Archives of Sexual Behavior, VoL 15, No.

4, 1986

Hazards Associated with Anal Erotic Activity

Jeremy Agnew 1'2

The recent fiberalization o f attitudes towards sexuality has brought with it

the desire by some individuals to seek alternate methods o f sexual stimula-
tion and gratification, among them an exploration o f anal eroticism. Various
practices associated with anal sexuality carry with them the potential f o r
medical complications. In this paper some o f the hazards associated with
anal eroticism are outlined and potential complications are discussed. Topics
discussed include anal masturbation, enemas, sexually related anorectal disease,
and the hazards o f foreign objects introduced into the rectum. The intent
o f this paper is to provide concerned professionals dealing with various aspects
o f human sexuality with information relevant to anal eroticism.
KEY WORDS: anorectal pathology; enemas; klismaphilia; anal sexuality; sexually transmitted
disease.

INTRODUCTION

With societal attitudes towards sexuality becoming increasingly liberal,

many adults are engaging in sexual experimentation to discover new and alter-
nate methods of sexual stimulation and gratification. Among these methods
are various expressions of anal eroticism. Anatomical, physiological, and
psychosexual aspects of anal eroticism have been described elsewhere (Agnew,
1985) and are not treated here. Rather, this paper focuses on some of the
problems that may occur due to such activity.

IElectromedical Research Consultants, 2110 Wood Avenue, Colorado Springs, Colorado 80907.
2To whom correspondence should be addressed.

307
0004-0002/86/0800-0307505.00/0 © 1986PlenumPublishingCorporation
308 Agnew

FOREIGN OBJECTS

Various objects may be inserted into the anus and rectum to provide
sexual stimulation during heterosexual or homosexual activity or as a part
of anal masturbatory activity. These devices may range in size from quite
small objects, such as standard douche and enema nozzles (Hite, 1982), to
very large objects, such as broom handles or soda bottles (Barone, Sohn,
and Nealon, 1977).
The anus and rectum, unlike the vagina, contain no natural lubricating
function. Thus insertion of unlubricated objects or inadequate dilation of
the anus before insertion of a large object can result in tissue laceration. The
internal and external anal sphincters are elastic rings of muscle which generally
remain tightly constricted except during defecation. The anal sphincters are
also intended for material to pass through them in a direction that leads out
of the body. When an attempt is made to insert something in the reverse
direction, the muscles of the sphincters constrict.
Unlike the vagina, which is lined with stratified squamous epithelium
and is surrounded by a muscular tube intended for penile intromission, the
rectum is lined with a delicate mucosal surface and a single layer of colum-
nar epithelium intended primarily for the reabsorption of water and elec-
trolytes. This structure is incapable of mechanical protection against abrasion
and severe damage to the colonic mucosa can result if objects that are large,
sharp, or pointed are inserted into the rectum, or if objects are inserted high
into the rectum and enter the convolutions of the sigmoid colon.
The rectum above the pectinate line is generally insensitive to pain. Thus
perforation of the colonic wall may occur without the individual being aware
of it at the time. Any such perforation results in peritonitis due to the release
of normal colonic organisms into the abdominal cavity.
It is easy for an individual to lose control of an object inserted into
the anus, especially if the object is well-lubricated and if the individual is
in a state of high sexual arousal. The object may slip up into the rectum,
out of the individual's grasp. Reverse peristaltic waves have been observed
in the intestine (Scott, 1976) and may cause the object to travel high into
the rectum and require medical intervention for removal. It is also not unusual
for the object to be of such a nature that it penetrates the colonic wall and
requires extensive surgical intervention to repair the damage (Barone et al.,
1977).
Though emergency room physicians have in the past had to deal with
transanal removal of objects such as enema nozzles and rectal thermometers
lost in the rectum during self-treatment by individuals, they are now being
called upon to also remove other more unusual objects. Some of these ob-
jects reported in the literature are quite large. Benjamin, Klamecki, and Haft
Hazards of Anal Erotic Activity 309

(1969) reported on the removal of a carborundum sharpening stone, a tur-

nip, a toothbrush holder, a water glass, and a light bulb from the rectums
of patients who had used these objects for anal masturbatory activity. Lucas
and Ryan (1947) reported on the removal of soft-drink bottles, a steer's horn,
cucumbers, apples, hard-boiled eggs, and a broom handle. Other
miscellaneous objects have been a soldering iron handle (Daffner, 1976); a
carbonated beverage bottle (Chenet and Cameron, 1972); a broom handle,
vibrators, bananas, a soda battle, and a large rubber phallus (Barone et al.,
1977); and a salami, carrots, broomsticks, and whip handles (Marino and
Mancini, 1978).
One of the newer variants in anal sexual activity is fist fornication, which
is the practice of inserting the hand, usually up to the wrist, but possibly
even up to the forearm, into the rectum of a sexual partner (Marino and
Mancini, 1978; Sohn and Robilotti, 1977). Though primarily practiced by
male homosexuals, this is also practiced by female homosexuals (Jay and
Young, 1979). The insertion of such a large object as a hand or fist creates
the potential for rupture of the rectum or severe damage to the anus or rec-
tal walls (Sohn, Weinstein, and Gonchar, 1977).

ENEMAS

Enemas may be used as a part of heterosexual or homosexual stimula-

tion or for anal masturbation. Enemas are often used to cleanse the bowel
prior to anal intercourse. However, in addition, some individuals are sex-
ually aroused by giving enemas and some are aroused by receiving them
(klismaphilia). Various aspects of sexually oriented enemas, known to their
devotees as "water sports," have been discussed elsewhere (Agnew, 1982;
Denko, 1973, 1976; Kaplan, 1976).
The obvious hazard related to an enema is potential laceration of the anus
or rectal mucosa due to improper insertion of the enema nozzle (Szunyogh,
1958; Large and Mukheiber, 1956) or possible perforation of the anterior rectal
wall by the nozzle (Roland and Rogers,1959). Enema devotees have been known
to attempt full insertion of a rubber colon tube into their rectum (Denko, 1973).
While this procedure can be performed successfully by trained medical per-
sonnel, it is inadvisable for recreational use due to the potential for perforating
the colonic wall. In particular, it is difficult to successfully round the sharp
curves of the sigmoid colon and the tube, which is 24 inches long, may either
coil up in the rectum or the distal end may perforate the colonic wall if in-
sertion is forced with the distal end of the catheter trapped in a blind pouch
of intestine. Frech and Lanier (1957) list the three most likely causes of rectal
perforation during an enema procedure as (i) using a hard nozzle, instead
310 Agnew

of a soft-rubber rectal tube; (ii) injection pressure being too high; and (iii)
the enema nozzle being inserted with the patient in a sitting position.
Improper techniques for enemas may also be used. It is not unknown
for the end of the tubing to be attached to a faucet instead of to an enema
bag or for the bag to be hung at excessive heights, such as from the top of
a door (Smith and Gips, 1963). Both would lead to excessive injection pressure
and a direct faucet connection would result in uncontrolled water temperature.
Very high pressures and large volumes of enema solution are sometimes in-
jected as part of sadomasochistic practices. Three or 4 quarts, to as much
as 5 quarts, of enema solution may be injected, as opposed to the 1 to 2
quarts usually recommended for a cleansing enema. This practice carries with
it the potential for colonic rupture and the possibility of reflux of colonic
contents and microorganisms into the small intestine through a leaky or
overstressed ileocecal value. Sadomasochistic practices may also involve the
injection of enemas of substances such as dishwashing detergents that are
highly irritating to the colonic mucosa and may cause caustic colitis (Arena,
1964; Kirchner et al., 1977). Hyperemia and increased mucus production have
been noted on proctoscopy following chemically irritant enema solutions
(Tillery and Bates, 1966). Egdell and Johnson (1973) reported on the case
of a 23-year-old woman who developed hypotension and erythema follow-
ing an enema of castile soap in water. Acute colitis following soapsuds enemas
has been reported by Barker (1945) and Patterson (1951).
Large volume or repeated tap-water enemas may cause water intoxica-
tion due to colonic absorption and the alteration of circulating blood volume.
Symptoms may include weakness, pallor, vomiting, dizziness, and sweating
(Fuerst, Wolff, and Weitzel, 1974; Hiatt, 1951). More severe reactions in-
clude shock, coma, and convulsions (Ziskind and Gellis, 1958). Colonic ir-
rigations, which generally use several gallons of water flowing in and out
of the bowel, have been reported to cause abdominal distention and cramps,
nausea, epigastric distress, weakness, and fainting (Patterson, 1951). Repeated
tap-water enemas can result in significant hypokalemia (Dunning and Plum,
1956). Simodynes (1981) described a man who went into preoperative shock
for no apparent reason. Upon investigation it was found that he had been
giving himself enemas that produced results similar to a series of colonic ir-
rigations. He had, in effect, been rectally dialyzing himself, which resulted
in severe hypocalcemia and hypokalemia.
Various intoxicants, such as beer or wine, or hallucinogens, such as
peyote, may be injected into the body in the form of an enema. Due to the
absorptive function of the colonic mucosa, alcohol is absorbed very rapidly
into the bloodstream by this route. This can lead to a fast onset of intoxica-
tion and possible overdose if administered too rapidly or in a concentrated
form, such as distilled spirits. Rectally injected intoxicants or hallucinogens
Hazards of Anal Erotic Activity 311

closely resemble intravenous injections in rapidity of effects (Furst and Coe,

1977).

ANORECTAL DISEASES

Sexually transmitted diseases (STDs) are not restricted to the genitals.

Most common STDs, as well as some specialized ones due to intestinal
pathogenic organisms, may be transmitted via anal erotic activity.
Gonorrhea: Rectal gonorrhea may be contracted via anal intercourse,
both by women engaging in heterosexual anal intercourse and more com-
monly by men engaging in homosexual relations (Hyde, 1982; Marino and
Mancini, 1978). Symptoms may include itching and discharge from the rec-
tum, but the disease may also be asymptomatic.
Syphilis: If anal intercourse has occurred with an infected person, the
spirochete can penetrate the mucus membrane of the rectum and a syphilitic
chancre may appear around the anus (Owen, 1983).
Anogenital Herpes: Anal intercourse with an infected person may cause
the development of small painful bumps or blisters around the anus. This
is usually caused by the Type II Herpes simplex virus (Hyde, 1982; Owen,
1983).
AIDS: Autoimmune disturbances may be induced via anal activity.
AIDS is probably caused by multiple factors, but the presence of semen in
the colon and subsequent penetration into the vascular bed of the rectal
mucosa following anal intercourse has recently been implicated in male
homosexuals as a possible source of the human T-cell lymphotropic (HTLV
III) virus, the probable cause of AIDS (Sonnabend, Witkin, and Purtilo,
1983).
Pathogenic Organisms: Anal activity can lead to transmission of enteric
pathogens by several different methods. Giardia lamblia, entamoeba
histolytica, shigella, or salmonella infections may result from oral-anal or
penile-anal activity. The obvious cause is the transmission of intestinal
organisms from the rectum to the vagina, with the development of subse-
quent vaginitis, due to engaging in vaginal intercourse immediately follow-
ing anal intercourse without adequately cleansing the penis. The same transfer
of organisms may also occur after manual stimulation of the anus or inser-
tion of a finger into the rectum, followed by clitoral stimulation or insertion
of the finger into the vagina without washing the hands.
Less obvious modes of transmission of infection are from person to per-
son via inadequately cleaned dildos used by different individuals for anal
penetration, or from anal and then vaginal penetration by the same person;
via inadequately cleaned enema equipment used by different individuals; and
312 Agnew

via combination syringes used for both enemas and vaginal douching either
by different individuals or by the same individual. These last two causes are
not uncommon and may be unrelated to sexual activity. Reverse pressure
caused by peristalsis in the intestine during an enema may result in intestinal
organisms being forced out of the rectum back into the syringe and result
in contamination of the enema bag and tubing (Merrill, 1967; Meyers, 1960;
Steinbach et al., 1960). These organisms can be transmitted rectally to another
person using the same enema equipment or can be transmitted from rectum
to vagina in the same person if the syringe is used both for enemas and vaginal
douching. Istre et al. (1982) reported on a series of illnesses and deaths in
a chiropractic clinic caused by the transmission of amebiasis between in-
dividuals on an inadequately cleaned colonic irrigation apparatus.
Colonic Irritation: Frequent rectal sexual activity, either from repeated
anal intercourse, frequent enemas, or continued insertion of foreign objects
into the anus and rectum, can lead to a variety of anorectal symptoms in-
cluding diarrhea, excessive mucus production, anorectal pain, tenesmus, in-
testinal cramps, flatus, bloody discharge, purulent discharge, blood in the
stools, anorectal laceration, anal or rectal ulcers, anal fissures, pruritus
ani, and varying degrees of rectal prolapse. Collectively many of these symp-
toms have been termed the "gay bowel syndrome" (Sohn and Robilotti, 1977).
Miscellaneous: Various other problems may be transmitted by anal sex-
ual activity, including streptococcal and meningococcal infections, anal warts,
cytomegalovirus, helminths, and hepatitis A and B virus (Owen, 1983).
Allergic proctitis can be caused by substances, such as soaps, sham-
poos, suntan lotions, or medicinal creams that may be used as lubricants
during anal intercourse (Owen, 1983). Even K-Y Lubricating Jelly, a substance
intended and commonly used for douche and enema tube lubrication, has
been known to cause contact allergy (Fisher and Brancaccio, 1979).
There may be continued rectal leakage of fecal material, mucus, and
moisture due to inadequate closure of the anal sphincters caused by repeated
anal insertion of large objects stretching the sphincter muscles. This leakage
may be a causitive factor in pruritus ani (Sullivan and Garnjobst, 1978).
Anal sexual activity, such as frequent anal intercourse or enemas, may
be a causative factor in hemorrhoids or may aggravate existing hemorrhoids
(Rowan and Gillette, 1978).

CONCLUSION

Even though anal sexual activity may be a relatively harmless exten-

sion of human sexual practices, it carries with it the potential for serious
consequences. Thus it is important for individuals engaging in such activity
Hazards of Anal Erotic Activity 313

and for professionals dealing with these individuals to have an understand-

ing of all the aspects and consequences of this variant in human sexual
behavior.

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