Respect, Protect, and Pleasure Ms. J

Published: January 21, 2014

There I was, a deer in the fluorescent headlights, my feet in stirrups and my undercarriage catching the freshly methylated breeze of the clinic. I had finally gone to the doctor to address a discomfort I had in my “down there” area. (I had not yet made friends with Ms. J, my bujaina. I called her “down there”, “underneath”, or when I was feeling especially cold towards her, “anus”). I had spoken to my mother about this growing discomfort underneath and she had said it might be a heamorrhoid because “you sit down a lot” – I was a student at the time and sitting down was, indeed, one of my main responsibilities. I went to the clinic to get help.

After hushed explanations to the receptionist and a few minutes of sitting down and trying to touch absolutely nothing in the waiting area, my name was called and I consulted with a nurse. She asked me to take my pants off, sit at the edge of the table and put my feet in stirrups. (I had never done it that way before, but I went with it). There were a few minutes of silent and awkward prodding and wincing. Having found no malady after rudely poking at Ms. J, she opened the door, stepped out and called in a doctor to confirm that my case was confusing.

The doctor turned out to be one I did not particularly trust. On a previous occasion, he had awkwardly taken my sexual history without making eye-contact or introducing himself. He asked me a series of strange questions including “are you an MSM?” When I asked for my medical records (curious to see what sense he could have possibly made of the inane questions and reluctant answers), he asked me if it was perhaps because I was worried about what was going on against the gay community in Kenya. We were in the US, and nothing alarming was happening in Kenya as far as I knew. He explained that the records were confidential, except if an unknown suite in my insurance company wanted to see them. I explained how far South Africa (my home country) is from Kenya, punctuating my words with severely disparaging looks.

He walked in, asked the nurse some questions, and decided that I needed to see a specialist. They Googled for one on the computer inside the consultation room. In their eagerness, they had forgotten to allow me to veil Ms. J again while calling for reinforcements and Googling for help. So I remained spread-eagled on the table in a sea of fluorescent light. It was decidedly unpornographic. Ms. J saw more action in that hour than she had in the preceding 6 months. That thought made me sad.

Nurse and Doctor Stirrups referred me to a specialist in another part of town. I was not sure exactly his specialization – I was too busy being shocked by how much money someone was going to pay for my visit (fortunately, I had health insurance). After patiently waiting for my name to come up, I was led into his office. I took a surreptitious picture of a book lying on his cluttered desk: “The Ins and Outs of Gay Sex – A Medical Handbook for Men.” He finally came in and shook my hand, a kind faced 50-something year old whose heaviness gave the reassurance of a paper weight against the wind. He sat on the other side of his desk and I explained why I was there.

Dr: When was the last time you had sex?
Dr (*laughs): On the way here?
K (*mock outrage): “Excuse me! …Uhmm, a few months ago.”
Dr: “Did you top? Did you bottom?”
K: “Yes.”
Dr: “When you bottomed, did you have any pain?”
K: “Only at first.”
Dr: “Any bleeding?”
K: “No.”

He directed me to his table where he left me behind a screen to take off my pants so that he could come back and inspect my junk. Thankfully, there were no stirrups this time. He asked some banal questions while checking the outside and inside of Ms. J., making sure to announce everything he was going to do before doing it: “Where are you from?”, “Where is your family now?”, “I am about to insert a finger”,  “What are you studying?”…  I had never thought about my family while Ms. J was being visited. It was weird and unsettling, but I knew that he was trying to put me at ease, and I really appreciated that. He showed me some paper towels to use for cleanup and invited me back to his desk when I was ready. At his desk, this doctor (who I had just decided to name my Butt-Doctor) told me what he was screening for, and he told me ways to manage my discomfort while we wait for the results.

***

In organizing a series of webinars on Anal Health for the MSMGF, I have been reflecting on these contrasting experiences with healthcare providers, which both took place in very well-resourced settings, and neither of which were homophobic in the slightest. Even though Nurse and Doctor Stirrups may not have intended to have this effect, their ill-informed exploration of Ms. J and their lack of concern for my privacy were jarring. The environment they created was not conducive to an open exchange of information that would help us figure out what was happening with my body. Having already felt an ineptitude around the discussion of sex, I would not choose to go to Nurse and Doctor Stirrups if I had STI symptoms. Because I had that negative experience with them, I would be reluctant to go there even with flu symptoms.

My Butt-Doctor, on the other hand, not only made me feel comfortable enough to talk about my sex life in some detail, he had the skills and knowledge to investigate my problem and explain what he was doing and why he was doing it. His office felt safe from the moment I walked in. Seeing the book on his desk made me think that he knew what he was doing even before I started speaking with him. He was respectful of my body and of the way I have sex. After our consult, I felt like it would be almost as easy to tell him if I had warts on my dick as it would be to tell him if I had a persistent headache.

The aim of the MSMGF webinar series on Anal Health is to equip members of our global network of lay and professional healthcare workers with a certain level of knowledge, skills, and language to deliver the care that their clients deserve. This entails not only being non-judgmental about the ways that patients live their lives, but being skilled to deliver needed care and being understanding of the fullness of their sexual lives. It means that anal sex cannot only be conceived of in terms of the risk it poses for HIV and STI transmission; it must be understood as an expression, as a pleasure, as a source of confidence or insecurity, as a source of shame or pride. Anal sex has to be understood in the multiple and complicated ways that other kinds of sex are.

We attempt to expand the way that anal sex is discussed (in the field of public health, it is often discussed as a “problem” in and of itself), by beginning with the radical assumption that anal sex causes, first and foremost, pleasure. And pleasure is a good thing. The ways in which we seek and enjoy pleasure are related, both as cause and consequence, to numerous areas of concern to public health, including mental health, drug use, HIV, and other STIs. We do not all, however, go around with the sole objective of vanquishing HIV; we go around living and loving, playing, fucking, and licking, because it feels good. And because it is good to feel good.

We open the series today with a presentation on the physiology of anal sex and how it relates to pleasure. We hope that there will be much discussion in the question and answer session immediately following the presentation, and we have opened up the MSMGF Blog to continue the discussion online. Today’s presenter, Bryan Kutner, has kindly agreed to respond to comments and questions in this Blog space that were not raised during the webinar. Please feel free to engage on this topic below, and keep an eye out for forthcoming webinars in the series.

Happy 2014!

Keletso

Keletso Makofane is a South African Fulbright Scholar and a graduate of the Columbia University Mailman School of Public Health. The first webinar in the MSMGF’s series on Anal Health took place today, January 21st, at 7AM PST – a recording of the webinar is available here. An interactive discussion with the presenter will take place here MSMGF Blog during and after the webinar. 

Comments 19

  1. Question: I accidentally hurt my partner during our first anal play. I used gloves and lube. I want to try again, but he is worried it won't feel good again. Any recommendations?

  2. Question: I often get many questions regarding how to clean yourself out before anal sex. I thought that perhaps you could speak to that point.

  3. Excellent question!

    First, if you've got adequate fiber in your diet, your rectum should be fairly clean after each bowel movement. Fiber bulks up faeces, allows for a proper feeling of fullness, and cues the rectal reflex to do its magic, without pushing, to empty your rectum with little to no faeces/shit left inside or on your toilet paper. Of course, that means having access to high fiber foods or fiber supplements. Also, it can take a few days for the body to adjust to added fiber and in the meantime stool can be too loose or too hard. So give yourself time.

    Second, even with a pristine rectum, a simple washing of the anus with a little soap and water freshens things up. Think of it like washing your genitals before having sex. Do not go much further than your anal canal, because the lining of the rectum is less durable and can dry out in contact with soap. Some people have access to a bidet or a detachable shower head, and that allows for a cleaning as well after having a bowel movement.

    Third, see the response below to the question about douching!

  4. Definitely. First, find out what hurt and be very welcoming and encouraging that you want to give him pleasure, not pain. Find out if there were any moments of pleasure or even just neutral feelings. Some people don’t like or feel neutral about a finger in the anal canal, but once they feel pressure against the prostate they enjoy something new.

    Some people don’t enjoy fingers at all, but like a fist or a dildo or a dick. As you experiment, it’s super important to stop at the first hint of pain – or just pause where you are until the pain goes away. Always allow the partner being penetrated to determine whether to move forward, pause, or stop altogether. That will allow your partner to relax more, and for you both to pay attention to what felt good or neutral that turned into feeling painful. You might also let your partner play with himself anally while you do other things to him that he finds fun. Anal play can be a bit like a massage, and people like different levels of pressure, stroking, and stimulation.

    So, without knowing exactly what hurt, I can only say try to explore the bits that feel good. It might just feel meh at first until you’re both relaxed. But at least meh is better than pain, and might become something more as you explore more. That said, not everyone enjoys anal play, so if you’re partner simply isn’t into it then you’ll have to grant him that.

    If there's a more specific source for the hurt, let me know and I'll try to give a more specific answer!

  5. Yes! Rubbing against the prostate is very similar to the sensation of orgasm – which is really just the squeezing of muscles around the prostate. Ejaculation often happens alongside orgasm, but it's possible to stimulate the prostate and experience anything from a mild to an extreme orgasm – without cumming. Magic, eh!

  6. Question: can u discuss the safety or not of douches? bottom cleansing is a mystery to me, but thankfully, not for my boyfriend.

  7. The lining of the rectum secretes a little bit of lubrication. That lubrication comes from the rectal mucosa, and that’s what people mean when they refer to anal secretions.

    In terms of HIV, the rectum has a high concentration of CD4 cells (which HIV can infect and use to reproduce itself). In someone living with HIV who is not virally suppressed, the CD4 cells in anal secretions would typically have a high concentration of viral particles. That means it’s possible to contract HIV from anal secretions, even if those secretions do not contain blood.

  8. Question: Some of the doctors I work with talk about loss of control of anal muscles as a result of frequent and ongoing anal sex. They use this fact to justify the argument that the anus “is not designed” for penetration like the vagina is. According to them the loss of these muscles will prevent people from holding their shit in. Is it true that muscle function can decrease as a result of anal sex? How can the muscles be trained to stay strong?

  9. So long as the hand is lubricated, has no sharp nails or cuticles (a glove or internal condom can be helpful here), and there's no pain involved, fisting itself won't have any longterm negative impact on anal health. If anything, maintaining pleasure with an object as large as a fist requires a great deal of relaxation and coordination of muscles, and those muscles are likely to have increased blood flow and health as a result.

  10. Luckily we got to this question in the latter part of the webinar!

    Increasing pleasure in that part of the body increases blood flow and coordination; it's the opposite of what those doctors have said. (Assuming that the penetration is consensual and involves adequate lubrication.)

    Over time, as we age, we lose the ability to hold shit and gas inside the body. I've read at least one study, that suggested that men who'd received anal penetration were no more likely to experience anal incontinence than men who had not. We're looking for that study so that you can bring it back to doctors you work with!

    In terms of exercising muscles, YES. You can exercise the pelvic floor and other anal muscles like the sphincters by practicing Kegel exercises. http://en.wikipedia.org/wiki/Kegel_exercise

  11. I was just listening to the webinar from yesterday, great stuff, if I may ask, how common is it to use of the female condom for butt sex, are we actively promoting that as a public health intervention?… are there available lessons to teach MSM on inserting the female condom?

    I was just thinking the condomize campaign and the bias towards educating people on using the female condom for vaginal sex…as if it were sort of exclusive

  12. Such an interesting topic! Here are a few resources.

    A. The "female condom" is also called the "internal condom" or "bottom condom" in order to remind people that it can be used anally as well as vaginally. In fact, the internal condom was originally called the Aegis, and designed for anal intercourse. Unfortunately, it did not receive FDA approval.

    For the original FDA unapproved brochure, see:
    https://www.dropbox.com/s/2zoq7gpycj1vrox/AEGIS%20Male%20Rectal%20Condom%20brochure.pdf

    For the story on the FDA not approving it for anal use, see the last few paragraphs here:
    http://www.pridealive.org/Queer_Health/analhealth.htm

    For an updated version of how to use the internal condom, see this brochure:
    http://www.acponline.org/acp_press/fenway/how-to-put-on-a-female-condom-for-anal-sex.pdf

    For an instructional cartoon video in multiple languages:
    https://www.youtube.com/user/SWF32x/videos

    B. To answer your question about whether to recommend the internal condom for anal use, see a few free online research articles:
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2797077/#!po=10.0000
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2679779/
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1508971/

  13. Thank you for the amazing webinar! Is the .PDF and/or PowerPoint of the presentation available, or is it just the recording?

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