AnalPleasureSlides PDF

Smarter Sex is the
New Safer Sex:

Anal Pleasure & Health
21 January 2014
MSMGF
Bryan Kutner
bryan.kutner@gmail.com
+ =
Smarter Sex Series
A face-to-face training intervention for HIV workers, to
increase comfort, knowledge, and skill with the menu of
harm reduction options involving anal sex by focusing on:
A. The basics of anal physiology, pleasure, and health
B. Ways to communicate with clients that lead naturally

toward HIV prevention (gain-framed messaging &
motivational interviewing)
Smarter Sex: Anal Pleasure & Health Trainer: Bryan Kutner

MSMGF - 21 January 2014 3 bryan.kutner@gmail.com
What Well Do Today
A. Prevalence of anal sex & the anal taboo
B. Basic anal physiology with a focus on pleasure
C. 10 questions every HIV worker should be able to answer
D. Further resources (Q&A continues on MSMGF Blog!)

Mantras
Slow and steady

Ouch!
Have fun!

Where Yall From? 43 & counting!
Botswana Italy Puerto Rico
Brazil Jamaica Romania
Burundi Japan Russian Federation
Cambodia Kenya Slovenia
Image: International Rectal Microbicide Advocates. http://www.rectalmicrobicides.org

Canada Lao Peoples South Africa
China Democratic Republic Spain
Denmark Mali Sri Lanka
France Mauritius Switzerland
Germany Mexico Thailand
Ghana Netherlands Togo
Guatemala New Zealand Uganda
Hong Kong Nigeria United Kingdom
India Norway United States
Indonesia Peru US Outlying Islands
Ireland Portugal Anywhere else?

Images: www.wikipedia.com
Prevalence of Anal Intercourse
Its not an MSM health issue its a health issue for anyone
with an ass
By absolute numbers, more heterosexuals have had anal

intercourse than homosexuals conservative estimates
suggest 4-7 x more women than men have received anal sex
in their lifetimes (Halperin, 1999)
For the latest reviews of selected studies, see Baggaley et al.,

2010; Boily et al., 2011; Heywood & Smith, 2012

Prevalence of AI (e.g., Baggaley et al., 2010)



Heres the Deal on Prevalence
Excellent reviews & meta-analyses of HIV risk
Missing population-based samples for most regions

(Heywood & Smith, 2012)
Lacking behavioral frequency

(McBride & Fortenberry, 2010)
No meta-analysis of global prevalence of anal intercourse

or other forms of anal sex

But What About Anal Sex?
Our public health response to HIV
has narrowly focused on forms of
anal pleasure that pose the greatest
risk for transmission: fucking
Most surveys dont ask about forms
of anal sex other than intercourse
No solid data for lesbians or
transgender people
Marginalizes diverse forms of anal pleasure, and the
diversity of people who enjoy that diversity

Case Study: Public Health Messaging
NYC 2010
www.nyc.gov/html/doh/html/pr2010/pr016-10.shtml
100,000 women engage in

anal sex with men each year
23% of these women were

likely to use condoms
61% of MSM were likely to

use condoms for anal sex

Case Study,
NYC 2010
Image: okpolicy.org/let-them-eat-judgment-legislation-targets-the-poor
For both men and women, the overall
message is clear: Never engage in unprotected
anal sex. Use a condom every time.
MSMGF - 21 January 2014 15 - NYC Health Commissioner
Case Study,
NYC 2010
mage: okpolicy.org/let-them-eat-judgment-legislation-targets-the-poor
For both men and women, the overall
message is clear: Never engage in unprotected
vaginal sex. Use a condom every time.
MSMGF - 21 January 2014 Wait
16 Are you telling us to go extinct!
Image: psykopaint.com/blog/tutorial/14-great-free-photo-sites/attachment/07-23128/
A taboo is a prohibition, often

Eating cats or dogs lacking justification and of
(for example) unknown origin specific to a
given culture
Smarter Sex: AnalJ. Pleasure

Morin, & Health
Anal Pleasure Trainer:
and Health: A Guide for Men, Women and Couples, 4th Edition Revised. San Francisco, CA: Down There Press, Bryan Kutner
May 2010.
Clinicians bias reinforces the taboo
Health workers see people who need help, so we are more likely to see
people with anal health problems
The job reinforces a taboo (Its dangerous! Ive seen horrible things
happen to people who dont use condoms! Thats bad! Dont do it!)
Yet telling people to stop doesnt stop them, despite our best intentions
And if we communicate the taboo, then we resign people to expect the

harm they feel during anal sex, even though the harm is preventable
We can reframe prevention as helping people have better sex, rather than
just preventing HIV

MSMGF - 21 January 2014 bryan.kutner@gmail.com
Biomedical Interventions on the Horizon
To end the epidemic we have to offer more than just a single HIV
prevention tool its more than condoms these days, thankfully!
People may eventually use biomedical interventions without

condoms and thats better than the alternative of no prevention
Health workers have to tolerate our bias against anal pleasure

enough to promote the benefits of anal health, without narrowly
focusing on HIV and then eventually bridge to HIV prevention
Basic information about anatomy and pleasure is a start

Pleasure is a Radical Assumption
We attempt to expand the way that anal sex is often discussed as a
problem in and of itself in the field of Public Health, 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 STIs and HIV, to mental health, to drug use, and
to the other areas that are of concern to the field of Public Health.
We do not, however, go around with the sole objective of preventing
HIV, we go around living and loving, playing, fucking, licking, because
it feels good. And because it is good to feel good.
- Keletso Makofane, MSMGF Blog

msmgf-blog.blogspot.com/

Some Basic Questions Clients Ask
That You Can Easily Learn to Answer!
1. When Im getting fucked, it feels like Im gonna pee then like Im gonna cum - but
nothing comes out. Whats going on?
2. Usually I orgasm only from my clitoris. But last night I came during anal sex. What the
fuck is going on?!
3. Sometimes I get tense when Im bottoming, even though Im enjoying it and its
really annoying me.
4. The last thing I want to do is leave shit on someones dick. What can I do about it?
5. Look Im not going to stop douching. Is there anything I need to know?
6. When I fucked this guy, his dick went soft. Am I doing something wrong?
7. Ive heard some questionable things about lube. Whats the story?
8. Bleeding is normal, right?
9. Ive heard about male multiple orgasms is that really possible for a man?
10. Can I tighten things up down there? Im a little afraid Ill get loose if I get fucked too
much.

Anatomy Roadmap
Heres the last of the digestive tract lets look at each of
the major anal erogenous zones: anal canal then rectum
http://coloncancer.about.com/od/thebasics/ig/Anatomy-of-the-Large-Intestine/Large-Intestine-Diagram.htm
Images: http://www.umm.edu/patiented/articles/large_intestine_000326.htm and
Anatomy: the Anus
: www.shadygroveadventisthospital.com/adam/Surgery%20and%20Procedures/13/100154.html
The anus is the asshole,
visible externally as the
opening of the anal canal
It is densely packed with

nerves and is very
sensitive to touch, which
may be pleasurable
Its erotic regardless of

gender anyone with an
asshole has the potential
to feel anal pleasure

Anal Canal
Just beyond the anus
is the anal canal (the
first few cm / inches)
Two rings of muscle

close and open the
anal canal

Anal Canal
The anal canal is made of
www.shadygroveadventisthospital.com/adam/Surgery%20and%20Procedures/13/100154.html
two sphincters at the end
of the rectum
A sphincter is a circular
muscle that contracts
and expands
These two muscles open

and close sort of like your
mouth!

Anal Canal: Two Sphincters
Image: scientopia.org/blogs/scicurious/2009/05/08/friday-weird-science-ruining-
The outer sphincter
is a voluntary muscle.
You control it at will
like your mouth.
The inner sphincter is

an involuntary
muscle. You have to
the-mood-blame-the-rair
relax or feel
stimulated to open it.

Anal Canal
Image: assets1.scripps.org/encyclopedia/graphics/images/en/9390.jpg.
Colon
Colon is about 2 m (6 ft) long
Part of the digestive system
Moves waste (gas & shit) from
small intestine to the rectum
Sigmoid colon is the S-shaped
end of the colon, leading into
the rectum

Rectum
The rectum is about 12-23 cm
(5-9) long, and 1 cm () wide
and stretches
Serves as a warehouse for poop
& gas right before release that
means its generally free of crap
and readily accessible erotically
When the rectum fills, we feel
the urge to relax or release,
called the rectal reflex

Rectum Rectal Reflex
When gas or shit leaves the

sigmoid colon and enters the
rectum, we feel the urge to empty
our bowels
That feeling of fullness is the rectal
Images: Jack Morin. Anal Pleasure and Health: A Guide for Men, Women

reflex the urge to shit or fart
and Couples,. 4th Edition Revised. Down There Press: May 2010
when the rectum is full
Fullness communicates to the
pubo-rectal sling the muscle
responsible for 80% of continence
in the body: Its time to go!

Rectal Reflex & S-shape of the Rectum
Image: Lembo, A., & Camilleri, M. (2003). Chronic constipation. The New England Journal of Medicine, 349(14), 13601368.
Three Factors Disrupt the Rectal Reflex
Image: Lembo, A., & Camilleri, M. (2003). Chronic constipation. The New England
ignoring the urge
resisting a fart
Journal of Medicine, 349(14), 13601368.

absence of
adequate fiber
In certain positions, penetration can poke the pubo-rectal sling, triggering the
rectal reflex even though you dont have to pass gas or faeces. The key is to pay
attention to the rectal reflex when you actually fart or shit so that when you use
your ass erotically, youre aware of the difference in sensation and can relax.

Kofi When Im getting fucked, it feels like Im
gonna pee then like Im gonna cum - but
nothing comes out. Whats going on?
Welcome to your prostate!
You can feel it about 4 cm inside

the rectum, pressing toward the
belly button
Its right next to the bladder and

the urethra passes through it
But whats so great about the

prostate?

Pressure on the Prostate Hits the P-Spot
The sensation of
orgasm results from
the pressure of
muscle contractions
around the prostate
This can happen even

without ejaculation
cumming and orgasm
are different things
This URL has a cool animation!

litford.net/geekulture/2010/11/psychedelic-prostate-examination/
Prostate: The P-Spot
Rubbing the prostate
through the rectal wall can
produce orgasm or
heighten orgasm and
ejaculation
It might feel like peeing at

first, because its close to
the bladder
Its like the G-spot in

female anatomy!
Also the bulb of the penis

is right there too

Usually I orgasm only from my clitoris.
Kofi
But last night I came during anal sex.
What the fuck is going on?!
Did we assume Kofi was cisgender male what if Kofi has a clitoris?
Welcome to Kofis clitoris an

organ whose sole purpose is
pleasure and it has legs that
extend into the pelvic floor
musculature
The legs of the clitoris allow the
experience of pleasure and
possibly orgasm during anal sex
in the rectum

Legs of the Clitoris
For a great video about the legs of the clitoris, go to:

blog.museumofsex.com/the-internal-clitoris/
Its really amazing!
Lets Get to Some More Questions!

Tendai Sometimes I get tense when Im
bottoming, even though Im enjoying
it and its really annoying me.
Its likely stimulation of the pubo-rectal sling!

Get to know your rectal reflex DO NOT PUSH when you
have to shit or fart just relax (and enjoy)
Play with flared bottom sex toys or objects follow the
rectum, dont poke it
Play with positions bottom squatting on top, on the
side, can take out the S-curve and lessen the likelihood of
hitting the sling
It varies with the shape of what youre putting in too
dicks, for example, differ in shape & size
The rectal reflex & pubo-rectal sling respond to
psychological as well as physical stimulation

Modishe The last thing I want to do is
leave shit on someones dick.
What can I do about it?
Fiber (An apple a day keeps the
shit away) can regulate bowel
movements; supplements
(psyllium, flaxseed) can help with
planning & expectancy
Probiotics/yogurt post-
antibiotics
Entering the sigmoid colon
increases the likelihood of
encountering faeces

Modishe The last thing I want to do is
leave shit on someones dick.
What can I do about it?
The internal condom (also

known as the female
condom) might be handy
here for this persons
concerns while bottoming
Check out the video on the
right in Dioula, Moree,
French, and English at
youtube.com/user/SWF32x
?feature=watch

Modishe Look Im not going
to stop douching. Is
there anything I need
to know?
Douching may be common, especially

among poz men (Carballo-Dieguez et al., 2007)
With adequate fiber, you wont need to douche
or use an enema - but HIV med side effects,
enteric illnesses can loosen bowels & added
fiber may be contraindicated
Rectal mucosa is 1 cell thick, not very lubricated,
easily tears with inserted objects without lube
Douching removes natural lubrication and
compromises rectal lining integrity
If youre committed to douching, use warm
water and a smooth tipped, lubricated device a
few hours before sex

Modishe When I fucked this
guy, his dick went
soft. Am I doing
something wrong?
Remember how the bulb of the

penis extends into the body? And
pressure against the prostate can
feel like orgasm?
This guy of yours might just be
experiencing more pleasure in his
ass than on his dick
Its actually pretty common to
migrate erotic attention from the
penis to the ass while getting
fucked or rimmed or played with

Modishe Ive heard some
questionable things
about lube. Whats
the story?
Lubricants prevent tearing in the

rectum; anal sweat & rectal mucous
typically arent enough to prevent tears
Not all lubes work the same, some may
harm but we have only a few studies
Oil isnt recommended bacteria, latex
Rectal microbicides are on the horizon!
Stay tuned for MSMGFs upcoming webinar on lube access & safety
In the meantime, check out IRMAs link for a more thorough written
response

Modishe Ive heard some
questionable things
about lube. Whats the
story?
Heres a quick guide to

which kinds of lube to use
available at
pinterest.com/pin/191403
052883727348/

Modishe Bleeding is normal,
right?
Pain is a signal of potential damage and

blood is a sign of actual damage
Dont worry its likely not permanent,

but just from not using enough lube
Because of the anal taboo, people

expect pain and therefore suffer
bleeding rather than take measures to
prevent it
Using lubrication, only inserting smooth objects (no RuPaul nails!), adequate fiber,
going slowly with a new partner
If bleeding is regular for you, seek medical advice!

Modishe Ive heard about Kofi
Can I tighten things
male multiple up down there? Im
orgasms is that a little afraid Ill get
really possible for a loose if I get fucked
man? too much.
Excellent questions! Both answers

have to do with your pelvic floor
muscles
If youre enjoying sex without pain,

youre exercising those muscles
Exercising pelvic floor muscles

increases blood flow, control, and
intensity of orgasm!

Floor
Pelvic
MSMGF - 21 January 2014

Muscles
Smarter Sex: Anal Pleasure & Health

48
Trainer: Bryan Kutner
Image: Jack Morin. Anal Pleasure and Health: A Guide for Men, Women and Couples, 4th Edition Revised. Down There Press: May 2010.
Smarter Sex: Anal Pleasure & Health
49
Trainer: Bryan Kutner
Image: Jack Morin. Anal Pleasure and Health: A Guide for Men, Women and Couples, 4th Edition Revised. Down There Press: May 2010.
Pelvic Floor Muscles: Kegel Exercises
By exercising these muscles,
you can both develop the
capacity for multiple orgasm
and also strengthen your
anal muscles
Lets try a few right now
Google or Wikipedia Kegel

exercises for instructions
Check out this book on becoming

multi-orgasmic with male genitalia
(Chia, M. & Abrams D., 2010)

Audience
Questions & Answers

Image: http://cindyscott.org/2013/11/20/raise-fist-hands/ 51 bryan.kutner@gmail.com
Modishe I cant use a condom Kofi
Sex while Im high is while fucking. Is there
amazing. Im afraid anything else I can do?
if I stop, sex will just
be boring.
Weve been dating
for a few months
My viral load is and already
Bata Fred
undetectable now slipped once. Im
and I just have thinking about
condomless sex doing away with
with other positive condoms.
guys.
Depending on your perspective, these may be more difficult to

respond to while still respecting the clients autonomy

Which Brings Us to
What We Didnt Cover
Counseling
Interventions
Ways to communicate HIV Harm Reduction
about anal pleasure & Extending support, being empathetic, and
health that lead encouraging solutions that both minimize
harm (to self and to others) and respect self-
naturally toward determination and autonomy
conversations about HIV
prevention

If youre not sure what these are
HIV Harm Reduction Some work far better than others
at preventing HIV not all are
Use of external or internal condoms available globally yet
Routine HIV testing
Routine STI testing, whether symptomatic or
not if possible
Dont know what
Establishing a limited # of partners these are? Check out
Serosorting
VMMC (voluntary medical male circumcision) MSMGFs
Negotiated safety within relationships
Selecting lower risk sex
Compendium &
Strategic positioning other webinars!
Ejaculating outside the body
TasP (treatment as prevention) msmgf.org/files/msmgf/documents/
PEP (post-exposure prophylaxis) TechBulletins/EN/Sec1MSMGF_Tech
PrEP (pre-exposure prophylaxis) Bulletins2012.pdf

A Fistful of Additional Resources
The first is the Bible of anal pleasure and health. Easy to read, pretty gender inclusive, and very helpful!
Morin, Jack (2010). Anal Pleasure and Health: A Guide for Men, Women and Couples,
4th Edition Revised. Down There Press: San Francisco, CA.
10 Rules of Anal Sex. sexuality.org/authors/morin/analrule.html
Kinsey Institute. Sexual health info. kinseyconfidential.org
PrEP. Easy to follow community education on PrEP to prevent HIV. men.prepfacts.org
Terrence Higgins Trust. Excellent harm reduction publications on MSM sex. tht.org.uk
Know Your Risk. A guide to harm reduction for MSM. knowtherisk.org.au
International Rectal Microbicide Advocacy. Lube safety, and microbicide research &
advocacy. rectalmicrobicides.org
MSMGF. Of course! msmgf.org and msmgf-blog.blogspot.com/

References
Baggaley, R. F., White, R. G., & Boily, M. C. (2010). HIV transmission risk
through anal intercourse: systematic review, meta-analysis and implications
for HIV prevention. International Journal of Epidemiology, 39(4), 1048
1063.
Boily, M. C., Dimitrov, D., Abdool Karim, S. S., & Masse, B. (2011). The future
role of rectal and vaginal microbicides to prevent HIV infection in
heterosexual populations: implications for product development and
prevention. Sexually Transmitted Infections, 87(7), 646653.
Carballo-Dieguez, A., Bauermeister, J. A., Ventuneac, A., Dolezal, C., Balan, I., &
Remien, R. H. (2007). The Use of Rectal Douches among HIV-uninfected and
Infected Men who Have Unprotected Receptive Anal Intercourse:
Implications for Rectal Microbicides. AIDS and Behavior, 12(6), 860866.

References
Halperin, D. T. (1999). Heterosexual anal intercourse: prevalence, cultural
factors, and HIV infection and other health risks, Part I. AIDS Patient Care
and STDs, 13(12), 717730.
Heywood, W., & Smith, A. M. A. (2012). Anal sex practices in heterosexual and
male homosexual populations: a review of population-based data. Sexual
Health, 9(6), 517.
McBride, K. R., & Fortenberry, J. D. (2010). Heterosexual Anal Sexuality and
Anal Sex Behaviors: A Review. Journal of Sex Research, 47(2-3), 123136.
Morin, Jack (2010). Anal Pleasure and Health: A Guide for Men, Women and
Couples, 4th Edition Revised. Down There Press: San Francisco, CA.

Acknowledgements
Versions of this presentation were reviewed by Harry & Stefan,
who generously donated their time as well as their feedback:
Stefan Baral MD MPH MBA CCFP

FRCPCDirector
Harvey J MakadonDirector
Key Populations Program
National LGBT Health Education CenterThe
Center for Public Health and Human Rights
Fenway InstituteClinical Professor of
Department of
MedicineHarvard Medical SchoolBoston,
EpidemiologyJohns Hopkins School of Public
MA, USA
Health
Baltimore, MD, USA
The face-to-face version of the broader Smarter Sex series was piloted at the Harm
Reduction Coalitions NYC Training Institute (www.harmreduction.org)

Contact Information
If you have continuing questions or would like a face-to-face training
on this topic, feel free to contact the presenter:
Bryan Kutner, MPHTrainer & Curriculum Writer

PhD student, Dept of Psychology, University of Washington
Twitter: @kutses


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What is the purpose of the training?

What is the purpose of the training?

What topics are covered in the training?

What topics are covered in the training?

Smarter Sex is the

New Safer Sex:

A. The basics of anal physiology, pleasure, and health

B. Ways to communicate with clients that lead naturally

Smarter Sex: Anal Pleasure & Health Trainer: Bryan Kutner

B. Basic anal physiology with a focus on pleasure

C. 10 questions every HIV worker should be able to answer

D. Further resources (Q&A continues on MSMGF Blog!)

Smarter Sex: Anal Pleasure & Health Trainer: Bryan Kutner

Slow and steady

Smarter Sex: Anal Pleasure & Health Trainer: Bryan Kutner

Image: International Rectal Microbicide Advocates. http://www.rectalmicrobicides.org

Smarter Sex: Anal Pleasure & Health Trainer: Bryan Kutner

By absolute numbers, more heterosexuals have had anal

For the latest reviews of selected studies, see Baggaley et al.,

Smarter Sex: Anal Pleasure & Health Trainer: Bryan Kutner

Smarter Sex: Anal Pleasure & Health Trainer: Bryan Kutner

Smarter Sex: Anal Pleasure & Health Trainer: Bryan Kutner

Smarter Sex: Anal Pleasure & Health Trainer: Bryan Kutner

Missing population-based samples for most regions

Lacking behavioral frequency

No meta-analysis of global prevalence of anal intercourse

Smarter Sex: Anal Pleasure & Health Trainer: Bryan Kutner

Smarter Sex: Anal Pleasure & Health Trainer: Bryan Kutner

100,000 women engage in

23% of these women were

61% of MSM were likely to

Smarter Sex: Anal Pleasure & Health Trainer: Bryan Kutner

A taboo is a prohibition, often

Smarter Sex: AnalJ. Pleasure

And if we communicate the taboo, then we resign people to expect the

Smarter Sex: Anal Pleasure & Health Trainer: Bryan Kutner

People may eventually use biomedical interventions without

Health workers have to tolerate our bias against anal pleasure

Basic information about anatomy and pleasure is a start

Smarter Sex: Anal Pleasure & Health Trainer: Bryan Kutner

- Keletso Makofane, MSMGF Blog

Smarter Sex: Anal Pleasure & Health Trainer: Bryan Kutner

Smarter Sex: Anal Pleasure & Health Trainer: Bryan Kutner

It is densely packed with

Its erotic regardless of

Smarter Sex: Anal Pleasure & Health Trainer: Bryan Kutner

Two rings of muscle

Smarter Sex: Anal Pleasure & Health Trainer: Bryan Kutner

The anal canal is made of

These two muscles open

Smarter Sex: Anal Pleasure & Health Trainer: Bryan Kutner

The inner sphincter is

Smarter Sex: Anal Pleasure & Health Trainer: Bryan Kutner

Smarter Sex: Anal Pleasure & Health Trainer: Bryan Kutner

Smarter Sex: Anal Pleasure & Health Trainer: Bryan Kutner

When gas or shit leaves the

Smarter Sex: Anal Pleasure & Health Trainer: Bryan Kutner

Journal of Medicine, 349(14), 13601368.

Smarter Sex: Anal Pleasure & Health Trainer: Bryan Kutner