a generic message contain ing the
information about the qualitative part of the study and the
URL where a brief questionnaire was posted. Of the 218
women who had experienced anal intercourse and were
e-mailed about the possibility of additional participation,
31.2 % (n=68) responded by sending in their narratives.
Data-driven thematic analysis, a method of identifying
concepts (‘‘themes’’) embedded in participants’ accounts
(Attride-Stirling, 2001; Braun & Clarke, 2006), was used to
analyze this qualitative dataset. Only one of the four open-
ended questions (‘‘How would you describe arousal and
pleasure associated with anal sex? What about the pain or
discomfort that may accompany the practice?’’) was analyzed
in this article. The goal was to explore a full range of pain
themes, i.e., specific experience-based elaborations of the
experience and meanings of pain at anoreceptive intercourse.
To qualify as a pain theme (PT), a narrative needed to contain
at least a brief description of physical sensation and a set of
meanings related to anal intercourse. After the first author
identified a total of 48 PTs, using open coding to mark rele-
vant parts of the narratives, the selected material was cate-
gorized independently by both authors. Departing from the
usual practice of thematic analysis, in which categories (or
organizational themes) represent macro themes emerging
from the data (Attride-Stirling, 2001), four categories—(1)
painful and non-pleasurable experience; (2) painful and plea-
surable experience; (3) painless but non-pleasurable experi-
ence; (4) painless and pleasurable experience—were con-
structed a priori, based onconceptual reasoning. Only a couple
of categorization discrepancies were observed when compar-
ing the authors’ notes. Such high concordance in classifying
the material was to be expected given the limited analytical
focus and straightforward character of a priori defined cate-
gories. Disparately categorized narratives were excluded from
further analysis. A number of themes were found to belong to
more than one category. These mixed narratives were treated
as a fifth category, the one that included descriptions of anal
intercourse as pleasurable only when painless. In thefinal step,
all pain themes were disassociated from the four predefined
categories and analyzed using axial coding to arrive at orga-
nizational themes.
Results
Quantitative Assessment
Sample Characteristics
Participants’ age range was 18–60 years (M=27.85; SD =
8.12). On average, surveyed women had completed 14.07
Arch Sex Behav
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(SD =2.56) years of formal schooling, with a majority
(55.7 %) reporting at least one parent with secondary edu-
cation. One-third of women (33.0 %) had at least one parent
who was college-educated. A majorityof participants (74.6 %)
had a sexual partner at the time of survey. Of the partnered
women, 26.2 % were married, 14.7% cohabitating, and
59.1 % in a relationship, but not living together withtheir part-
ner. Median number of sexual partners in the past 12 months
was two (M=3.20, SD =3.45). A large majority of surveyed
womenreportedlifetimeexperience of anal intercourse
(79.1 %), with the mean age at first anal intercourse being
21.08 years (SD =2.75). A total of 172 participants (15.8 %)
experienced anal intercourse before the age of 18.
First Anoreceptive Intercourse
Three quarters of the surveyed women (75.5 %) had their first
anal intercourse with a steady partner. Less than one tenth
(8.4 %) of the participants with the experience reported that
this first anoreceptive intercourse happened with someone
they did not know well. Interestingly, only a small majority of
women planned for this experience (53.5 %), i.e., discusse d it
with their partner beforehand. Women who communicated
about anal intercourse prior to trying it were more likely to
have used a lubricant, v
2
(2) =108.0, p\.001, and to have
reported some anal foreplay than those who had not discuss
it beforehand with their partner, v
2
(1) =58.07, p\.001. A
majority of women who planned for the experience reported
lubricant use (51.8 %) and foreplay (79.8 %), in contrast to
23.9 and 59.9 % of women who did not plan to engage in anal
intercourse.
When asked for the reason for engaging in anoreceptive
intercourse, 42.9 % of participants said that they wanted to try
it, 23.8 % responded that their partner wanted it, while 22.6 %
stated that it just happened, spontaneously. A small minority
of women reported that their partner was insisting on having
anal sex or that they were intoxicated (high on drugs and/or
alcohol) at the time (4.7 and 3.1 %, respectively).
Pain-Related Experiences
Asked about pain or discomfort associated with their first
anal intercourse, only about a quarter of women (26.6 %)
responded that they felt no pain or discomfort, while 40.3 %
had to stop because pain was too intense to continue. Despite
strong pain, 7.4 % of women reported that they continued
with the intercourse. In total, 28.7 % of the participants who
tried anal intercourse discontinued with the practice after that
first or one additional experience.
Women who reported strong or unbearable pain were
significantly more likely to have reported no anal foreplay,
v
2
(1) =8.52, p\.01, inconsiderate or rough partner, v
2
(2) =
25.64, p\.001, and no use of lubricant or saliva, v
2
(2) =
18.27,p\.001.Expectedly,women who reportedsuchintense
pain were also less likely than other participants to have
repeated the experience, v
2
(2) =49.51, p\.001. However,
every third woman (32.5 %) who felt intense pain the first
time she tried it reported engaging in anal intercourse at least
once a month in the past year. This probably reflects the
finding that a majority of women whose first experience was
very painful but who continued to engage in anoreceptive
intercourse reported that the pain reduced over time. One-third
(32.2%) of the participants who continued the practice—
76.8 % of the women who tried anal intercourse reported
several or more episodes in the past 12 months—stated that
the pain is currently of lower intensity and shorter duration,
while an additional 26.5 % reported either lower intensity or
shorter lasting pain. However, only 6 % of the participants
with the negative initial experience (intense pain) reported
that they do not feel any pain anymore.
Only a small subgroup of women (n=26; 3.5 %) seemed
to persistently engage in anal sex despite strong or unbearable
pain. Confirming the finding from our earlier study (S
ˇtulhofer
& Ajdukovic
´,2011), these women scored significantly lower
on sexual assertiveness than other participants, t(25) =3.64,
p\.01; Cohen’s d=.85.
Less than a third (27.7 %) of participants who regularly
engaged in anal intercourse stated that they rarely or never
experience pain/discomfort with anoreceptive intercourse.
Characteristics of Anoreceptive Pain and Self-Assessed
Causes
All three indicators of the quality of pain associated with
anoreceptive intercourse were moderately correlated, rs=
.30–.53, p\.001. When characterizations of pain given by
152 participants who routinely reported either strong or
unbearable pain associated with anal intercourse were ana-
lyzed, 59 women (38.8 %) described the pain as sharp or
piercing, 32 (21.1 %) found it burning, and 22 (14.5 %) char-
acterized the pain as dull. There was, however, a substantial
overlap in the descriptions, most notably between sharp and
burning pain (n=15).
When surveyed women were asked about probable causes
of the pain they feel with anoreceptive intercourse, a majority
stated that they cannot relax enough (39.1 %). The second
most frequent answer was a lack of anal foreplay (34.9 %).
Arousal and Pleasure-Related Experiences
Most women who continued with the practice (i.e., 71.3 % of
the participants who tried anal intercourse) reported it to be
very pleasurable and arousing (58.1 %). As expected, there
was a strong correlation between the indicators of pleasure
and sexual arousal related to anal intercourse, r=.81, p\
.001. When compared to their first anal intercourse, 52.0 and
Arch Sex Behav
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41.1 % of women found the current experience more arousing
or more pleasurable, respectively. Additional 17.8 % of par-
ticipants stated that they began to enjoy anal intercourse.
When women who never tried anal intercourse (20.9 % of
the total sample), those who tried it but did not continue with
the practice (28.6 % of the experienced subsample), and
women who seem to have incorporated anal intercourse in
their sexual repertoire (71.3 % of the experienced subsample)
were compared for sexual satisfaction, controlling for age,
significant differences emerged, F(2, 1529) =13.47, p\
.001. The highest average level of sexual satisfaction was
found in the group of participants who practiced anal inter-
course (M=11.02, SD =3.16) and it differed significantly
from the scores reported by women who never engaged in it
(M=10.46, SD =3.15) and those who tried anal intercourse,
but discontinued the practice (M=9.88, SD =3.25).
Correlates of Pleasurable Anoreceptive Intercourse
Finally, multivariate linear regression analysis was carried
out to explore the correlates of the level of pleasure associated
with anoreceptive intercourse. In addition to sociodemo-
graphic controls (age and education), relationship-related
(having a steady partner) and socio-sexual variables (fre-
quency of orgasm at sexual intercourse, frequency of mastur-
bation, and overall sexual satisfaction) were a priori deter-
mined as relevant correlates and entered as independent
variables. As Table 1shows, all independent variables, with
the exception of having a steady partner, were significantly
associated with the outcome. Within this particular regres-
sion model, which explained a meager 10.1 % of variance in
the dependent variable, masturbatory frequency and orgas-
mic ability were the strongest predictors of the level of plea-
sure associated with anoreceptive intercourse.
Qualitative Assessment
A total of 68 women aged 18–60 years (M=31.0, SD =
8.90), of whom a majority (n=58, 85.3 %) were in a steady
relationship, participated in the qualitative part of the study.
About three quarters of the participants reported that anal
penetration frequently feels uncomfortable (n=23), painful
(n=10) or uncomfortable and painful (n=19), at least in the
beginning. A minority (n=16) of women wrote that they
usually feel no pain or discomfort during anal intercourse.
This last group provided the most heterogeneous narratives,
as they contained three different types of pain themes: (1)
consistent absence of pain, (2) current absence of pain due to
experience, and (3) infrequent pain associated with inade-
quate sexual arousal.
Theme 1: Anal Intercourse is Painful and Pleasureless
As previously mentioned, all pain themes were a priori cat-
egorized into four groups. The first group described experi-
ences that were painful to the extent that they de-motivated
further explorations—either instantly or after a few addi-
tional attempts:
No, I don’t want to try it—ever again. That first expe-
rience was one too many! (F27, age 22)
For me, anal sex equals strong pain and discomfort.
(F20, age 25)
I have no positive experiences with anal sex. I felt no
pleasure, only pain, and it was anything but pleasurable.
(F36, age 30)
Every time I tried it [anal intercourse], it ended with a
total loss of desire on my part. Pain was the trigger—it
made me stop. (F26, age 30)
Theme 2: Anal Intercourse is Painful but also Pleasurable
However, for a number of women pain seemed to have a very
different role. The second group of pain themes elaborated on
the relatedness between pain or discomfort and sexual arousal
and pleasure, pointing to various ways in which pain was
acceptable, even welcomed at anal sex. For some women,
pain played a key role in the pleasure associated with anal
intercourse. In the following narratives, the otherwise nega-
tive physical sensations were given a different symbolic
meaning:
Pain played an important role. It was some sort of
adrenalin, something without which I could imagine
my sex life less and less. It was something exceptionally
arousing for me. (F15, age 27)
It is something special, I am not sure how to describe
it…it’s different from‘‘regular’’ sex…and, yes, the pain
contributes somewhat to sexual arousal, at least in my
case. (F9, age 24)
Pain is part of the pleasure. The culmination is anal
orgasm. (F19, age 19)
Table 1 Sociodemographic, relationship-related, and sociosexual
correlates of the level of pleasure associated with anoreceptive inter-
course among women aged 18–60 years (n=706)
b(SE) p
Age .09 (.01) .05
College educated -.08 (.08) .05
Has a steady partner -.07 (.10) .06
Frequency of orgasm at vaginal intercourse .21 (.03) .001
Frequency of masturbation .18 (.02) .001
Sexual satisfaction .12 (.02) .01
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A few women reported associating their pain or discomfort
with the excitement and pleasure of being dominated, sub-
missive, or simply challenging social norms and taboos:
My arousal and pleasure are strongly related to anal sex.
The presence of pain is especially pleasurable. I am
submissive in sex and I guess it’s the primary reason
why anal sex excites me. (F62, age 26)
Both the arousal and pleasure (at anal intercourse) are
something extraordinary, perhaps because anal sex is
still a taboo. (…) Pain can occasionally add to this
pleasure (associated with anal intercourse) because
somehow you’re testing your own limits in a way—
testing how far you are ready to go…(F64, age 25)
Pain is less important than this feeling of powerless-
ness, but the pain feels fine, too…(F68, age 35)
For other participants, the pain/discomfort was a vehicle
for experiencing (or confirming) trust and emotional inti-
macy with their partner:
For me, anal sex is pleasurable in spite of pain and
discomfort because my partner is extremely aroused yet
exceptionally gentle, which is what I need. He is gentle
because it hurts me, but after some time the pain morphs
into pleasure, although it never completely disappears.
(F51, age 25)
Also, it is about the relationship and my partner’s
domination in this act. It is my trust in him and my total
surrender—and the way they mix with pain, discom-
fort, but also pleasure—that make this experience so
extraordinary. (F21, age 28)
Anal sex makes me feel ‘‘bad.’’ I become submissive
and surrender to his body. (F33, age 24)
It should be noted, though, that the pain these women were
referring to seemed to be low to moderate in intensity—
unlike the pain reported in the first group of pain themes:
Well, this initial discomfort and the pleasure that fol-
lows make for a very exciting combination. A little pain
can add to pleasure. (F67, age 46)
It is different because I cannot quite compare it to
vaginal sex (…). In a moderate amount, pain adds to
great sex. (F42, age 20)
Theme 3: Anal Intercourse is Painless and Pleasureless
The third group of pain themes reflected the experience of
anal intercourse as painless but not pleasurable. Expectedly,
this was the smallest of the four groups, containing a single
experience:
I did not continue practicing anal sex. I don’t consider it to
be anything special. I do not feel pain, so I cannot write about
it. (F52, age 21)
Theme 4: Anal Intercourse is Pain-Free and Pleasurable
Among participants who reported painless and pleasurable
anoreceptive intercourse (the fourth group of pain themes)
only a few seemed never to have experienced pain or dis-
comfort. The rest of the women indicated that they learned
how to relax to avoid pain on all or most occasions. For some,
however, successful avoidance of pain or discomfort remained
dependent on the level of their sexual arousal and, less often,
on their partner’s skills:
In my case, anal sex is not painful at all. On the contrary,
it feels very good (…) Anal pleasure is something I feel
in my whole body, while vaginal pleasure is more local-
ized. (F58, age 36)
There was some pain in the beginning, but we got pretty
experienced so there is no pain anymore. You need to
learn how to relax your butt muscles. (F39, age 20)
If there’s sexual arousal, there’s no pain. Yes, it’s the
arousal and then pleasure that do the trick. (F66, age 46)
If I am aroused enough, there’s no pain…(F10, age 28)
A high level of arousal is needed, a kind of getting crazy
about sex, to be able to completely relax that part of your
body. (F44, age 41)
Anal sex is indeed different and more particular than
vaginal or oral sex. It is different because your partner
needs to know and understand that it is a different thing
for a woman and he has to act according to her needs. If
there is any role for pain, it is to remind your partner to
adjust…(F18, age 23)
Itwas greatwith the last partner with whom I usedto have
anal sex because he would do just about anything for me
to enjoy it without any discomfort…(F35, age 26)
Theme 5: Anal Intercourse is Pleasurable if Painless
Many pain themes could not easily fit into any of the four
predefined categories as they described mixed experiences.
The themes in this combined category included accounts of
women who are usually able to engage in painless, enjoyable
anal intercourse and who described pain and pleasure as
mutually exclusive sensations (not-pleasurable-if-painful).
In these narratives, pain during anal intercourse was typically
attributed to difficulties with specific timing and delicate
choreography of movements required for pleasurable (pain-
free) anal intercourse:
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Sometimes it happens that we start too abruptly, in the heat
of passion, but then we‘‘calm down’’and try it again, more
slowly. Then it is all right (F8, age 25).
If I feel pain in the beginning, which means that pene-
tration has been unsuccessful, I stop it no matter what.
(F59, age 60)
Usually I do not mind sex to be a bit rough, but I will not
have it in anal sex. (F44, age 41)
There’s no pain if the partner does as agreed upon,
initially slowly…(F49, age 24)
I cannot stand any kind of pain, especially as it (sex in
general) should be pleasurable. However, it does hap-
pen that it hurts (anal penetration), probably because I
am not relaxed enough at that particular moment. (F55,
age 33)
In my personalopinion, there’s no roomfor pain in sex—
it should be joy and pleasure…(F28, age 48)
In the final step, all pain themes were disassociated from
the four predefined categories and analyzed using axial
coding. The procedure, aiming to cluster similar themes into
larger or organizing themes, resulted in the emergence of
three organizing themes: (1) pain as insurmountable obstacle
and negation of pleasure, (2) strategic pain avoidance or pain
reduction, and (3) eroticization of pain. The three organizing
themes described dominant experiences and perspectives on
anal intercourse, ranging from completely negative accounts
to assessments that linked some levels of pain at anoreceptive
intercourse with increased arousal and desire. Most pain
themes, however, best fit the ‘‘strategic theme’’that reflected
experienced-based and couple-developed strategies to min-
imize or even eliminate pain associated with anal intercourse.
Within this organizing theme, pain was usually perceived
either as incompatible with or colliding with sexual pleasure.
Discussion
The aim of this study was to provide detailed quantitative and
qualitative accounts of pain at heterosexual anal intercourse
in a retrospectively-assessed life course perspective. Simi-
larly to other studies (McBride & Fortenberry, 2010), most
participants had their first anal intercourse in the context of a
steady relationship. The experience was often unplanned (not
discussed beforehand) and unprepared for, as reflected in a
lack of anal foreplay and rare use of a lubricant. The reasons
given for engaging in anoreceptive intercourse were varying,
with only a small minority of women suggesting a lack of
agency. The first experience was painful or uncomfortable for
most women, but particularly for those who reported no
preparation. A majority of women continued to engage in anal
intercourse, which reflected the frequent claim that the pain or
discomfort decreased with experience. Although it seemed
that pain/discomfort remained associated with anoreceptive
intercourse for about two-thirds of participants, it was almost
invariably experienced only at the onset of activity. Over a
half of women who seemed to incorporate anal intercourse
into their sexual repertoire found the practice very pleasur-
able and arousing. Furthermore, a substantial proportion of
women reported that the arousal and pleasure they associate
with anal intercourse increased over time. This clearly con-
tradicts the findings published by Rogala and Tyde
´n(2003),
who reported that a majority of women in a large-scale clin-
ical study evaluated anal sex experience as negative. A pos-
sible explanation of the discrepancy points to a younger age
(median age was 22 years), and presumably less experience
with anal intercourse, among Swedish participants.
The findings from the qualitative part of the study corrob-
orated the above findings and added a more complex picture
of symbolic elaborations of anal pain/discomfort. This was
expected, as the written accounts enable a greater sense of
understanding, and even control over, what is happening in
one’s life and provide a space for reflecting on emotionally
charged experiences (Orbuch, 1997). Three major pain themes
emerged from the material. The first represented predomi-
nantly negative accounts in which pain was described as a
dramatic obstacle to any positive sexual feelings. Invariably,
it led to the discontinuation of anal sex practice. At the other
end was the theme that described different ways of erotici-
zation of pain or discomfort, most often by associating it with
the experience of high-intensity erotic passion or through
arousing feelings of sexual submissiveness and thoughts of
being overwhelmed by the partner’s desire. The eroticization
of pain or discomfort at anoreceptive intercourse is likely
related to sociocultural meanings attached to anal sex—par-
ticularly tothe notion of forbidden experience—which would
be interesting to explore in a future study.
The final organizing theme presented narratives depicting
a more strategic approach to anal eroticism, one which aimed
to minimize or even eliminate pain associated with anal
intercourse. As pain was most often perceived as incompat-
ible with sexual pleasure in this broad theme, several expe-
rience-based couple strategies were presented—including
relying on the partner’s skills, engaging in anal intercourse
only if, and when, a high level of sexual arousal is reached,
and employing specific anal sex choreography (slow and
gradual penetration) that assists sphincter relaxation.
According to the study findings, the importance of a spe-
cific learning process required for the inclusion of anal inter-
course in one’s sexual repertoire can hardly be overrated.
Although a learning process is most probably required for
every pleasurable sexual activity, its role in anal sex is some-
what specific. Unlike in other instances where experience
tends to enhance pleasure, for a majority of women the learning
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process associated with anal sex seems to focus on reduc-
ing or eliminating pain and discomfort that may hinder plea-
surable s ensations. However, early e xperiences with anal inter-
course seem problematic for a majority of women also due to
prevailing initial ignorance about the specifics of anal inter-
course. Our data suggested that most young women and their
partners seem ill-prepared for experimenting with anal inter-
course—and not only when it was unplanned. Considering
high STI and HIV risks associated with anal intercourse, and
substantially lower rates of condom use at anal in comparison
to vaginal intercourse reported in the literature (McBride &
Fortenberry, 2010;S
ˇtulhofer & Bac
´ak, 2011), a more system-
atic information dissemination and the inclusion of discus-
sions about anal eroticism in sexuality education programs
would seem necessary in an era of increasing popularity of
anal sex among heterosexual couples.
Study Limitations
This non-probabilistic study sampleclearly precludesany con-
clusions about the true prevalence of anal intercourse among
Croatian women aged 18–60. It is very likely that volunteer
bias has inflated the proportion of participants who have
engaged in anal intercourse, as a recent national probability
study carried out among somewhat younger women (18–35
years) reported a percentage that wasthree times lower thanthe
one reported in this study (S
ˇtulhofer, Kuljanic
´,&S
ˇtulhofer,
2010). However, there is no particular reason to assume that
this bias also affected the prevalence of pain or discomfort at
anoreceptive intercourse. Women with negative experiences
of anal sex may have been similarly motivated to report about
their experiences as those with more positive experiences.
Finally,as our study did not assess painfulcoitus, an interesting
and relevantquestion regarding possible associations between
pain associated with anal andvaginal intercourse(both involve
some of the same pelvic floor muscles) remains to be addres-
sed. A related question, which could not be addressed in our
study, is whether the fear of pain and fear avoidance may also
play a role in‘‘anodyspareunia’’and not only in vulvar pain (cf.
Desrochers, Bergeron, Khalife, Dupuis, & Jodoin, 2009).
Although the qualitative part of our study did not involve
interaction with participants who provided their accounts, the
online method employed maximized confidentiality and
proved the only feasible option to collect qualitative data as
the female co-author of this study found it almost impossible
to recruit (anonymous) women to talk about their experiences
with anal intercourse. In the period of several months, the
researcher was able to complete only nine interviews—all
involving her acquaintances or friends. Although the fact that
the qualitative assessment tools were developed on the basis
of the interviews with acquaintances or friends is certainly a
limitation (related to the sociocultural homogeneity of personal
networks), it is plausible that familiarity and trust between the
researcher and her participants resulted in more honest and
detailed narratives.
Conclusions
According to the findings of this mixed-methods study, which
is one of a couple of studies that explored pain and discomfort
at heterosexual anal intercourse, anal eroticism seems to play
an important role for a substantial number of heterosexual
women and their partners. Although pain or discomfort often
accompanied anoreceptive intercourse, often only in the
initial phase, its intensity seemed to have reduced substan-
tially over time for most participants. Overall, this study’s
findings point to an important learning process, with partic-
ular emphasis on good partner communication and anal
foreplay, which seems to be required for a successful inclu-
sion of anal eroticism into a couple’s sex life.
Acknowledgments The authors would like to thank Sophie Bergeron
for her comments and suggestions.
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