Less Silence, More Science: Making Anal Sex Safer

Marc-Andre LeBlanc

One of the dangerous silences of global HIV prevention efforts has been the neglect of anal intercourse between women and men as well as the HIV prevalence among gay men and other men who have sex with men in Asia, Africa and other parts of the developing world.

When we think about anal intercourse – and many women and men think about it, and do it, much more often than anyone is willing to admit – we tend to assume that we're talking about gay men at risk for HIV in the Global North.

It's true that anal intercourse is a widely practiced behavior among gay men and other men who have sex with men, with the vast majority (95%) of gay men in the United States reporting having engaged in anal intercourse. But in absolute numbers, seven times more heterosexual women than gay men in the US practice receptive anal intercourse.

In many parts of the world, including North America, Latin America, Western Europe, Australia and New Zealand, unprotected anal intercourse is recognized as a significant driver of the HIV pandemic. But one of the dangerous silences of global HIV prevention efforts has been the neglect of anal intercourse between women and men as well as the HIV prevalence among, and indeed, the very existence of, gay men and other men who have sex with men in Asia, Africa and other parts of the developing world.

This neglect costs lives.

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This neglect costs the lives of gay men and other men who have sex with men. Studies have shown that in many parts of Latin America, Africa and Asia, rates of HIV prevalence among gay men and other men who have sex with men are significantly higher than in the general population. In many parts of the developing world, these men and anal sex are highly stigmatized, widely criminalized, and virtually ignored in HIV prevention efforts.

And this neglect costs women's lives, and the lives of men who have sex with women. While rarely discussed in the scientific literature, anal intercourse is increasingly understood as a relatively common practice among heterosexual couples. In the US and UK, between 10% and 35% of heterosexual women report practicing receptive anal intercourse. Lifetime reports of anal intercourse with opposite-sex partners are as high as 40% for US males. Anal intercourse between men and women has been linked to HIV infection in many parts of the world.

Globally, almost all anal intercourse is unprotected. We are more than 26 years into the HIV pandemic, and the receptive partners during anal sex still have no prevention options they can control.

Hope on the Horizon

Appalled at this state of affairs, a group of advocates and researchers have come together to form International Rectal Microbicide Advocates (IRMA). IRMA is a global network of over 600 advocates, policy-makers and leading scientists from 40 countries on six continents forging a robust rectal microbicide research and development agenda.

Currently in development, rectal microbicides are products that could be available in the form of a cream, gel, douche or enema, that may be used to protect against HIV transmission when used during anal intercourse.

International Rectal Microbicide Advocates (IRMA) released Less Silence, More Science: Advocacy to Make Rectal Microbicides in February 2008, at the Microbicides 2008 conference. The report serves as an authoritative reference on rectal microbicide research, and describes global challenges, and key advocacy goals and strategies.

The Current State of Research

Rectal microbicide research is more robust in 2008 than it has ever been, but it is still woefully underfunded. In 2006, only $7 million per year was invested globally in rectal microbicides research. It is conservatively estimated that it will cost at minimum $350 million over the next 10 to 15 years, or roughly $35 million a year to develop a comprehensive rectal microbicide research program. Annual spending needs to increase five-fold to ensure timely discovery and development of a rectal microbicide.

In 2007, IRMA conducted the world's largest survey on anal sex. The purpose of the web-based survey was to gather data on the types of lubricants people use, as well as preferred lube characteristics. Almost 9,000 people responded from 107 countries. The survey showed that a rectal microbicide formulated as a lubricant provides an excellent opportunity to provide protection to those who engage in anal intercourse. Indeed, a rectal microbicide formulated as a lube would probably be highly acceptable, especially if it has no flavor, color or smell, and is available in both thick and liquid consistencies, and with the option of a water or silicone base. The survey also showed that when testing lubricant products for rectal safety and testing candidate rectal microbicides for safety and efficacy, researchers should consider the implications of other substances (saliva, water, vaginal fluid) added to the product.

Getting Things Done

With the promise of widespread acceptance of a lubricant rectal microbicide in hand, IRMA will accelerate research by mapping out the key areas requiring urgent attention to move rectal microbicides research forward; by advocating for a five-fold increase in rectal microbicides funding; by encouraging the testing of commercial lubricants for rectal safety; and by advocating for increased research into global anal intercourse. IRMA will also seek to ensure rectal safety of vaginal microbicides and to integrate rectal microbicides into broader prevention efforts.

For more information on IRMA and rectal microbicides, including a copy of the report, please consult visit this site. You can also sign up for IRM's listserv, and check their blog for more news and updates.

Roundups Sexuality

This Week in Sex: Why Men Fake Orgasms and How Real Ones May Help Them Avoid Prostate Cancer

Martha Kempner

Many men pretend to have orgasms to make their partners feel better—and report higher levels of sexual satisfaction, at the same time. Another study suggests that the more ejaculation, the better if men want to reduce their prostate cancer risk. And there may be more help for women with sexual arousal problems.

This Week in Sex is a weekly summary of news and research related to sexual behavior, sexuality education, contraception, STIs, and more.

When Men “Fake It,” Their Motives Are Often Altruistic 

In the pilot episode of the TV show Masters of Sex, Dr. William Masters seems shocked to learn that women might fake orgasms. When he asks his new assistant, Virginia Johnson (who becomes his research partner and later his wife), why women might do such a thing, she replies: “To get a man to climax quickly. Usually so the woman can get back to whatever it is she’d rather be doing.”

Masters and Johnson, whose real-life work and relationship was fictionalized in that Showtime series, were pioneers of sex research in the 1950s and 1960s. Those who follow in their footsteps today are still trying to answer some of the same questions.

A new study from two Canadian researchers looks not at why women fake orgasms, but why men do—and what, if any, correlation there is between faking it and relationship satisfaction.

Researchers surveyed 230 young men between ages 18 and 29 who had admitted to faking an orgasm at least once in their current relationship. Using an online survey, they asked these men at what point in their relationship they began to fake orgasms, how often they did so, and why. They also measured sexual desire and relationship satisfaction.

On average, the men began faking orgasms 14 months into the relationship. On average, the men said they faked an orgasm in about 30 percent of their sexual encounters; 71 percent of participants reported having faked an orgasm during penile-vaginal intercourse; 27 percent during oral sex; 22 percent during anal intercourse; 18 percent during manual stimulation by a partner; and 5 percent while being stimulated with a sex toy by a partner.

Many of the reasons the men gave for faking orgasm revolved around making their partners feel better—including giving their partner an ego boost, feigning simultaneous orgasms, or avoiding upsetting their partner.

Interestingly, men who faked it for these relationship reasons tended to report higher levels of sexual desire. The authors theorize, “It is possible that men feel good when giving a partner pleasure, either out of love and generosity, or because it provides indirect reassurance of their own sexual adequacy, leading them to associate this reward with sexual activity, further leading them to seek more sex (i.e., experience higher levels of sexual desire).”

Men who faked orgasms also had higher levels of relationship satisfaction, though the authors point out that pretending might not lead to relationship satisfaction; those who are already satisfied may be more likely to fake orgasms for the sake of their partner’s feelings.

While it’s reassuring to know that some men fake orgasms for altruistic reasons, we here at This Week in Sex are not big fans of the fake orgasm, regardless of the gender or the reason. Once in a while is understandable “to get back to whatever it is [you’d] rather be doing,” as Johnson said. But, for the most part, we think it’s better to talk to partners about why you didn’t have a real one this time and what could be different next time.

Is Frequent Ejaculation a Cancer Prevention Method? 

Another new study found that men who ejaculated more frequently were less likely to be diagnosed with prostate cancer. Researchers followed about 32,000 men for almost 20 years, using the national Health Professionals Follow-up Study  at the Harvard School of Public Health. The men were all in their 20s when the study started in 1992 and therefore their 40s (or close to it) when it ended in 2010. They filled out questionnaires that asked about their sexual behavior (including masturbation), and researchers also looked at the men’s medical records.

During the course of the study, about 4,000 of the men were diagnosed with prostate cancer. The researchers’ analysis showed that men who ejaculated at least 21 times a month in their 20s were 19 percent less likely to be diagnosed with prostate cancer than men who ejaculated no more than seven times a month at that age. Similarly, men who ejaculated more often in their 40s were 22 percent less likely to be diagnosed with prostate cancer diagnosis.

There are some limitations of the study, including the possible inaccuracy of self-reported data on ejaculation and the lack of diversity among participants. In addition, one urologist who spoke to Reuters questioned the fact that the relationship between ejaculation and prostate cancer applied mostly to less invasive forms of the disease. Dr. Behfar Ehdaie of the Memorial Sloan Kettering Cancer Center in New York, who was not part of the study, noted: “If ejaculation frequency was truly a causal factor for prostate cancer development, we would expect to find the association across all prostate cancer risk categories.”

And, of course, correlation does not equal causation. There could be other reasons that men who ejaculate less often are more likely to get prostate cancer. Specifically, as study co-author Dr. Jennifer Rider points out, men who ejaculate less than three times a month may be suffering from other health issues.

Still, there could be a prevention strategy in the findings. Rider told Reuters in an email: “The results of our study suggest that ejaculation and safe sexual activity throughout adulthood could be a beneficial strategy for reducing the risk of prostate cancer.”

Given that ejaculation tends to be enjoyable, it seems like a pretty good idea to try even while more research into the correlation is being conducted.

Emerging Options for Women With Sexual Arousal Issues

When the drug Addyi was under development, people referred to it as “female Viagra” because it was intended to address women’s sexual dysfunction. But the two treatments actually work very differently. While Viagra causes an erection by increasing blood flow to the penis, Addyi (or flibanserin) works on chemicals in the brain to increase sexual desire.

Now, researchers are developing a new treatment for women that is actually much more similar to Viagra. A company called Creative Medical Technologies filed a patent last week for a treatment that uses regenerative stem cells to increase blood flow to the vagina. Unlike Addyi, this treatment is designed for women who desire sex but are having trouble becoming aroused. Increasing blood flow to the vagina can cause the clitoris to become erect and the vagina to lubricate, both of which are important parts of the arousal stage of sexual response.

The treatment still needs more research and, of course, FDA approval, which was a very controversial process for Addyi’s maker. Moreover, it’s not clear how big the market is for female sexual dysfunction treatment, as prescriptions for Addyi have been low since its market release last October.

Roundups Sexual Health

This Week in Sex: News From the HIV Epidemic

Martha Kempner

This week in sex: Scientists report the first case of HIV transmission to a patient adhering to PrEP protocols, two studies show a new vaginal ring can help women prevent HIV, and young people still aren't getting tested for the virus.

This Week in Sex is a weekly summary of news and research related to sexual behavior, sexuality education, contraception, STIs, and more.

With the death of Nancy Reagan, the 1980s AIDS crisis is back in the national spotlight. But, of course, HIV and AIDS are still ongoing problems that affect millions of people. This week in sex, we review scientists reporting the first case of HIV transmission to a patient adhering to PrEP protocols, two studies showing a new vaginal ring can help women prevent HIV, and evidence that young people still aren’t getting tested for the virus.

First Case of HIV Transmission While on Truvada

Last week, Canadian scientists reported on what they believe to be the first HIV infection in a patient who was following a PreP (Pre-Exposure Prophylaxis) regimen.

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PrEP is a method of HIV prevention. By taking a daily pill that contains two HIV medicines, sold under the name Truvada, individuals who are HIV-negative but considered to be at high risk of contracting the virus can prevent infection. Studies have found that PrEP is very effective—the Centers for Disease Control and Prevention estimates that people who take the medication every day can reduce their risk of infection by more than 90 percent from sex and by more than 70 percent from injection drug use. One study of men taking PrEP found no infections over a two-and-a-half-year period.

PrEP is less effective when not taken regularly, but the new case of reported PrEP failure involves a 43-year-old man who said that he took his medication daily. His pharmacy records back up that assertion. The man’s partner has HIV, but is on a drug regimen and has an undetectable viral load. The man did report other sexual encounters without condoms with casual partners in the weeks leading up to his diagnosis.

Dr. David Knox, the lead author of this case study, notes that it is difficult to know if a patient really did adhere to the drug regimen, but the evidence in this case suggests that he did. He concluded, “Failure of PrEP in this case was likely due to the transmission of a PrEP-resistant, multi-class resistant strain of HIV 1.”

Experts say, however, that they never expected PrEP to be infallible. As Richard Harrigan of the British Columbia Center for Excellence in HIV/AIDS told Pink News, “I certainly don’t think that this is a situation which calls for panic …. It is an example that demonstrates that PrEP can sometimes be ineffective in the face of drug resistant virus, in the same way that treatment itself can sometimes be ineffective in the face of drug resistant virus.”

Still, some fear that the new study will add to the ongoing debate and apathy that seem to surround PrEP. While some experts see it as a must-have prevention tool, others worry that it will encourage men who have sex with men to forgo using condoms and perhaps increase their risk for other sexually transmitted infections. Still, only 30,000 people in the United States are taking the drug—an estimated one-twentieth of those who could benefit from it.

A New Vaginal Ring Could Help Women Prevent HIV Infection

Researchers have announced promising results from two studies looking at new technology that could help women prevent HIV. The dapivirine ring, named after the drug it contains, was developed by the International Partnership for Microbicides. It looks like the contraceptive ring, Nuvaring, and is similarly inserted high up into the vagina for a month at a time. Instead of releasing hormones to prevent ovulation, however, this ring releases an antiretroviral drug to prevent HIV from reproducing in healthy cells. (A ring that could prevent both pregnancy and HIV is being developed.)

The two studies of the ring are being conducted in Africa. One study recruited about 2,600 women in Malawi, South Africa, Uganda, and Zimbabwe. It found that the ring reduced HIV infection by 27 percent overall and 61 percent for women over age 25. The other study, which is still underway, involves just under 2,000 women in seven sites in South Africa and Uganda. Early results suggest that the ring reduced infection by 31 percent overall when compared to the placebo.

Both studies found that the ring provided little protection to women ages 18-to-21. Researchers are now working to determine how adherence and other biological factors may have impacted such an outcome.

Young People Not Getting Tested for HIV

A study in the February issue of Pediatrics found that HIV testing rates among young people have not increased in the last decade. The researchers looked at data from the Youth Risk Behavior Survey (YRBS), which asks current high school students about sexual behaviors in addition to questions about drugs and alcohol, violence, nutrition, and personal safety (such as using bike helmets and seat belts). Specifically, the YRBS asks students if they’ve ever been tested for HIV.

Using YRBS data collected between 2005 and 2013, the researchers estimated that 22 percent of teens who had ever had sex had been tested for HIV. The percent who had received HIV tests was higher (34 percent) among those who reported four or more lifetime partners. Overall, male teens (17 percent) were less likely than their female peers (27 percent) to have been tested.

Researchers also looked at data from the Behavioral Risk Factor Surveillance System, which asks similar questions to young adults ages 18 to 24. Among people in this age group, between the years of 2011 to 2013, an average of 33 percent had ever been tested. This review of data also found that the percentage of young women who get tested for HIV has been decreasing in recent years—from 42.4 percent in 2011 to 39.5 percent in 2013.

The authors simply conclude, “HIV testing programs do not appear to be successfully reaching high school students and young adults.” They go on to suggest, “Multipronged testing strategies, including provider education, system-level interventions in clinical settings, adolescent-friendly testing services, and sexual health education will likely be needed to increase testing and reduce the percentage of adolescents and young adults living with HIV infection.”