Through centuries of trial and error, people have discovered ways to make receptive anal sexual activity both pleasurable and hygienic. Curiosity has led individuals to explore various positions and lubricants to find what works best for them.

It is important to recognize that many providers and those they care for may have unconscious biases and personal beliefs that can influence their clinical practice and advice. Here are some instructions and facts from scientific articles and resources to guide you and your clients interested in receptive anal activities.

Myth: Anal sex is only for men who have sex with men (MSM) – gay men.

As a matter of fact, anal play and sexual activity can be enjoyed by anyone.

The interest in anal play and sexual activities span a broad range of genders, sexualities, and ages all over the United States. Each year more and more people are exploring and learning the pleasures that can come from anal play. As of 2022, 40% of Americans have tried receptive anal activities at least once in their life. Anal play has seen participation across all age groups, with 68% of gen X (ages 44-59) and 73% of millennials (ages 28-43) engaging in it.

In the United States 3% of heterosexual men have participated in receptive anal intercourse, while 33% of heterosexual men have participated in insertive anal intercourse. Over 65% of gay men and over 83% of bisexual men have participated in insertive and/or receptive anal intercourse in their lifetime.

In the United States approximately 40% of cisgender heterosexual, lesbian, and bisexual women find pleasure from touch inside or around the outside of the anus. However many of them prefer Receptive Anal Activities (RAA)paired with stimulation of the vagina or clitoris.

Myth: There’s no chance of pleasure with anal sexual activity, it hurts.

Truthfully, receptive anal activity can feel pleasurable!

Receptive anal activities can be highly pleasurable, as evidenced by their popularity. With patience, good communication, and ample lubrication, the experience can be enjoyable for all involved. The neurological connections in this area contribute to its potential for pleasure.

Anodyspareunia is a term used to describe pain during anal penetration. There are several reasons why penetration might be painful. Physical causes include not using enough lubricant, moving too quickly, or trying to insert something too large for your body at the moment. Psychological factors, like performance anxiety or not being mentally prepared, can also contribute to discomfort. Additionally, there are medical reasons that might make receptive anal intercourse painful, such as hemorrhoids, pelvic muscle tightness, sexually transmitted infections (STI), nerve pain, or fissures. Pain can also result from a reaction to certain lubricants, creams, or ointments.

The pelvis is a highly sensitive area, filled with nerves that can create sensations ranging from pain to pleasure. The pudendal nerve, inferior hypogastric nerve, and pelvic splanchnic nerves, and their branches are intertwined with the organs and muscles in the pelvis. These nerves send signals to the brain that can be associated with pleasure, such as pressure, stretching, warmth, relaxation, and friction. They also transmit sensations of pain, including achiness, sharpness, stinging, soreness, and burning, as well as feeling of urinary or fecal urgency.

Pleasure Centers

For those assigned male at birth (AMAB), the prostate is often considered a center of pleasure. The dense, walnut-sized gland is located about two inches into the rectum on the front wall. It is surrounded by the inferior hypogastric nerve, which can send pleasurable sensations throughout the body when stimulated, potentially leading to pleasure and orgasm. Stimulation in this area is often referred to as the P-spot, which is located in the area of the prostate gland.

In those assigned female at birth (AFAB), the area between the vagina and rectum can also be a source of significant pleasure. The cervix, Skene’s gland, clitoris, and vestibular bulbs are all sounded by nerves that can be pleasurably stimulated through anal penetration. This specific type of stimulation can lead to both pleasure and orgasm. Stimulation in the anal area is often referred to as the A-spot, which is medically known as the anterior fornix erogenous zone.

For both sexes, there are pleasure zones around and inside the anus. The inferior rectal nerve, a branch of the pudendal nerve, surrounds the anus and some report pleasurable sensations when an object opens and moves through this area. Additionally, the pelvic splanchnic nerve encircles the rectum, contributing to a sensation of warmth and fullness.

The size, shape, direction, and depth of the inserted object, as well as the position of the receptive body, can all influence the sensations of pain and pleasure. It is helpful to start by exploring anal touch and penetration on your own. When involving a partner, communicate openly about what feels good and what does not. Share where you experience pleasure and where you would like more attention.

Myth: Anal sex is an unhygienic practice.

Receptive anal activity requires knowledge of anatomy and good hygiene practices.

When the idea of anal activities first comes to mind, some people may think, ‘I’m putting something into a place where things are meant to come out.’ It’s true that at the end of our digestive tract is the rectum and anus. What we eat is broken down, absorbed, and the waste is expelled through the anus. With this in mind, it is crucial to understand your own body before engaging in anal activities.

Pay attention to the timing of your bowel movements and consider eating a diet rich in fiber, plenty of water, along with prebiotics and probiotics, which can support healthy digestion. It might be wise to avoid foods that upset your digestion, such as spicy or inflammatory foods, dairy if you’re lactose intolerant, or grain if you have gluten intolerance.

Take time to discover the diet that works best for you. Fasting before anal activities can be common, but is not the answer. Refer to the Bristol stool scale; if your stool falls within the 3 to 4 ranges, where stool comes out soft, easy to pass, and looks like a sausage, your stool health is likely in a good spot.

Understanding the anatomy involved in anal penetration is crucial. The rectum is about 12 to 15 cm (about 5-6 inches) in length before reaching the 90-110 degree bend at the rectosigmoid junction. Stool accumulates and remains in the sigmoid colon, the end of the descending colon, until your body signals that it is time for a bowel movement. This means most anal play will not encounter stool.

When it comes to cleaning or douching, the area to focus on is the rectum, which may have some residue from your last bowel movement. In theory, a few rinses should effectively clean this space. You’ll know the area is clean when the water comes out clear, signaling that you are ready for receptive anal activities. More douching is not necessarily better—over-douching and douching too frequently is a problem. It can cause irritation, take more time, and irritate or damage the rectum’s protective lining.

Around 87-97% of men who have sex with men (MSM) douche before sex, according to Alex Carballo-Diéguez et al.. There are various methods, tools, and solutions available for this cleaning process. Here are a few of the most common practices. 

• Tools: Approximately 77% of people use a douche bulb, typically made of rubber, silicone, or plastic, to clean out. This tool consists of a container with a tip or nozzle that can be filled and then squeezed out through a slender tube inserted an inch or so into the rectum. Alternatively, some people use a hose attached to a faucet, or a combination of both methods.
• Solutions: Commercial douches are generally made with a saline solution, some with mineral oil or are laxative-based.   In a study by  Marian Javanbakht et al., 82% of their 1,070 participants use water for this purpose. The recommended temperature is warm, not hot, water.
• Technique: Most people report spending 10 to 30 minutes on this process. Do not rush, take as much time as you need to feel ready. It is generally recommended to hold the water in the rectum for 10-30 seconds before expelling it. On average, participants needed about three rinses for water to come out clear. Sometimes, residual water may linger in your colon, so it is recommended to wait 15-30 minutes before engaging in anal activities.

To summarize, set aside 10-30 minutes for the cleaning process, using a small douching bulb to rinse the rectum with warm water. Hold the water in for about 10 seconds before expelling it into the toilet. This may require three tries, more or less, to achieve clear water.

Myth: Any brand of lubricant works fine.

It’s true that lubricant is crucial for receptive anal activities.

Finding the best choice for yourself can be challenging. Generic brands available at local pharmacies often are not the best choice. These are the features to look out for when purchasing anal lubrication.

The anus does not produce natural lubrication and is therefore more prone to dryness. In contrast, the vagina benefits from the Bartholin and Skene’s glands which, when stimulated, create a lubricating discharge helpful for penetration.

Without lubricant, anal penetration can lead to tears and trauma, contributing to the common myth that anal sex is always painful. The purpose of lubricant is to ensure a smooth entry into the anus and to prevent discomfort during receptive anal activities.

Apply lubricant to all surfaces, including the inserted object, around the anus, and inside the anus using a personal lubricant applicator. Use a quarter-sized amount or about a tablespoon on each surface. Be generous with the lubricant and add more as needed.

Most common lubricants are water-based, silicone, or oil-based.

1. Water-based lubricants are the most commonly used and easily accessible. They’re great for condom use, toy play, and are easy to clean up. They often contain preservatives and additives, and you may need to reapply them to prevent dryness. While lubricant ingredients are FDA approved, some can cause irritation and sensitivity in certain people. Unfortunately, most lubricants do not include key information on the label, so it is important to choose products specifically labeled for anal play. Do not hesitate to ask questions at the store to find the one that suits your needs best. Water-based lubricants have some drawbacks with anal use, particularly related to their osmolality and pH levels. Here are some factors to consider when choosing a water-based lubricant:

• Osmolarity: A hyper-osmolor lubricant will draw liquid out of cells, causing them to break down. Hypo-osmolar products flood cells that can lead to their rupture. ISO-osmolarity lubricants, on the other hand, do not cause cellular breakdown. Look for lubricant with an osmolarity less than 1,200 mOsm/kg, ideally 380 mOsm/kg.
  
• pH: The pH of the vagina ranges from 3.8-4.5, while the rectum is more neutral, around pH 7. The lubricants used for vaginal penetration and anal penetration should be different and kept separate during sexual activities. Altering the pH level in the rectum can damage cells and disrupt the microbiota, which serves as a protective barrier against infections. Choose a lubricant for anal activities with a pH range of 5.5–7.
  The World Health Organization (WHO) provides a list of lubricants that meet the recommended criteria for anal use, including specific pH and osmolality values, in their Advisory Note (Annex 1). You can refer to this document for detailed guidelines and product properties.
  
• Preservatives: Preservatives are essential for extending the shelf life of water-based lubricants, but they can also disrupt the natural microbiota of the rectum. Chlorhexidine, which has a shelf life of three years, is commonly used as an antibacterial agent in mouthwash and some lubricants. P-hydroxybenzoic acid, or parabens, prevent the growth of mold and bacteria, but can harm organs and disrupt hormones in the body. Avoid these preservatives, as they have been reported to cause irritation and discomfort for some people.
  
• Additives: These should be avoided. Glycerin is a hyperosmolar substance that breaks down cells and is commonly used as a laxative to induce peristalsis. Propylene glycol is a cosmetic ingredient that enhances slip and moisture. Polyquaternium 7, 10, or 15 are commonly used as moisturizers for skin and hair. Nonoxynol-9 is a spermicide that can irritate the epithelial cells in the rectum and may even promote the replication of the HIV virus. Other additive ingredients include menthol for a cooling sensation, capsaicin for warming, lidocaine for numbing, as well as fragrances, artificial flavors.

2. Silicone Lubricants are excellent for skin-on-skin contact due to their long-lasting slipperiness. Unlike some other lubricants, silicone does not alter pH balance or interact with the cells of the rectum. It is safe to use with condoms and can be used in wet environments like the shower; however, be cautious application spillage, as surfaces may become slippery. Although silicone lubricant usually has a higher price point, this lubricant is recommended for anal play. It is inert, meaning pH and osmolarity are not a concern. Silicone lubricant should not be used with silicone toys, as it can break them down. Its durability also means it may leave stains or marks on surfaces like sheets or walls. To prevent this, it is recommended to use a cover, such as a towel, that can be easily cleaned after a wash cycle.

3. Oil-based products are slippery and readily available at grocery stores or pharmacies. The appeal of labels like ‘organic’ and ‘all-natural’ can be tempting, but it is importantly to check the ingredient list for additives and preservatives. When choosing an oil-based product, opt for unrefined options and be aware of potential allergies of tree nut oils. Oil-based products can degrade latex condoms and dental dams, but they are safe to use with polyurethane and nitrile toys and condoms. A helpful tip: when using household oils, use a separate container for anal play to prevent contamination and avoid accidentally using it for consumption.Synthetic oils, such as petroleum-based products (like Vaseline) or mineral oils, are not recommended for similar reasons as other oil-based products.
   
   Of note, saliva is not the answer in lieu of lubricant. Saliva contains its own microbiota and can carry germs and bacteria increasing the risk of transmitting STIs. Additionally it will dry quickly, which can lead to friction and abrasion.

Myth: Doggy style is the best position for receptive anal activities

In fact, people enjoy many different positions for receptive anal activity.

The size, shape, direction, and depth of the inserted object, as well as the position of the receptive body, can all influence the sensations of pain and pleasure. Given the sensitivity of the anus, it is essential to approach it with care. Be patient, use plenty of lubrication, focus on relaxation with deep breathing, and keep open communication with all parties involved.

Many people get position and anal play ideas from pornography. Adult film actors are professionals in sex work, “olympians of lovemaking”, and can be likened to acrobatics in the circus de soleil for intercourse. These individuals have plenty of practice and a lot of behind the scenes preparation.

Some may worry their anal sphincter is too tight, but if stool can pass through, the area can generally accommodate penetration. It is important to be aware of pelvic muscle tension and practice pelvic floor relaxation exercises.  Before engaging in penetration with a partner, practice alone using one or two fingers, dilators, or a small toy. This preparation can take 2-6 weeks with dilators and mindfulness relaxation techniques.

To prepare, use pelvic floor relaxation positions such as the happy baby pose and child’s pose. These techniques can also be beneficial during receptive anal activities. While in these positions, practice diaphragmatic breathing and focus on relaxing the pelvic floor and sphincter muscles.

The Receptive Partner is in Control

This cannot be emphasized enough. At the start of this practice, prioritize communication, whether verbal or through body language. Both partners should be attentive to each other’s signals, listening, observing, and feeling the cues. The best position for the receptive partner to maintain control and be aware of social and visual cues is the “riding” or “cowgirl” position.

In this setup, the insertive partner lies on their back (supine) while the receptive partner kneels or squats onto the inserted object. Be sure to use plenty of lubricant, and descend slowly onto the erect penis or toy while taking deep breaths. The insertive partner should remain still, allowing the receptive partner to adjust and get comfortable in this position. Pillows or wedges can be added for better control.  The receptive partner may hold onto the bed frame or headboard for support and comfort.

Other suggested positions include “doggy style” and “missionary”. Doggy style allows for easy access, with the receptive party on all fours, similar to child’s pose, kneeling and facing away while the insertive party enters from behind. This position places the receptive person in a position that may be easier to stretch and relax their pelvic floor muscles facilitating easier penetration. Since there is no face-to-face contact in this position, it is important to check in with each other regarding comfort and speed. The missionary position also offers easy access, with the receptive party lying on their back (supine) with their leg ups. This position is akin to the happy baby pose, which similarly stretches and relaxes the pelvic floor muscles. In this position, both parties can face each other, allowing them to be attuned to each other’s facial expressions and body language.

As everyone gains more experience, exploring additional positions can be encouraged. Discover which positions are reliable and you prefer most. Take your time, especially during initial insertion, to ensure comfort and ease. Most importantly, focus on the pleasure rather than the myths surrounding receptive anal activities.

Wrapping Up Receptive Anal Activity for All Bodies

This blog discussed the increasing cultural acceptance of receptive anal activities in America, offering scientifically backed insights. It covers population data, pleasure, preparation, positions, and lubricant use, serving as a resource for clinicians and patient education.

Key points include the widespread practice across different demographics, the nervous system’s ability to derive pleasure from anal play, the importance of preparation, personal preferences for positions, and the effectiveness of silicone-based lubricants versus others. Ongoing research and testing will continue to refine best practices.

Please share this blog post and the receptive anal activity educational handout Anal Health and Sexual Wellness: Essential Tips for Safe and Enjoyable Anal Sex with colleagues in pelvic health and clients alike who may benefit from the information provided.

For detailed guidance on using dilators, click below to explore my Vaginal Dilator Kit: The Clinician’s Four-Part Guide. While the kit is designed primarily for vaginal use, it includes valuable handouts on mindset and dilator techniques that are useful for all dilator users, including those interested in anal applications.

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This blog post was developed with Preston Bradley, SPT, as part of an independent study project in Pelvic Health with the Division of Physical Therapy in the Department of Rehabilitation Medicine at the University of Washington, DPT program.

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