Abstract
The ability to experience pleasurable sexual activity is important for human health. Receptive anal intercourse (RAI) is a common, though frequently stigmatized, pleasurable sexual activity. Little is known about how diseases of the colon, rectum, and anus and their treatments affect RAI. Engaging in RAI with gastrointestinal disease can be difficult due to the unpredictability of symptoms and treatment-related toxic effects. Patients might experience sphincter hypertonicity, gastrointestinal symptom-specific anxiety, altered pelvic blood flow from structural disorders, decreased sensation from cancer-directed therapies or body image issues from stoma creation. These can result in problematic RAI — encompassing anodyspareunia (painful RAI), arousal dysfunction, orgasm dysfunction and decreased sexual desire. Therapeutic strategies for problematic RAI in patients living with gastrointestinal diseases and/or treatment-related dysfunction include pelvic floor muscle strengthening and stretching, psychological interventions, and restorative devices. Providing health-care professionals with a framework to discuss pleasurable RAI and diagnose problematic RAI can help improve patient outcomes. Normalizing RAI, affirming pleasure from RAI and acknowledging that the gastrointestinal system is involved in sexual pleasure, sexual function and sexual health will help transform the scientific paradigm of sexual health to one that is more just and equitable.
Key points
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Receptive anal intercourse (RAI) is common worldwide.
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Pleasurable RAI occurs through stimulation of the perianal or anal nerves and prostate or paraurethral glands, inducing vasodilation, erectile tissue engorgement, anopelvic tissue sensitization, and anal sphincter and pelvic muscular contractions.
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Patients with a stoma and anorectal stump should be counselled on hygiene and dilator use to minimize infections, maintain anorectal patency, and prevent a permanent stoma, promoting RAI restoration.
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Antidiarrhoeals, anti-flatulence medications, fibre supplements, lower residue diet to control regularity, avoiding spicy foods, timing meals, and defecation prior to RAI can help control symptoms and relieve distress.
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Survivors of anal, rectal, and colon cancer and patients with gastrointestinal disease should be counselled on problematic RAI due to anal sphincter, neurovasculature, and prostate or paraurethral gland damage resulting in arousal dysfunction, anodyspareunia or orgasm dysfunctions.
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Management strategies, including anal dilators for anodyspareunia, anal vibrators for arousal disorders, pelvic floor strengthening for anorgasmia and psychological interventions for decreased desire, should be discussed with patients.
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References
World Health Organization. Sexual and Reproductive Health and Research (SRH). Including the Human Reproduction Special Programme (HRP). WHO https://www.who.int/teams/sexual-and-reproductive-health-and-research-(srh)/overview (2023).
Ford, J. V. et al. The world association for sexual health’s declaration on sexual pleasure: a technical guide. Int. J. Sex. Health 33, 612–642 (2021).
Dewitte, M. & Reisman, Y. Clinical use and implications of sexual devices and sexually explicit media. Nat. Rev. Urol. 18, 359–377 (2021).
Dickstein, D. R. et al. Sexual health and treatment-related sexual dysfunction in sexual and gender minorities with prostate cancer. Nat. Rev. Urol. 20, 332–355 (2023).
Kutner, B. A., Simoni, J. M., DeWitt, W., Gaisa, M. M. & Sandfort, T. G. M. Gay and bisexual men who report anal sex stigma alongside discomfort discussing anal sex with health workers are less likely to have ever received an anal examination or anal swab. LGBT Health 9, 103–113 (2022).
Kutner, B. A., Wu, Y., Balán, I. C. & Meyers, K. “Talking about it publicly made me feel both curious and embarrassed”: acceptability, feasibility, and appropriateness of a stigma-mitigation training to increase health worker comfort discussing anal sexuality in HIV services. AIDS Behav. 24, 1951–1965 (2020).
Human Rights Watch. World Report 2022: Events of 2021 (Human Rights Watch, 2022).
Bhandari, A. Uganda’s anti-gay bill is the latest and worst to target LGBTQ Africans. Reuters https://www.reuters.com/graphics/UGANDA-LGBT/movakykrjva/ (2023).
Mendos, L. R., Botha, K., Carrano Lelis, R., López de la Peña, E., Savelev, I. & Tan, D. State-sponsored Homophobia. Global Legislation Overview Update. ILGA https://www.ecoi.net/en/file/local/2044751/ILGA_World_State_Sponsored_Homophobia_report_global_legislation_overview_update_December_2020.pdf (2020).
Garros, A. et al. Risk of fecal incontinence following receptive anal intercourse: survey of 21,762 men who have sex with men. J. Sex. Med. 18, 1880–1890 (2021).
Meuwly, M., Auderset, D., Stadelmann, S., Suris, J. C. & Barrense-Dias, Y. Anal intercourse among heterosexual young adults: a population-based survey in Switzerland. J. Sex. Res. 58, 1061–1068 (2021).
Magno, L. et al. Gender-based discrimination and unprotected receptive anal intercourse among transgender women in Brazil: a mixed methods study. PLoS ONE 13, e0194306 (2018).
Kumar, B. & Ross, M. W. Sexual behaviour and HIV infection risks in Indian homosexual men: a cross-cultural comparison. Int. J. STD AIDS 2, 442–444 (1991).
McBride, K. R. Heterosexual women’s anal sex attitudes and motivations: a focus group study. J. Sex. Res. 56, 367–377 (2019).
Wheldon, C. W. et al. Unrecognized sexual dysfunction in gay and bisexual men after prostate cancer treatment: the antecedents and impact of anodyspareunia. J. Sex. Med. 20, 515–524 (2023).
Maierhofer, C. N., Lancaster, K. E. & Turner, A. N. Anal sex is more common than having a twitter account in the United States. Sex. Transm. Dis. 45, 783–785 (2018).
Caballero-Hoyos, R., Monárrez-Espino, J., Ramírez-Ortíz, M. G. & Cárdenas-Medina, F. M. Factors associated with unprotected anal sex among men who have sex with men in Mexico. Infect. Dis. Rep. 14, 547–557 (2022).
Meng, X. et al. Relative risk for HIV infection among men who have sex with men engaging in different roles in anal sex: a systematic review and meta-analysis on global data. AIDS Behav. 19, 882–889 (2015).
Galea, J. T. et al. Rectal douching prevalence and practices among peruvian men who have sex with men and transwomen: implications for rectal microbicides. AIDS Behav. 20, 2555–2564 (2016).
Carlos, S. et al. Heterosexual oral and anal sex in Kinshasa (D.R.Congo): data from OKAPI prospective cohort. PLoS ONE 14, e0210398 (2019).
Morhason-Bello, I. O. et al. Heterosexual oral and anal sex: perceptions, terminologies, and attitudes of younger and older adults in Ibadan, Nigeria. Arch. Sex. Behav. 52, 161–175 (2023).
Mazeingia, Y. T., Olijjira, L. & Dessie, Y. Anal sexual experience and HIV risk awareness among female sex workers in Dire Dawa, eastern Ethiopia. Glob. Health Res. Policy 2, 27 (2017).
Hirst, J., Pickles, J., Kenny, M., Beresford, R. & Froggatt, C. A qualitative exploration of perceptions of anal sex: implications for sex education and sexual health services in England. Cult. Health Sex. 25, 241–255 (2023).
Xia, D. et al. Psychosocial problems and condomless anal sex among transgender women in two cities of China: study based on the syndemic framework. Int. J. Environ. Res. Public Health 19, 16161 (2022).
Parchem, B., Aguayo-Romero, R. A., Alizaga, N. M., Poppen, P. J. & Zea, M. C. Sexual role identity and anal sex positioning among Brazilian, Colombian, and Dominican immigrant sexual minority men. J. Sex. Res. 59, 632–642 (2022).
Ybarra, M., Price-Feeney, M. & Mwaba, K. Prevalence and correlates of anal sex among secondary school students in Cape Town, South Africa. AIDS Care 30, 821–829 (2018).
Dangerfield, D. T. II, Gravitt, P., Rompalo, A. M., Tai, R. & Lim, S. H. Correlates of anal sex roles among Malay and Chinese MSM in Kuala Lumpur, Malaysia. Int. J. STD AIDS 27, 313–320 (2016).
Hensel, D. J., von Hippel, C. D., Lapage, C. C. & Perkins, R. H. Women’s techniques for pleasure from anal touch: results from a U.S. probability sample of women ages 18–93. PLoS ONE 17, e0268785 (2022).
Geynisman-Tan, J. et al. Anal penetrative intercourse as a risk factor for fecal incontinence. Female Pelvic Med. Reconstr. Surg. 24, 252–255 (2018).
Bailey, J. V., Farquhar, C., Owen, C. & Whittaker, D. Sexual behaviour of lesbians and bisexual women. Sex. Transm. Infect. 79, 147–150 (2003).
Clements-Nolle, K., Marx, R., Guzman, R. & Katz, M. HIV prevalence, risk behaviors, health care use, and mental health status of transgender persons: implications for public health intervention. Am. J. Public Health 91, 915–921 (2001).
Nemoto, T., Operario, D., Keatley, J., Han, L. & Soma, T. HIV risk behaviors among male-to-female transgender persons of color in San Francisco. Am. J. Public Health 94, 1193–1199 (2004).
Bauer, G. R., Travers, R., Scanlon, K. & Coleman, T. A. High heterogeneity of HIV-related sexual risk among transgender people in Ontario, Canada: a province-wide respondent-driven sampling survey. BMC Public Health 12, 292 (2012).
Reyes, A. P., León, N. Y., Frost, E. R. & Harley, V. R. Genetic control of typical and atypical sex development. Nat. Rev. Urol. 20, 434–451 (2023).
Berger, I., Ansara, Y. G. & Riggs, D. Intersex people’s experiences of medical interventions, sex education, and physical intimacy. Psychol. Sex. https://doi.org/10.1080/19419899.2023.2252446 (2023).
Dodge, B. et al. Sexual behaviors of U.S. men by self-identified sexual orientation: results from the 2012 national survey of sexual health and behavior. J. Sex. Med. 13, 637–649 (2016).
Branfman, J., Stiritz, S. & Anderson, E. Relaxing the straight male anus: decreasing homohysteria around anal eroticism. Sexualities 21, 109–127 (2018).
Phillips, T. R. et al. Oral, vaginal and anal sexual practices among heterosexual males and females attending a sexual health clinic: a cross-sectional survey in Melbourne, Australia. Int. J. Env. Res. Public Health 18, 12668 (2021).
Branson, R. Anal Sex Statistics, 2024. International Union of Sex Workers https://www.iusw.org/anal-sex-statistics/ (2024).
Goldstein, E. How often Americans have anal sex. Future Method https://futuremethod.com/blogs/the-science-of-sex/statistics-on-american-anal-sex-habits (2019).
Williams, D. J., Coto, L. & Berkowitz, D. “It’s absolutely intense, and I love it!” a qualitative investigation of “pegging” as leisure. Leisure Sci. https://doi.org/10.1080/01490400.2023.2226669 (2023).
Marshall, D. C. et al. Female erectile tissues and sexual dysfunction after pelvic radiotherapy: a scoping review. CA Cancer J. Clin. 21, 353–359 (2022).
Dickstein, D. R. & Marshall, D. C. Top, bottom or vers? Creating a more equitable health system for sexual and gender minority patients with prostate cancer. Nat. Rev. Urol. 19, 321–322 (2022).
Wallington, D. G. & Holliday, E. B. Preparing patients for sexual dysfunction after radiation for anorectal cancers: a systematic review. Pract. Radiat. Oncol. 11, 193–201 (2021).
Perez de Arce, E., Quera, R., Ribeiro Barros, J. & Yukie Sassaki, L. Sexual dysfunction in inflammatory bowel disease: what the specialist should know and ask. Int. J. Gen. Med. 14, 2003–2015 (2021).
Romano, L. et al. Erectile and sexual dysfunction in male and female patients with celiac disease: a cross-sectional observational study. Andrology 10, 910–918 (2022).
Shafik, A. & El-Sibai, O. The anocavernosal erectile dysfunction syndrome. II Anal fissure and erectile dysfunction. Int. J. Impot. Res. 12, 279–283 (2000).
Keller, J. J. & Lin, H. C. Haemorrhoids are associated with erectile dysfunction: a population-based study. Int. J. Androl. 35, 867–872 (2012).
Averyt, J. C. & Nishimoto, P. W. Addressing sexual dysfunction in colorectal cancer survivorship care. J. Gastrointest. Oncol. 5, 388–394 (2014).
Joseph, K. et al. Patient reported quality of life after helical IMRT based concurrent chemoradiation of locally advanced anal cancer. Radiother. Oncol. 120, 228–233 (2016).
Gana, T. & Hunt, L. M. Young women and anal sex. BMJ 378, o1975 (2022).
Chen, E., Dickstein, D. R., Kim, U., Zaorsky, N. & Sanghvi, P. Inclusion of sexual orientation and gender identity in clinical trials is necessary for health equity. Int. J. Radiat. Oncol. Biol. Phys. 116, 118–121 (2023).
Mendez, L. C., Hsieh, E., Earle, C. C. & Wong, S. Synchronous anal canal carcinoma in a heterosexual couple. BMC Cancer 18, 884 (2018).
Benson, A. B. et al. Anal carcinoma, version 2.2023, NCCN clinical practice guidelines in oncology. J. Natl Compr. Cancer Netw. 21, 653–677 (2023).
Wheldon, C. W., Sykes, K. J., Ramaswamy, M., Bass, S. B. & Collins, B. N. Integrating HPV vaccination within prep care delivery for underserved populations: a mixed methods feasibility study. J. Commun. Health 48, 640–651 (2023).
Romano, L. et al. Sexual dysfunction in gastroenterological patients: do gastroenterologists care enough? A nationwide survey from the Italian Society of Gastroenterology (SIGE). Dig. Liver Dis. 54, 1494–1501 (2022).
Liot, E. et al. Patients’ related sexual outcomes in colorectal surgery. Front. Oncol. 12, 968978 (2022).
Mercer, C. H. et al. Changes in sexual attitudes and lifestyles in Britain through the life course and over time: findings from the National Surveys of Sexual Attitudes and Lifestyles (Natsal). Lancet 382, 1781–1794 (2013).
Rissel, C. et al. Heterosexual experience and recent heterosexual encounters among Australian adults: the Second Australian Study of Health and Relationships. Sex. Health 11, 416–426 (2014).
de Visser, R. O., Smith, A. M., Rissel, C. E., Richters, J. & Grulich, A. E. Sex in Australia: heterosexual experience and recent heterosexual encounters among a representative sample of adults. Aust. N. Z. J. Public. Health 27, 146–154 (2003).
Ipsos. LGBT+ Pride 2021 Global Survey. Ipsos https://www.ipsos.com/sites/default/files/ct/news/documents/2021-06/lgbt-pride-2021-global-survey-ipsos.pdf (2021).
Ipsos. LGBT+ Pride 2023. Ipsos https://www.ipsos.com/sites/default/files/ct/news/documents/2023-05/Ipsos%20LGBT%2B%20Pride%202023%20Global%20Survey%20Report%20-%20rev.pdf (2023).
Jones, J. M. U.S. LGBT Identification Steady at 7.2%. Gallup https://news.gallup.com/poll/470708/lgbt-identification-steady.aspx#:~:Text=Story%20Highlights&Text=Learn%20more%20in%20Gallup’;s%202024,in%202022%2C%20at%207.2%25 (2023).
Buston, K. & Hart, G. Heterosexism and homophobia in Scottish school sex education: exploring the nature of the problem. J. Adolesc. 24, 95–109 (2001).
Hollows, K. Anodyspareunia: a novel sexual dysfunction? An exploration into anal sexuality. Sex. Relatsh Ther. 22, 429–443 (2007).
Kutner, B. A., Simoni, J. M., Aunon, F. M., Creegan, E. & Balán, I. C. How stigma toward anal sexuality promotes concealment and impedes health-seeking behavior in the U.S. among cisgender men who have sex with men. Arch. Sex. Behav. 50, 1651–1663 (2021).
Parent, M. C. & Wille, L. Heterosexual self-presentation, identity management, and sexual functioning among men who have sex with men. Arch. Sex. Behav. 50, 3155–3162 (2021).
Crowhurst, M. Heteroprivilegism: three layers of discriminatory practices that target non-heterosexual subjects. NJ 26, 21–34 (2002).
Quatrini, A. On social injustice and word creation on the web, 2020 BLM movement in relation to neologisms. Eur. Acad. Res. 9, 3355 (2021).
Worthen, M. G. F. Transgender under fire: hetero-cis-normativity and military students’ attitudes toward trans issues and trans service members post DADT. Sex. Res. Soc. Policy 16, 289–308 (2019).
Winder, T. J. A. The discursive work of “Bottom-Shaming”: sexual positioning discourse in the construction of black masculinity. Gend. Soc. 37, 774–799 (2023).
Gruskin, S., Yadav, V., Castellanos-Usigli, A., Khizanishvili, G. & Kismödi, E. Sexual health, sexual rights and sexual pleasure: meaningfully engaging the perfect triangle. Sex. Reprod. Health Matters 27, 29–40 (2019).
Hoare, B. S. & Khan, Y. S. Anatomy, abdomen and pelvis: female internal genitals. StatPearls [Internet] https://www.ncbi.nlm.nih.gov/books/NBK554601/ (updated 24 July 2023).
Gaither, T. W. et al. Atlas of the receptive anal sex experience among people with prostates. J. Sex. Med. 20, 126–138 (2023).
Everaert, K. et al. Neuroanatomy and neurophysiology related to sexual dysfunction in male neurogenic patients with lesions to the spinal cord or peripheral nerves. Spinal Cord 48, 182–191 (2010).
Everaerd, W. in The International Encyclopedia of Human Sexuality (eds Bolin, A. Whelehan, P.) 1115–1354 (Wiley, 2015).
Masters, W. & Johnson, V. E. Human Sexual Response (Ishi Press International, 2010).
IsHak, W. W. The Textbook of Clinical Sexual Medicine 1st edn (Springer International Publishing, 2017).
Burnett, A. L. The role of nitric oxide in erectile dysfunction: implications for medical therapy. J. Clin. Hypertens. 8, 53–62 (2006).
Krassioukov, A. & Elliott, S. Neural control and physiology of sexual function: effect of spinal cord injury. Top. Spinal Cord Inj. Rehabil. 23, 1–10 (2017).
Nummenmaa, L., Suvilehto, J. T., Glerean, E., Santtila, P. & Hietanen, J. K. Topography of human erogenous zones. Arch. Sex. Behav. 45, 1207–1216 (2016).
Ahmed, A., Arbor, T. C. & Qureshi, W. A. Anatomy, abdomen and pelvis: anal canal. StatPearls [Internet] https://www.ncbi.nlm.nih.gov/books/NBK554531/ (updated 22 May 2023).
Shah, A. & Khan, Y. S. Anatomy, abdomen and pelvis: arteries and veins. StatPearls [Internet] https://www.ncbi.nlm.nih.gov/books/NBK560486/ (updated 25 July 2023).
Yeoh, S. et al. Incorporating blood flow in nerve injury and regeneration assessment. Front. Surg. 9, 862478 (2022).
Oakley, S. H. et al. Innervation and histology of the clitoral–urethal complex: a cross-sectional cadaver study. J. Sex. Med. 10, 2211–2218 (2013).
Agnew, J. Some anatomical and physiological aspects of anal sexual practices. J. Homosex. 12, 75–96 (1985).
Gorsch, R. V. Proctologic Anatomy (Williams & Wilkins, 1955).
Marshall, D. C. et al. A first radiotherapy application of functional bulboclitoris anatomy, a novel female sexual organ-at-risk, and organ-sparing feasibility study. Br. J. Radiol. 94, 20201139 (2021).
Previnaire, J. G. The importance of the bulbocavernosus reflex. Spinal Cord Ser. Cases 4, 2 (2018).
Niu, X. et al. Application of bulbocavernosus reflex combined with anal sphincter electromyography in the diagnosis of MSA and PD. Int. J. Neurosci. 132, 851–856 (2022).
Panchatsharam, P. K., Durland, J. & Zito, P. M. Physiology, erection. StatPearls [Internet] https://www.ncbi.nlm.nih.gov/books/NBK513278/ (updated 1 May 2023).
Woodard, T. L. & Diamond, M. P. Physiologic measures of sexual function in women: a review. Fertil. Steril. 92, 19–34 (2009).
Cunningham, D. J. Cunningham’s Textbook of Anatomy 11th edn (ed. Romanes, G. J.) (Oxford University Press, 1972).
Goligher, J. C., Duhle, H. L. & Nixon, H. H. Surgery of The Anus, Rectum and Colon 4th edn (Bailliere Tindale, 1981).
Kinsey, A. C., Pomery, W. B. & Martin, C. E. Sexual Behavior in the Human Male (W.B. Saunders Co., 1948).
Fowler, C. J., Swinn, M. J., Goodwin, R. J., Oliver, S. & Craggs, M. Studies of the latency of pelvic floor contraction during peripheral nerve evaluation show that the muscle response is reflexly mediated. J. Urol. 163, 881–883 (2000).
Previnaire, J. G. & Alexander, M. The sacral exam — what is needed to best care for our patients? Spinal Cord. Ser. Cases 6, 3 (2020).
Bharucha, A. E. Pelvic floor: anatomy and function. Neurogastroenterol. Motil. 18, 507–519 (2006).
Mercado-Perez, A. & Beyder, A. Gut feelings: mechanosensing in the gastrointestinal tract. Nat. Rev. Gastroenterol. Hepatol. 19, 283–296 (2022).
Furness, J. B., Rivera, L. R., Cho, H. J., Bravo, D. M. & Callaghan, B. The gut as a sensory organ. Nat. Rev. Gastroenterol. Hepatol. 10, 729–740 (2013).
Gilbert, J. A. et al. Current understanding of the human microbiome. Nat. Med. 24, 392–400 (2018).
Dai, Z., Wu, Z., Hang, S., Zhu, W. & Wu, G. Amino acid metabolism in intestinal bacteria and its potential implications for mammalian reproduction. Mol. Hum. Reprod. 21, 389–409 (2015).
Palumbo, V. D. et al. Altered gut microbic flora and haemorrhoids: could they have a possible relationship? J. Clin. Med. 12, 2198 (2023).
Priadko, K. et al. Intestinal microbiota, intestinal permeability and the urogenital tract: is there a pathophysiological link? J. Physiol. Pharmacol. 73, 575–585 (2022).
Cai, P., Rong, H., Zhu, Q., Dai, X. & Zhao, J. The potential roles of gut microbiome in anal fistula. AMB Express 13, 58 (2023).
Li, G. et al. Differences in the gut microbiome of women with and without hypoactive sexual desire disorder: case control study. J. Med. Internet Res. 23, e25342 (2021).
Geng, Q. et al. Correlation between gut microbiota diversity and psychogenic erectile dysfunction. Transl. Androl. Urol. 10, 4412–4421 (2021).
Eltas, A., Oguz, F., Uslu, M. O. & Akdemir, E. The effect of periodontal treatment in improving erectile dysfunction: a randomized controlled trial. J. Clin. Periodontol. 40, 148–154 (2013).
Goh, C. E. et al. Association between nitrate-reducing oral bacteria and cardiometabolic outcomes: results from ORIGINS. J. Am. Heart Assoc. 8, e013324 (2019).
Gualtero, D. F. et al. Oral microbiome mediated inflammation, a potential inductor of vascular diseases: a comprehensive review. Front. Cardiovasc. Med. 10, 1250263 (2023).
Vujkovic-Cvijin, I. et al. HIV-associated gut dysbiosis is independent of sexual practice and correlates with noncommunicable diseases. Nat. Commun. 11, 2448 (2020).
Carda-Diéguez, M. et al. Variations in vaginal, penile, and oral microbiota after sexual intercourse: a case report. Front. Med. 6, 178 (2019).
Zabor, E. C. et al. Association between periodontal disease, bacterial vaginosis, and sexual risk behaviours. J. Clin. Periodontol. 37, 888–893 (2010).
Li, S. et al. Alteration in oral microbiome among men who have sex with men with acute and chronic HIV infection on antiretroviral therapy. Front. Cell Infect. Microbiol. 11, 695515 (2021).
Amato, K. R. et al. The human gut microbiome and health inequities. Proc. Natl Acad. Sci. USA 118, e2017947118 (2021).
Ursell, L. K. et al. The interpersonal and intrapersonal diversity of human-associated microbiota in key body sites. J. Allergy Clin. Immunol. 129, 1204–1208 (2012).
Iljazovic, A., Amend, L., Galvez, E. J. C., de Oliveira, R. & Strowig, T. Modulation of inflammatory responses by gastrointestinal Prevotella spp. – from associations to functional studies. Int. J. Med. Microbiol. 311, 151472 (2021).
Gorvitovskaia, A., Holmes, S. P. & Huse, S. M. Interpreting Prevotella and Bacteroides as biomarkers of diet and lifestyle. Microbiome 4, 15 (2016).
Vélez, C., Casimiro, I., Pitts, R., Streed, C. Jr. & Paul, S. Digestive health in sexual and gender minority populations. Am. J. Gastroenterol. 117, 865–875 (2022).
Hjorth, M. F. et al. Prevotella-to-Bacteroides ratio predicts body weight and fat loss success on 24-week diets varying in macronutrient composition and dietary fiber: results from a post-hoc analysis. Int. J. Obes. 43, 149–157 (2019).
Altmäe, S., Franasiak, J. M. & Mändar, R. The seminal microbiome in health and disease. Nat. Rev. Urol. 16, 703–721 (2019).
Kelley, C. F. et al. Condomless receptive anal intercourse is associated with markers of mucosal inflammation in a cohort of men who have sex with men in Atlanta, Georgia. J. Int. AIDS Soc. 24, e25859 (2021).
Javanbakht, M., Stahlman, S., Pickett, J., LeBlanc, M.-A. & Gorbach, P. M. Prevalence and types of rectal douches used for anal intercourse: results from an international survey. BMC Infect. Dis. 14, 95 (2014).
Haaland, R. E. et al. Repeated rectal application of a hyperosmolar lubricant is associated with microbiota shifts but does not affect PrEP drug concentrations: results from a randomized trial in men who have sex with men. J. Int. AIDS Soc. 21, e25199 (2018).
Dong, T. S. et al. How discrimination gets under the skin: biological determinants of discrimination associated with dysregulation of the brain-gut microbiome system and psychological symptoms. Biol. Psychiatry 94, 203–214 (2023).
Mallott, E. K. et al. Human microbiome variation associated with race and ethnicity emerges as early as 3 months of age. PLoS Biol. 21, e3002230 (2023).
Madison, A. & Kiecolt-Glaser, J. K. Stress, depression, diet, and the gut microbiota: human-bacteria interactions at the core of psychoneuroimmunology and nutrition. Curr. Opin. Behav. Sci. 28, 105–110 (2019).
McCabe, M. P. et al. Incidence and prevalence of sexual dysfunction in women and men: a consensus statement from the fourth international consultation on sexual medicine 2015. J. Sex. Med. 13, 144–152 (2016).
Faubion, S. S. & Rullo, J. E. Sexual dysfunction in women: a practical approach. Am. Fam. Physician 92, 281–288 (2015).
Phillips, N. A. Female sexual dysfunction: evaluation and treatment. Am. Fam. Physician 62, 127–136, 141-122 (2000).
Reed, G. M. et al. Disorders related to sexuality and gender identity in the ICD-11: revising the ICD-10 classification based on current scientific evidence, best clinical practices, and human rights considerations. World Psychiatry 15, 205–221 (2016).
Rosser, B. R., Metz, M. E., Bockting, W. O. & Buroker, T. Sexual difficulties, concerns, and satisfaction in homosexual men: an empirical study with implications for HIV prevention. J. Sex Marital Ther. 23, 61–73 (1997).
Damon, W. & Rosser, B. R. Anodyspareunia in men who have sex with men: prevalence, predictors, consequences and the development of DSM diagnostic criteria. J. Sex Marital Ther. 31, 129–141 (2005).
Rosser, B. R., Short, B. J., Thurmes, P. J. & Coleman, E. Anodyspareunia, the unacknowledged sexual dysfunction: a validation study of painful receptive anal intercourse and its psychosexual concomitants in homosexual men. J. Sex Marital Ther. 24, 281–292 (1998).
Plewka, A. & Haak, D. Anal dyspareunia — biological and psychosocial correlates of painful anal intercourses in population. Psychiatr. Pol. 57, 457–465 (2023).
Peixoto, M. M. & Nobre, P. Prevalence of sexual problems and associated distress among gay and heterosexual men. Sex. Relatsh Ther. 30, 211–225 (2015).
Peixoto, M. M. & Nobre, P. Prevalence of sexual problems and associated distress among lesbian and heterosexual women. J. Sex Marital Ther. 41, 427–439 (2015).
Gaither, T. W. et al. Relationship between pelvic sensations and lifetime exposure to receptive anal intercourse among people with prostates. J. Sex. Med. 20, 1195–1205 (2023).
Grabski, B. & Kasparek, K. Sexual anal pain in gay and bisexual men: in search of explanatory factors. J. Sex. Med. 17, 716–730 (2020).
Cheng, P. J. Sexual dysfunction in men who have sex with men. Sex. Med. Rev. 10, 130–141 (2022).
Vansintejan, J., Vandevoorde, J. & Devroey, D. The GAy MEn sex studies: anodyspareunia among Belgian gay men. Sex. Med. 1, 87–94 (2013).
Nercessian, T.-R., Banbury, S. & Chandler, C. A systematic review looking at anodyspareunia among cisgender men and women. J. Sex. Marital Ther. 49, 829–841 (2023).
Yessick, L. R., Gauvin, S. E. M., Salomons, T. V. & Pukall, C. F. Pain characteristics, sexual script flexibility, and penetration control cognitions in those experiencing anodyspareunia. Psychol. Sex. 14, 321–336 (2023).
Shah, S. G. et al. Effect of magnetic endoscope imaging on patient tolerance and sedation requirements during colonoscopy: a randomized controlled trial. Gastrointest. Endosc. 55, 832–837 (2002).
Marchi, M. et al. Post-traumatic stress disorder among LGBTQ people: a systematic review and meta-analysis. Epidemiol. Psychiatr. Sci. 32, e44 (2023).
Christian, L. M. et al. A biopsychosocial framework for understanding sexual and gender minority health: a call for action. Neurosci. Biobehav. Rev. 129, 107–116 (2021).
Jones, J. F. X. in Primer on the Autonomic Nervous System 3rd edn (eds Robertson, D. et al.) 601–602 (Academic Press, 2012).
Mathias, C. J. & Low, D. A. in Textbook of Neural Repair and Rehabilitation: Volume 2: Medical Neurorehabilitation (eds Gert, K. et al.) 415–436 (Cambridge University Press, 2014).
El Muhtaseb, M. S. et al. Depression and anxiety among chronic anal fissure patients. Int. J. Surg. Open 46, 100518 (2022).
Rosa, L. L. Anodyspareunia. Anal pain during anoreceptive sex in men who have sex with men [Spanish]. Rev. Argent. Coloproctología 31, 8–20 (2020).
Wheldon, C. W. et al. Pain and loss of pleasure in receptive anal sex for gay and bisexual men following prostate cancer treatment: results from the Restore-1 study. J. Sex. Res. 59, 826–833 (2022).
Chen, T.-C. et al. Clinical characteristics and treatment outcome of oropharyngeal squamous cell carcinoma in an endemic betel quid region. Sci. Rep. 10, 526 (2020).
Schönhofen, J. et al. Incidental findings during computed tomographic angiography diagnostic work-up in patients with arteriogenic erectile dysfunction. Swiss Med. Wkly 149, w20154 (2019).
Chadwick, S. B., Francisco, M. & van Anders, S. M. When orgasms do not equal pleasure: accounts of “bad” orgasm experiences during consensual sexual encounters. Arch. Sex. Behav. 48, 2435–2459 (2019).
Sartori, D. V. B. et al. Pelvic floor muscle strength is correlated with sexual function. Investig. Clin. Urol. 62, 79–84 (2021).
Graber, B. & Kline-Graber, G. Female orgasm: role of pubococcygeus muscle. J. Clin. Psychiatry 40, 348–351 (1979).
Shafik, A. The role of the levator ani muscle in evacuation, sexual performance and pelvic floor disorders. Int. Urogynecol. J. Pelvic Floor Dysfunct. 11, 361–376 (2000).
Padoa, A., McLean, L., Morin, M. & Vandyken, C. “The overactive pelvic floor (OPF) and sexual dysfunction” Part 1: pathophysiology of OPF and its impact on the sexual response. Sex. Med. Rev. 9, 64–75 (2021).
Padoa, A., McLean, L., Morin, M. & Vandyken, C. The overactive pelvic floor (OPF) and sexual dysfunction. Part 2: evaluation and treatment of sexual dysfunction in OPF patients. Sex. Med. Rev. 9, 76–92 (2021).
Turnbull, G. B. Sexual counseling: the forgotten aspect of ostomy rehabilitation. J. Sex. Educ. Ther. 26, 189–195 (2001).
Li, C.-C. Sexuality among patients with a colostomy: an exploration of the influences of gender, sexual orientation, and Asian heritage. J. Wound Ostomy Cont. Nurs. 36, 288–296 (2009).
Graziottin, A. & Serafini, A. HPV infection in women: psychosexual impact of genital warts and intraepithelial lesions. J. Sex. Med. 6, 633–645 (2009).
Cosnes, J., Gower-Rousseau, C., Seksik, P. & Cortot, A. Epidemiology and natural history of inflammatory bowel diseases. Gastroenterology 140, 1785–1794 (2011).
Elfeki, H. et al. Patient and healthcare professional perceptions of colostomy-related problems and their impact on quality of life following rectal cancer surgery. BJS Open 2, 336–344 (2018).
Lemini, R. et al. Permanent stoma: a quality outcome in treatment of rectal cancer and its impact on length of stay. BMC Surg. 21, 163 (2021).
Glynne-Jones, R. et al. Tumour- and treatment-related colostomy rates following mitomycin C or cisplatin chemoradiation with or without maintenance chemotherapy in squamous cell carcinoma of the anus in the ACT II trial. Ann. Oncol. 25, 1616–1622 (2014).
Dames, N. B. et al. ‘Let’s talk about sex’: a patient-led survey on sexual function after colorectal and pelvic floor surgery. Colorectal Dis. 23, 1524–1551 (2021).
Reese, J. B. et al. Gastrointestinal ostomies and sexual outcomes: a comparison of colorectal cancer patients by ostomy status. Support. Care Cancer 22, 461–468 (2014).
Kibret, A. A., Oumer, M. & Moges, A. M. Prevalence and associated factors of hemorrhoids among adult patients visiting the surgical outpatient department in the University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia. PLoS ONE 16, e0249736 (2021).
Randhawa, N. et al. Endoscopic ultrasound-guided botox injection for refractory anal fissure. J. Clin. Med. 11, 6207 (2022).
Aguilar-Alvarado, M. Y., Baker, B., Chiu, L. S. & Shah, M. K. Benign colorectal disorders. Prim. Care 50, 461–480 (2023).
Lundell, L. Reflux symptoms: functional and structural diseases and the approach from the GI specialist. Dig. Dis. 39, 590–597 (2021).
Goddard, S. L. et al. Self-reported anal symptoms and their association with anal pathology among gay and bisexual men: a cross-sectional observational analysis. Sex. Health 18, 123–129 (2021).
Goldstone, S. E. The Ins and Outs of Gay Sex: A Medical Handbook for Men (Dell Publishing, 1999).
Stratton, N. L. When the “Oohs” Are Painful, Not Pleasurable: An Investigation of Anodyspareunia Among Gay, Bisexual, and Queer Men. PhD Thesis, Ryerson University (2019).
van Reijn-Baggen, D. A., Elzevier, H. W., Putter, H., Pelger, R. C. M. & Han-Geurts, I. J. M. Pelvic floor physical therapy in patients with chronic anal fissure: a randomized controlled trial. Tech. Coloproctol. 26, 571–582 (2022).
Abdelaziz, A. S., Ghoneem, A. M. & Elewesy, E. A. The impact of surgical hemorrhoidectomy on male sexual function: a preliminary study. Urol. Ann. 11, 235–240 (2019).
Gao, D. J., Guo, Y. S., Yu, H. Y., Wang, Y. J. & Cui, W. G. Prevalence and related factors of prostatitis-like symptoms in young men [Chinese]. Zhonghua Nan Ke Xue 13, 1087–1090 (2007).
Lee Mortensen, G. & Larsen, H. K. Quality of life of homosexual males with genital warts: a qualitative study. BMC Res. Notes 3, 280 (2010).
Camargo, C. C., D’Elia, M. P. B. & Miot, H. A. Quality of life in men diagnosed with anogenital warts. Bras. Dermatol. 92, 427–429 (2017).
Sperber, A. D. & Dekel, R. Irritable bowel syndrome and co-morbid gastrointestinal and extra-gastrointestinal functional syndromes. J. Neurogastroenterol. Motil. 16, 113–119 (2010).
Fass, R., Fullerton, S., Naliboff, B., Hirsh, T. & Mayer, E. A. Sexual dysfunction in patients with irritable bowel syndrome and non-ulcer dyspepsia. Digestion 59, 79–85 (1998).
Gros, M., Gros, B., Mesonero, J. E. & Latorre, E. Neurotransmitter dysfunction in irritable bowel syndrome: emerging approaches for management. J. Clin. Med. 10, 3429 (2021).
Vahora, I. S., Tsouklidis, N., Kumar, R., Soni, R. & Khan, S. How serotonin level fluctuation affects the effectiveness of treatment in irritable bowel syndrome. Cureus 12, e9871 (2020).
Spohn, S. N. & Mawe, G. M. Non-conventional features of peripheral serotonin signalling — the gut and beyond. Nat. Rev. Gastroenterol. Hepatol. 14, 412–420 (2017).
Staudacher, H. M., Black, C. J., Teasdale, S. B., Mikocka-Walus, A. & Keefer, L. Irritable bowel syndrome and mental health comorbidity — approach to multidisciplinary management. Nat. Rev. Gastroenterol. Hepatol. 20, 582–596 (2023).
Zamani, M., Alizadeh-Tabari, S. & Zamani, V. Systematic review with meta-analysis: the prevalence of anxiety and depression in patients with irritable bowel syndrome. Aliment. Pharmacol. Ther. 50, 132–143 (2019).
Jing, E. & Straw-Wilson, K. Sexual dysfunction in selective serotonin reuptake inhibitors (SSRIs) and potential solutions: a narrative literature review. Ment. Health Clin. 6, 191–196 (2016).
Bradford, K. et al. Association between early adverse life events and irritable bowel syndrome. Clin. Gastroenterol. Hepatol. 10, 385–390.e1-3 (2012).
Jagielski, C. H., Chey, W. D. & Riehl, M. E. Influence of trauma on clinical outcomes, quality of life and healthcare resource utilization following psychogastroenterology intervention. J. Psychosom. Res. 146, 110481 (2021).
Marshall, D. C. et al. Effects of trauma history on cancer-related screening, diagnosis, and treatment. Lancet Oncol. 24, e426–e437 (2023).
Stephenson, R. & Finneran, C. Receipt and perpetration of intimate partner violence and condomless anal intercourse among gay and bisexual men in Atlanta. AIDS Behav. 21, 2253–2260 (2017).
Storholm, E. D. et al. Intimate partner violence and the sexual health of sexual minority men. LGBT Health 10, S39–S48 (2023).
Campbell, J. et al. Intimate partner violence and physical health consequences. Arch. Intern. Med. 162, 1157–1163 (2002).
Calton, J. M., Cattaneo, L. B. & Gebhard, K. T. Barriers to help seeking for lesbian, gay, bisexual, transgender, and queer survivors of intimate partner violence. Trauma Violence Abuse 17, 585–600 (2016).
Huecker, M. R., King, K. C., Jordan, G. A. & Smock, W. Domestic Violence. StatPearls [Internet] https://www.ncbi.nlm.nih.gov/books/NBK499891/ (updated 9 Apr 2023).
Granot, M. et al. Trauma, attachment style, and somatization: a study of women with dyspareunia and women survivors of sexual abuse. BMC Womens Health 18, 29 (2018).
Postma, R., Bicanic, I., van der Vaart, H. & Laan, E. Pelvic floor muscle problems mediate sexual problems in young adult rape victims. J. Sex. Med. 10, 1978–1987 (2013).
Kombe Kombe, A. J. et al. Epidemiology and burden of human papillomavirus and related diseases, molecular pathogenesis, and vaccine evaluation. Front. Public Health 8, 552028 (2020).
Pennycook, K. B. & McCready, T. A. Condyloma acuminata. StatPearls [Internet] https://www.ncbi.nlm.nih.gov/books/NBK547667/ (updated 21 Jun 2023).
Leslie, S. W., Sajjad, H. & Kumar, S. Genital warts. StatPearls [Internet] https://www.ncbi.nlm.nih.gov/books/NBK441884/ (updated 30 May 2023).
Tyros, G., Mastraftsi, S., Gregoriou, S. & Nicolaidou, E. Incidence of anogenital warts: epidemiological risk factors and real-life impact of human papillomavirus vaccination. Int. J. STD AIDS 32, 4–13 (2021).
Jin, F. et al. Risk factors for genital and anal warts in a prospective cohort of HIV-negative homosexual men: the HIM study. Sex. Transm. Dis. 34, 488–493 (2007).
Vela, S. et al. Effectiveness of physically ablative and pharmacological treatments for anal condyloma in HIV-infected men. PLoS ONE 13, e0199033 (2018).
Irisawa, R., Tsuboi, R., Saito, M. & Harada, K. Treatment of intra-anal warts with imiquimod 5% cream: a single-center prospective open study. J. Dermatol. 48, 476–480 (2021).
Luz, I. et al. High prevalence of anal sexually transmitted infections among men who have sex with men and transgender women attending a clinic for prevention of anal cancer in Salvador, Brazil. Pathogens 12, 1297 (2023).
Davis, T. W. & Goldstone, S. E. Sexually transmitted infections as a cause of proctitis in men who have sex with men. Dis. Colon Rectum 52, 507–512 (2009).
Martin, T. et al. Receptive anal intercourse in patients with inflammatory bowel disease: a clinical review. Inflamm. Bowel Dis. 23, 1285–1292 (2017).
Hirshfield, S. et al. Sexual dysfunction in an Internet sample of U.S. men who have sex with men. J. Sex. Med. 7, 3104–3114 (2010).
Zucker, R. et al. Triple site sexually transmitted infection testing as a crucial component of surveillance for men who have sex with men: a prospective cohort study. Int. J. STD AIDS 33, 114–122 (2022).
De Vincentis, S., Tartaro, G., Rochira, V. & Santi, D. HIV and sexual dysfunction in men. J. Clin. Med. 10, 1088 (2021).
Grov, C., Westmoreland, D., Carneiro, P. B., Bauermeister, J. A. & Carrico, A. W. Getting clear about rectal douching among men who have sex with men. Arch. Sex. Behav. 50, 2911–2920 (2021).
Clay, P. G. & Crutchley, R. D. Noninfectious diarrhea in HIV seropositive individuals: a review of prevalence rates, etiology, and management in the era of combination antiretroviral therapy. Infect. Dis. Ther. 3, 103–122 (2014).
Nimbi, F. M. et al. Sexual desire and fantasies in the LGBT+ community: focus on lesbian women and gay men. Curr. Sex. Health Rep. 12, 153–161 (2020).
Vansintejan, J., Janssen, J., Van De Vijver, E., Vandevoorde, J. & Devroey, D. The gay men sex studies: prevalence of sexual dysfunctions in Belgian HIV+ gay men. HIV AIDS 5, 89–96 (2013).
Jagdish, R. K. Sexual dysfunctions and their treatment in liver diseases. World J. Hepatol. 14, 1530–1540 (2022).
Romano, L. et al. Sexual dysfunction in patients with chronic gastrointestinal and liver diseases: a neglected issue. Sex. Med. Rev. 10, 620–631 (2022).
Gorgos, L. Sexual transmission of viral hepatitis. Infect. Dis. Clin. North Am. 27, 811–836 (2013).
Cota, J. M. et al. High frequency of potential phosphodiesterase type 5 inhibitor drug interactions in males with HIV infection and erectile dysfunction. PLoS ONE 16, e0250607 (2021).
Rangnekar, A. S. & Fontana, R. J. Managing drug-drug interactions with boceprevir and telaprevir. Clin. Liver Dis. 1, 36–40 (2012).
Burger, D. et al. Clinical management of drug–drug interactions in HCV therapy: challenges and solutions. J. Hepatol. 58, 792–800 (2013).
Fernández-Huerta, M. et al. Sexual transmission of intestinal parasites and other enteric pathogens among men who have sex with men presenting gastrointestinal symptoms in an STI unit in Barcelona, Spain: a cross-sectional study. Am. J. Trop. Med. Hyg. 101, 1388–1391 (2019).
Reses, H. E. et al. Risk factors for sporadic Giardia infection in the USA: a case-control study in Colorado and Minnesota. Epidemiol. Infect. 146, 1071–1078 (2018).
Sewell, K. K., McGarrity, L. A. & Strassberg, D. S. Sexual behavior, definitions of sex, and the role of self-partner context among lesbian, gay, and bisexual adults. J. Sex. Res. 54, 825–831 (2017).
Conners, E. E., Miller, A. D., Balachandran, N., Robinson, B. M. & Benedict, K. M. Giardiasis outbreaks — United States, 2012-2017. MMWR Morb. Mortal. Wkly Rep. 70, 304–307 (2021).
Heller, L. The Human Rights to Water and Sanitation (Cambridge University Press, 2022).
Blackburn, A. M., Katz, B. W., Oesterle, D. W. & Orchowski, L. M. Preventing sexual violence in sexual orientation and gender diverse communities: a call to action. Eur. J. Psychotraumatol. 15, 2297544 (2023).
Porta, C. M. et al. “Kicked out”: LGBTQ youths’ bathroom experiences and preferences. J. Adolesc. 56, 107–112 (2017).
Morin, J. Anal Pleasure & Health: A Guide For Men, Women, and Couples 4th edn (Down There Press, 2010).
GBD 2017 Inflammatory Bowel Disease Collaborators. The global, regional, and national burden of inflammatory bowel disease in 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet Gastroenterol. Hepatol. 5, 17–30 (2020).
Bisgaard, T. H., Allin, K. H., Keefer, L., Ananthakrishnan, A. N. & Jess, T. Depression and anxiety in inflammatory bowel disease: epidemiology, mechanisms and treatment. Nat. Rev. Gastroenterol. Hepatol. 19, 717–726 (2022).
McDowell, C., Farooq, U. & Haseeb, M. Inflammatory bowel disease. StatPearls [Internet] https://www.ncbi.nlm.nih.gov/books/NBK470312/ (updated 4 Aug 2023).
Uhlir, V., Stallmach, A. & Grunert, P. C. Fatigue in patients with inflammatory bowel disease — strongly influenced by depression and not identifiable through laboratory testing: a cross-sectional survey study. BMC Gastroenterol. 23, 288 (2023).
Balestrieri, P. et al. Nutritional aspects in inflammatory bowel diseases. Nutrients 12, 372 (2020).
Adolph, T. E. et al. The metabolic nature of inflammatory bowel diseases. Nat. Rev. Gastroenterol. Hepatol. 19, 753–767 (2022).
Kamp, K., Dudley-Brown, S., Heitkemper, M., Wyatt, G. & Given, B. Symptoms among emerging adults with inflammatory bowel disease: a descriptive study. Res. Nurs. Health 43, 48–55 (2020).
Coward, S. et al. Past and future burden of inflammatory bowel diseases based on modeling of population-based data. Gastroenterology 156, 1345–1353.e4 (2019).
Dibley, L., Norton, C., Schaub, J. & Bassett, P. Experiences of gay and lesbian patients with inflammatory bowel disease: a mixed methods study. Gastrointest. Nurs. 12, 19–30 (2014).
Ghusn, W. et al. S999. Social determinants of health in LGBTQIA+ patients with inflammatory bowel disease. Am. J. Gastroenterol. 117, e725 (2022).
Panés, J. & Rimola, J. Perianal fistulizing Crohn’s disease: pathogenesis, diagnosis and therapy. Nat. Rev. Gastroenterol. Hepatol. 14, 652–664 (2017).
de Zeeuw, S. et al. Update of complications and functional outcome of the ileo-pouch anal anastomosis: overview of evidence and meta-analysis of 96 observational studies. Int. J. Colorectal Dis. 27, 843–853 (2012).
Heimann, T. M., Swaminathan, S., Slater, G. I. & Kurtz, R. J. Perianal fistula after ileoanal pouch in patients with ulcerative colitis: a review of 475 patients operated on at a major IBD center. Dis. Colon Rectum 65, 76–82 (2022).
Gomez, J. et al. Hidradenitis suppurativa in sexual and gender minorities: a review and considerations for providers. J. Am. Acad. Dermatol. 89, 795–801 (2023).
Roda, G. et al. Systematic review with meta-analysis: proximal disease extension in limited ulcerative colitis. Aliment. Pharmacol. Ther. 45, 1481–1492 (2017).
Schlegel, N. et al. Sphincter-sparing intersphincteric rectal resection as an alternative to proctectomy in long-standing fistulizing and stenotic Crohn’s proctitis? Int. J. Colorectal Dis. 30, 655–663 (2015).
Park, S. J., Kim, W. H. & Cheon, J. H. Clinical characteristics and treatment of inflammatory bowel disease: a comparison of Eastern and Western perspectives. World J. Gastroenterol. 20, 11525–11537 (2014).
Chun, A. B., Rose, S., Mitrani, C., Silvestre, A. J. & Wald, A. Anal sphincter structure and function in homosexual males engaging in anoreceptive intercourse. Am. J. Gastroenterol. 92, 465–468 (1997).
Lin, X. et al. Intestinal strictures in Crohn’s disease: a 2021 update. Ther. Adv. Gastroenterol. 15, 17562848221104951 (2022).
Lightner, A. L. & Regueiro, M. Anorectal strictures in complex perianal CD: how to approach. Clin. Colon Rectal Surg. 35, 44–50 (2022).
Pogacnik, J. S. & Salgado, G. Perianal Crohn’s disease. Clin. Colon Rectal Surg. 32, 377–385 (2019).
Bonheur, J. L., Braunstein, J., Korelitz, B. I. & Panagopoulos, G. Anal skin tags in inflammatory bowel disease: new observations and a clinical review. Inflamm. Bowel Dis. 14, 1236–1239 (2008).
Safar, B. & Sands, D. Perianal Crohn’s disease. Clin. Colon Rectal Surg. 20, 282–293 (2007).
Opar, S. P. Photo quiz. Painful perianal lesions. Am. Fam. Physician 82, 419–421 (2010).
Sommer, K. et al. Intestinal mucosal wound healing and barrier integrity in IBD-crosstalk and trafficking of cellular players. Front. Med. 8, 643973 (2021).
Alexakis, C. et al. Ano-genital granulomatosis and Crohn’s disease: a case series of males presenting with genital lymphoedema. J. Crohns Colitis 11, 454–459 (2016).
Dederichs, F. et al. Genital granulomatosis in male and female patients with Crohn’s disease: clinical presentation and treatment outcomes. J. Crohns Colitis 12, 197–203 (2018).
Crohn’s and Colitis UK. Sex and relationships.Crohn’s & Colitis UK https://crohnsandcolitis.org.uk/media/wrshmklm/sex-and-relationships-ed5-2022.pdf (2022).
Hay, M. I have an inflammatory bowel disease. Here’s how it affects my sex life. Vice https://www.vice.com/en/article/pkpv39/how-inflammatory-bowel-disease-ulcerative-colitis-affects-my-sex-life (2022).
SEX: Straight Up (Well, Maybe Not So Straight). The Gay Digest https://gaydigest.wordpress.com/tag/crohns/ (2010).
Rui, W., Zhaoqi, L., Shaojun, L. & Decai, Z. Global, regional and national burden of inflammatory bowel disease in 204 countries and territories from 1990 to 2019: a systematic analysis based on the Global Burden of Disease Study 2019. BMJ Open 13, e065186 (2023).
Marín, L. et al. Sexual function and patients’ perceptions in inflammatory bowel disease: a case-control survey. J. Gastroenterol. 48, 713–720 (2013).
Zamponi, V. et al. Female sexual dysfunction in primary adrenal insufficiency. J. Clin. Med. 10, 2767 (2021).
Beese, S. E., Harris, I. M., Dretzke, J. & Moore, D. Body image dissatisfaction in patients with inflammatory bowel disease: a systematic review. BMJ Open Gastroenterol. 6, e000255 (2019).
Levitan, J., Quinn-Nilas, C., Milhausen, R. & Breuer, R. The relationship between body image and sexual functioning among gay and bisexual men. J. Homosex. 66, 1856–1881 (2019).
Nowicki, G. P., Marchwinski, B. R., O’Flynn, J. L., Griffths, S. & Rodgers, R. F. Body image and associated factors among sexual minority men: a systematic review. Body Image 43, 154–169 (2022).
Khoudari, G. et al. Rates of intestinal resection and colectomy in inflammatory bowel disease patients after initiation of biologics: a cohort study. Clin. Gastroenterol. Hepatol. 20, e974–e983 (2022).
Shen, B. et al. Treatment of pouchitis, Crohn’s disease, cuffitis, and other inflammatory disorders of the pouch: consensus guidelines from the International Ileal Pouch Consortium. Lancet Gastroenterol. Hepatol. 7, 69–95 (2022).
Scoglio, D., Ahmed Ali, U. & Fichera, A. Surgical treatment of ulcerative colitis: ileorectal vs ileal pouch-anal anastomosis. World J. Gastroenterol. 20, 13211–13218 (2014).
Abdalla, M. et al. Anorectal function after ileo-rectal anastomosis is better than pelvic pouch in selected ulcerative colitis patients. Dig. Dis. Sci. 65, 250–259 (2020).
Panganiban, R. & Clarke, K. S2112: Receptive anal intercourse in IBD patients: impact on treatment of anorectal disease. Am. J. Gastroenterol. https://gi.org/wp-content/uploads/2022/10/Colon-Clinical-Vignettes.pdf (2022).
Georganta, I. et al. The incidence of malignancy in the residual rectum of IBD patients after colectomy: a systematic review and meta-analysis. Tech. Coloproctol. 27, 699–712 (2023).
Stellingwerf, M. E. et al. Knotless seton for perianal fistulas: feasibility and effect on perianal disease activity. Sci. Rep. 10, 16693 (2020).
Siegel, R. L., Miller, K. D., Wagle, N. S. & Jemal, A. Cancer statistics, 2023. CA Cancer J. Clin. 73, 17–48 (2023).
Maddams, J., Utley, M. & Møller, H. Projections of cancer prevalence in the United Kingdom, 2010-2040. Br. J. Cancer 107, 1195–1202 (2012).
Miller, K. D. et al. Cancer treatment and survivorship statistics, 2022. CA Cancer J. Clin. 72, 409–436 (2022).
Parry, C., Kent, E. E., Mariotto, A. B., Alfano, C. M. & Rowland, J. H. Cancer survivors: a booming population. Cancer Epidemiol. Biomark. Prev. 20, 1996–2005 (2011).
Sung, H. et al. Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J. Clin. 71, 209–249 (2021).
Swerdlow, A. J. et al. Cancer incidence and mortality in men with Klinefelter syndrome: a cohort study. J. Natl Cancer Inst. 97, 1204–1210 (2005).
Hasle, H. et al. Occurrence of cancer in women with Turner syndrome. Br. J. Cancer 73, 1156–1159 (1996).
Baraibar, I. et al. Sex and gender perspectives in colorectal cancer. ESMO Open 8, 101204 (2023).
Abancens, M., Bustos, V., Harvey, H., McBryan, J. & Harvey, B. J. Sexual dimorphism in colon cancer. Front. Oncol. 10, 607909 (2020).
Boutas, I., Kontogeorgi, A., Dimitrakakis, C. & Kalantaridou, S. N. Soy isoflavones and breast cancer risk: a meta-analysis. In Vivo 36, 556–562 (2022).
Benitez Majano, S. et al. Surgical treatment and survival from colorectal cancer in Denmark, England, Norway, and Sweden: a population-based study. Lancet Oncol. 20, 74–87 (2019).
Benson, A. B. et al. Rectal cancer, version 2.2018, NCCN clinical practice guidelines in oncology. J. Natl Compr. Cancer Netw. 16, 874–901 (2018).
Boehmer, U. et al. Assessing the relationship between symptoms and health care utilization in colorectal cancer survivors of different sexual orientations. Support. Care Cancer 29, 5821–5830 (2021).
Ward, H. Cancer, Sex and Intimacy: The Experiences of Gay, Bisexual, and Queer Men. PhD Thesis, University of East London (2022).
Dickstein, D. R., Chen, E., Zaorsky, N. G., Hoffman, K. & Nguyen, P. Do ask, do tell: improving health outcomes for sexual and gender minorities with cancer. JNCI Cancer Spectr. 7, pkad075 (2023).
Mitteldorf, D. Psychotherapy with gay prostate cancer patients. J. Gay Lesbian Psychother. 9, 57–67 (2005).
Fergus, K. D., Gray, R. E. & Fitch, M. I. Sexual dysfunction and the preservation of manhood: experiences of men with prostate cancer. J. Health Psychol. 7, 303–316 (2002).
Kurdek, L. A. Are gay and lesbian cohabiting couples really different from heterosexual married couples? J. Marriage Fam. 66, 880–900 (2004).
Kurdek, L. A. What do we know about gay and lesbian couples? Curr. Direc. Psychol. Sci. 14, 251–254 (2005).
Kurdek, L. A. Differences between heterosexual-nonparent couples and gay, lesbian, and heterosexual-parent couples. J. Fam. Issues 22, 727–754 (2001).
Lin, C., Franceschi, S. & Clifford, G. M. Human papillomavirus types from infection to cancer in the anus, according to sex and HIV status: a systematic review and meta-analysis. Lancet Infect. Dis. 18, 198–206 (2018).
Stier, E. A., Chigurupati, N. L. & Fung, L. Prophylactic HPV vaccination and anal cancer. Hum. Vaccin. Immunother. 12, 1348–1351 (2016).
Giannone, G. et al. HPV vaccination and HPV-related malignancies: impact, strategies and optimizations toward global immunization coverage. Cancer Treat. Rev. 111, 102467 (2022).
Barroso, L. F. II, Stier, E. A., Hillman, R. & Palefsky, J. Anal cancer screening and prevention: summary of evidence reviewed for the 2021 centers for disease control and prevention sexually transmitted infection guidelines. Clin. Infect. Dis. 74, S179–S192 (2022).
Islami, F., Ferlay, J., Lortet-Tieulent, J., Bray, F. & Jemal, A. International trends in anal cancer incidence rates. Int. J. Epidemiol. 46, 924–938 (2017).
Grulich, A. E. et al. The epidemiology of anal cancer. Sex. Health 9, 504–508 (2012).
Machalek, D. A. et al. Anal human papillomavirus infection and associated neoplastic lesions in men who have sex with men: a systematic review and meta-analysis. Lancet Oncol. 13, 487–500 (2012).
Silverberg, M. J. et al. Risk of anal cancer in HIV-infected and HIV-uninfected individuals in North America. Clin. Infect. Dis. 54, 1026–1034 (2012).
Braun, H. et al. Cancer in transgender people: evidence and methodological considerations. Epidemiol. Rev. 39, 93–107 (2017).
Fein, L. A. et al. Low perceived anal cancer risk and screening utilization among high-risk transgender men and women living in an HIV / STI epicenter. AIDS Behav. 25, 2210–2218 (2021).
Saleem, A. M. et al. Risk of anal cancer in a cohort with human papillomavirus-related gynecologic neoplasm. Obstet. Gynecol. 117, 643–649 (2011).
Field, J., Fenton, C., Zhang, L., Brickman, C. & Mahadevan, U. Inflammatory bowel disease and the risk of anal squamous intraepithelial lesions and anal cancer in men who have sex with men. Inflamm. Bowel Dis. https://doi.org/10.1093/ibd/izad266 (2023).
Wong, S. Y. & Colombel, J. F. Cancer screening in patients with inflammatory bowel disease: don’t forget the anus! Inflamm. Bowel Dis. https://doi.org/10.1093/ibd/izad267 (2023).
Deshmukh, A. A., Damgacioglu, H., Georges, D., Sonawane, K. & Clifford, G. M. Human papillomavirus-associated anal cancer incidence and burden among us men, according to sexual orientation, human immunodeficiency virus status, and age. Clin. Infect. Dis. 77, 419–424 (2023).
Mauro, G. P., da Conceição Vasconcelos, K. G. M. & Carvalho, H. A. Quality of life and sexual function of men who have sex with men treated for anal cancer: a prospective trial of a neglected population. J. Sex. Med. 18, 1461–1466 (2021).
Yang, M.-J. et al. Psychosocial characteristics and quality of life among sexual and gender minority patients with cancer. JNCI Cancer Spectr. 18, pkad061 (2023).
Herek, G. M. Legal recognition of same-sex relationships in the United States: a social science perspective. Am. Psychol. 61, 607–621 (2006).
Tchelebi, L. T. et al. Current treatment and future directions in the management of anal cancer. CA Cancer J. Clin. 72, 183–195 (2022).
Sobrado, L. F., Nahas, C. S. R., Marques, C. F. S., Sobrado, C. W. & Nahas, S. C. Pretreatment colostomy in patients with anal squamous cell carcinoma: Risk factors for a permanent stoma. J. Surg. Oncol. 126, 740–747 (2022).
Koerber, S. A. et al. Chemoradiation in female patients with anal cancer: patient-reported outcome of acute and chronic side effects. Tumori 105, 174–180 (2019).
Joseph, K. et al. Long-term patient-reported quality of life of anal cancer survivors treated with intensity modulated radiation therapy and concurrent chemotherapy: results from a prospective phase II trial. Int. J. Radiat. Oncol. Biol. Phys. 117, 434–445 (2023).
Gilbert, A. et al. UK national cohort of anal cancer treated with intensity-modulated radiotherapy: one-year oncological and patient-reported outcomes. Eur. J. Cancer 128, 7–16 (2020).
Giglia, M. D. & Stein, S. L. Overlooked long-term complications of colorectal surgery. Clin. Colon Rectal Surg. 32, 204–211 (2019).
Marinello, F. G. et al. Selective approach for upper rectal cancer treatment: total mesorectal excision and preoperative chemoradiation are seldom necessary. Dis. Colon Rectum 58, 556–565 (2015).
van Heinsbergen, M. et al. Functional bowel complaints and quality of life after surgery for colon cancer: prevalence and predictive factors. Colorectal Dis. 22, 136–145 (2020).
Rooney, M. K. et al. Patient-reported bowel function and bowel-related quality of life after pelvic radiation for rectal adenocarcinoma: the impact of radiation fractionation and surgical resection. Clin. Colorectal Cancer 22, 211–221 (2023).
Hall, E. J. Radiobiology for the radiologist (Harper & Row, 1973).
Lukovic, J. et al. Evaluation of dosimetric predictors of toxicity after IMRT with concurrent chemotherapy for anal cancer. Radiother. Oncol. 178, 109429 (2023).
Corrigan, K. L. et al. Patient-reported outcomes after chemoradiation in patients with anal cancer: a qualitative analysis. Adv. Radiat. Oncol. 7, 100986 (2022).
Alayed, Y. et al. Dosimetric predictors of toxicity and quality of life following prostate stereotactic ablative radiotherapy. Radiother. Oncol. 144, 135–140 (2020).
Jackson, A. et al. Late rectal bleeding after conformal radiotherapy of prostate cancer. II. Volume effects and dose-volume histograms. Int. J. Radiat. Oncol. Biol. Phys. 49, 685–698 (2001).
Untiedt, S. et al. Impact of dose escalation on colostomy-free survival and treatment outcome in squamous cell anal carcinoma. Strahlenther. Onkol. 199, 749–760 (2023).
Myerson, R. J. et al. Elective clinical target volumes for conformal therapy in anorectal cancer: a radiation therapy oncology group consensus panel contouring atlas. Int. J. Radiat. Oncol. Biol. Phys. 74, 824–830 (2009).
Da Silva, G. M. et al. Histologic analysis of the irradiated anal sphincter. Dis. Colon Rectum 46, 1492–1497 (2003).
Bregendahl, S. et al. Neorectal hyposensitivity after neoadjuvant therapy for rectal cancer. Radiother. Oncol. 108, 331–336 (2013).
Haas, S. et al. Anal sphincter dysfunction in patients treated with primary radiotherapy for anal cancer: a study with the functional lumen imaging probe. Acta Oncologica 57, 465–472 (2018).
Vordermark, D., Sailer, M., Flentje, M., Thiede, A. & Kölbl, O. Curative-intent radiation therapy in anal carcinoma: quality of life and sphincter function. Radiother. Oncol. 52, 239–243 (1999).
Dalsania, R. M., Shah, K. P., Stotsky-Himelfarb, E., Hoffe, S. & Willingham, F. F. Management of long-term toxicity from pelvic radiation therapy. Am. Soc. Clin. Oncol. Educ. Book 41, 1–11 (2021).
Smart, A. C. et al. Gender-affirming surgery and cancer: considerations for radiation oncologists for pelvic radiation in transfeminine patients. Int. J. Radiat. Oncol. Biol. Phys. 117, 301–311 (2023).
Antonelli, R. Q. et al. Liquid silicone used for esthetic purposes as a potentiator for occurrence of post-radiotherapy genital lymphedema: case report. Sao Paulo Med. J. 135, 185–189 (2017).
Dickstein, D. R. & Buckstein, M. What rectal cancer patients may be able to safely avoid radiation? Curr. Colorectal Cancer Rep. 18, 61–67 (2022).
Bertoncelli Tanaka, M. et al. Prostate cancer in transgender women: what does a urologist need to know? BJU Int. 129, 113–122 (2022).
Sinawe, H. & Casadesus, D. Mitomycin. StatPearls [Internet] https://www.ncbi.nlm.nih.gov/books/NBK562249/ (updated 24 Jul 2023).
Casale, J. & Patel, P. Fluorouracil. StatPearls [Internet] https://www.ncbi.nlm.nih.gov/books/NBK549808/ (updated 24 Nov 2023).
Marsé, H., Van Cutsem, E., Grothey, A. & Valverde, S. Management of adverse events and other practical considerations in patients receiving capecitabine (Xeloda). Eur. J. Oncol. Nurs. 8, S16–S30 (2004).
Garrison, S. R. et al. Magnesium for skeletal muscle cramps. Cochrane Database Syst. Rev. 9, CD009402 (2020).
Haris, I. et al. Sexual dysfunction following breast cancer chemotherapy: a cross-sectional study in Yogyakarta, Indonesia. Cureus 15, e41744 (2023).
Grisold, W., Cavaletti, G. & Windebank, A. J. Peripheral neuropathies from chemotherapeutics and targeted agents: diagnosis, treatment, and prevention. Neuro-Oncology 14, iv45–iv54 (2012).
Zajączkowska, R. et al. Mechanisms of chemotherapy-induced peripheral neuropathy. Int. J. Mol. Sci. 20, 1451 (2019).
Voznesensky, M., Annam, K. & Kreder, K. J. Understanding and managing erectile dysfunction in patients treated for cancer. J. Oncol. Pract. 12, 297–304 (2016).
Boyette-Davis, J. A., Hou, S., Abdi, S. & Dougherty, P. M. An updated understanding of the mechanisms involved in chemotherapy-induced neuropathy. Pain Manag. 8, 363–375 (2018).
Cercek, A. et al. PD-1 blockade in mismatch repair–deficient, locally advanced rectal cancer. N. Engl. J. Med. 386, 2363–2376 (2022).
Dhawan, N., Afzal, M. Z. & Amin, M. Immunotherapy in anal cancer. Curr. Oncol. 30, 4538–4550 (2023).
Grover, S., Wang, Y. & Dougan, M. Immune checkpont inhibitor colitis. UpToDate https://www.uptodate.com/contents/immune-checkpoint-inhibitor-colitis (2023).
Olusoji, R. A., Eun, Y., Mohamed Salih, R., Osei, N. & Ahluwalia, M. Adrenal insufficiency in patients on immune checkpoint inhibitors: an all of Us data study. J. Clin. Oncol. 41, e14675 (2023).
Basch, E. et al. Patient-reported outcomes during and after treatment for locally advanced rectal cancer in the PROSPECT trial (Alliance N1048). J. Clin. Oncol. 41, 3724–3734 (2023).
Garcia-Aguilar, J. et al. Organ preservation in patients with rectal adenocarcinoma treated with total neoadjuvant therapy. J. Clin. Oncol. 40, 2546–2556 (2022).
Gerard, J.-P. et al. Neoadjuvant chemoradiotherapy with radiation dose escalation with contact x-ray brachytherapy boost or external beam radiotherapy boost for organ preservation in early cT2–cT3 rectal adenocarcinoma (OPERA): a phase 3, randomised controlled trial. Lancet Gastroenterol. Hepatol. 8, 356–367 (2023).
Schrag, D. et al. Preoperative treatment of locally advanced rectal cancer. N. Engl. J. Med. 389, 322–334 (2023).
Herbenick, D. et al. Women’s sexual satisfaction, communication, and reasons for (no longer) faking orgasm: findings from a U.S. probability sample. Arch. Sex. Behav. 48, 2461–2472 (2019).
Beaulieu, N., Bergeron, S., Brassard, A., Byers, E. S. & Péloquin, K. Toward an integrative model of intimacy, sexual satisfaction, and relationship satisfaction: a prospective study in long-term couples. J. Sex. Res. 60, 1100–1112 (2023).
Rosenberger, J. G., Schick, V., Herbenick, D., Novak, D. S. & Reece, M. Sex toy use by gay and bisexual men in the United States. Arch. Sex. Behav. 41, 449–458 (2012).
Swan, E. Colostomy, management and quality of life for the patient. Br. J. Nurs. 20, 24–28 (2011).
Godala, M., Gaszyńska, E., Durko, Ł. & Małecka-Wojciesko, E. Dietary behaviors and beliefs in patients with inflammatory bowel disease. J. Clin. Med. 12, 3455 (2023).
Karagama, Y. Abelchia: inability to belch/burp-a new disorder? Retrograde cricopharyngeal dysfunction (RCPD). Eur. Arch. Otorhinolaryngol. 278, 5087–5091 (2021).
Lin, S. Y. et al. Different position from traditional left lateral for colonoscopy? A meta-analysis and systematic review of randomized control trials. Chronic Dis. Transl. Med. 7, 27–34 (2021).
Ralph, S. Developing UK guidance on how long men should abstain from receiving anal sex before, during and after interventions for prostate cancer. Clin. Oncol. 33, 807–810 (2021).
Mlakar, B. Should we avoid stapled hemorrhoidopexy in males and females who practice receptive anal sex? Dis. Colon Rectum 50, 1727 (2007).
Carballo-Diéguez, A., Lentz, C., Giguere, R., Fuchs, E. J. & Hendrix, C. W. Rectal douching associated with receptive anal intercourse: a literature review. AIDS Behav. 22, 1288–1294 (2018).
Leyva, F. J. et al. Isoosmolar enemas demonstrate preferential gastrointestinal distribution, safety, and acceptability compared with hyperosmolar and hypoosmolar enemas as a potential delivery vehicle for rectal microbicides. AIDS Res. Hum. Retroviruses 29, 1487–1495 (2013).
Saleska, J. L. et al. Correlates of rectal douching practices among men who have sex with men in Kenya. Sex. Transm. Dis. 45, e94–e97 (2018).
Mayer, K. H. et al. Emtricitabine and tenofovir alafenamide vs emtricitabine and tenofovir disoproxil fumarate for HIV pre-exposure prophylaxis (DISCOVER): primary results from a randomised, double-blind, multicentre, active-controlled, phase 3, non-inferiority trial. Lancet 396, 239–254 (2020).
Landovitz, R. J. et al. Cabotegravir for HIV prevention in cisgender men and transgender women. N. Engl. J. Med. 385, 595–608 (2021).
Alrubia, S., Mao, J., Chen, Y., Barber, J. & Rostami-Hodjegan, A. Altered bioavailability and pharmacokinetics in Crohn’s disease: capturing systems parameters for PBPK to assist with predicting the fate of orally administered drugs. Clin. Pharmacokinet. 61, 1365–1392 (2022).
Effinger, A., O’Driscoll, C. M., McAllister, M. & Fotaki, N. Impact of gastrointestinal disease states on oral drug absorption — implications for formulation design — a PEARRL review. J. Pharm. Pharmacol. 71, 674–698 (2019).
Moss, D. M., Curley, P., Shone, A., Siccardi, M. & Owen, A. A multisystem investigation of raltegravir association with intestinal tissue: implications for pre-exposure prophylaxis and eradication. J. Antimicrob. Chemother. 69, 3275–3281 (2014).
Brooks, K. M. et al. Decreased absorption of dolutegravir and tenofovir disoproxil fumarate, but not emtricitabine, in an HIV-infected patient following oral and jejunostomy-tube administration. Pharmacotherapy 37, e82–e89 (2017).
Calcagno, A. et al. Low tenofovir plasma exposure in HIV oral pre-exposure prophylaxis recipients with gastrointestinal disorders. Antimicrob. Agents Chemother. 65, e01902-20 (2021).
Molina, J. M. et al. Post-exposure prophylaxis with doxycycline to prevent sexually transmitted infections in men who have sex with men: an open-label randomised substudy of the ANRS IPERGAY trial. Lancet Infect. Dis. 18, 308–317 (2018).
Kong, F. Y. S., Kenyon, C. & Unemo, M. Important considerations regarding the widespread use of doxycycline chemoprophylaxis against sexually transmitted infections. J. Antimicrob. Chemother. 78, 1561–1568 (2023).
Siegler, A. J. et al. Levels of clinical condom failure for anal sex: a randomized cross-over trial. EClinicalMedicine 17, 100199 (2019).
Fuchs, E. J. et al. Hyperosmolar sexual lubricant causes epithelial damage in the distal colon: potential implication for HIV transmission. J. Infect. Dis. 195, 703–710 (2007).
Hardy, D. When We Dare Not Speak its Name: Anal Taboo, Anal Health, and Affect Theory (Widener University, 2010).
Dezzutti, C. S. et al. Is wetter better? An evaluation of over-the-counter personal lubricants for safety and anti-HIV-1 activity. PLoS ONE 7, e48328 (2012).
White, S. Gay relationships and the challenges a stoma can cause. Securi Care https://www.securicaremedical.co.uk/blog/gay-relationships-and-the-challenges-a-stoma-can-cause (2020).
Lim, S. W. et al. Risk factors for permanent stoma after low anterior resection for rectal cancer. Langenbecks Arch. Surg. 398, 259–264 (2013).
Pellino, G., Sciaudone, G., Candilio, G., Canonico, S. & Selvaggi, F. Rectosigmoid stump washout as an alternative to permanent mucous fistula in patients undergoing subtotal colectomy for ulcerative colitis in emergency settings. BMC Surg. 12, S31 (2012).
NHS. Living with Colostomy. NHS https://www.nhs.uk/conditions/colostomy/living-with/ (2023).
Exploring Gay Intimacy with an Ostomy Bag: Is it Feasible? Meet An OstoMate https://www.meetanostomate.org/discussion-forum/viewtopic.php?t=10018 (2023).
Bhaskar, V., Sinha, R. J., Mehrotra, S., Mehrotra, C. N. & Singh, V. Long-term outcomes of sigmoid vaginoplasty in patients with disorder of sexual development — our experience. Urol. Ann. 10, 185–190 (2018).
Krakowsky, Y. et al. The effect of gender-affirming medical care on the vaginal and neovaginal microbiomes of transgender and gender-diverse people. Front. Cell Infect. Microbiol. 11, 769950 (2021).
Jones, E. S. & Rayner, B. L. The importance of guidelines. Cardiovasc. J. Afr. 25, 296–297 (2014).
Albrecht, H. & Gretschel, S. Laparoscopic sphincter reconstruction after abdominoperineal resection: feasibility and technical aspects. Tech. Coloproctol. 23, 367–372 (2019).
van Netten, J. J., Georgiadis, J. R., Nieuwenburg, A. & Kortekaas, R. 8–13 Hz fluctuations in rectal pressure are an objective marker of clitorally-induced orgasm in women. Arch. Sex. Behav. 37, 279–285 (2008).
Matzel, K. E. Update on neuromodulation for fecal incontinence. Ann. Laparosc. Endosc. Surg. https://doi.org/10.21037/ales-2022-03 (2022).
Brill, S. A. & Margolin, D. A. Sacral nerve stimulation for the treatment of fecal incontinence. Clin. Colon Rectal Surg. 18, 38–41 (2005).
Morin, M. et al. Multimodal physical therapy versus topical lidocaine for provoked vestibulodynia: a multicenter, randomized trial. Am. J. Obstet. Gynecol. 224, 189.e1–189.e12 (2021).
Keefer, L. Behavioural medicine and gastrointestinal disorders: the promise of positive psychology. Nat. Rev. Gastroenterol. Hepatol. 15, 378–386 (2018).
Rosen, N. O., Bergeron, S., Sadikaj, G. & Delisle, I. Daily associations among male partner responses, pain during intercourse, and anxiety in women with vulvodynia and their partners. J. Pain 16, 1312–1320 (2015).
Morais, L. H., Schreiber, H. L. & Mazmanian, S. K. The gut microbiota–brain axis in behaviour and brain disorders. Nat. Rev. Microbiol. 19, 241–255 (2021).
Keefer, L. et al. A Rome Working Team report on brain-gut behavior therapies for disorders of gut-brain interaction. Gastroenterology 162, 300–315 (2022).
Meana, M. & Binik, Y. M. The biopsychosocial puzzle of painful sex. Annu. Rev. Clin. Psychol. 18, 471–495 (2022).
Paulton, J., Gill, A. & Prevost, J. Gut-directed self-hypnosis for inflammatory bowel disease protocol: complimentary psychotherapy for remission augmentation, IBS-like symptoms, and surgery recovery. Gastroenterology 160, S72 (2021).
Eberspacher, C. et al. Self-mechanical anal dilatation: a simple trick to minimize postoperative pain and stenosis following hemorrhoidectomy with radiofrequency. Front. Surg. 8, 711958 (2021).
Grimstad, F., McLaren, H. & Gray, M. The gynecologic examination of the transfeminine person after penile inversion vaginoplasty. Am. J. Obstet. Gynecol. 224, 266–273 (2021).
Bakker, R. M. et al. Sexual rehabilitation after pelvic radiotherapy and vaginal dilator use: consensus using the Delphi method. Int. J. Gynecol. Cancer 24, 1499–1506 (2014).
Summerfield, J. & Leong, A. Management of radiation therapy-induced vaginal adhesions and stenosis: a New Zealand survey of current practice. J. Med. Radiat. Sci. 67, 128–133 (2020).
Lee, Y. Patients’ perception and adherence to vaginal dilator therapy: a systematic review and synthesis employing symbolic interactionism. Patient Prefer. Adherence 12, 551–560 (2018).
Bianco, F. et al. Short stump and high anastomosis pull-through (SHiP) procedure for delayed coloanal anastomosis with no protective stoma for low rectal cancer. Updates Surg. 73, 495–502 (2021).
Greca, F., Nevah, E., Hares, M. & Keighley, M. R. Value of an anal dilator after anal stretch for haemorrhoids. J. R. Soc. Med. 74, 368–370 (1981).
Shen, S. L., He, D. L. & Luo, Y. Clinical trials of combined therapy of an oral Chinese medicine with massage for chronic nonbacterial prostatitis [Chinese]. Zhonghua Nan Ke Xue 12, 851–853 (2006).
Ateya, A. et al. Evaluation of prostatic massage in treatment of chronic prostatitis. Urology 67, 674–678 (2006).
Moskowitz, D. A. & Garcia, C. P. Top, bottom, and versatile anal sex roles in same-sex male relationships: implications for relationship and sexual satisfaction. Arch. Sex. Behav. 48, 1217–1225 (2019).
Wellings, K. & Johnson, A. M. Framing sexual health research: adopting a broader perspective. Lancet 382, 1759–1762 (2013).
Maister, L., Fotopoulou, A., Turnbull, O. & Tsakiris, M. The erogenous mirror: intersubjective and multisensory maps of sexual arousal in men and women. Arch. Sex. Behav. 49, 2919–2933 (2020).
Turnbull, O. H., Lovett, V. E., Chaldecott, J. & Lucas, M. D. Reports of intimate touch: erogenous zones and somatosensory cortical organization. Cortex 53, 146–154 (2014).
Polter, E. J. et al. Creation and psychometric validation of the sexual minorities and prostate cancer scale (SMACS) in sexual minority patients-the restore-2 study. J. Sex. Med. 19, 529–540 (2022).
Flynn, K. E., Lin, L. & Weinfurt, K. P. Sexual function and satisfaction among heterosexual and sexual minority U.S. adults: a cross-sectional survey. PLoS ONE 12, e0174981 (2017).
Weinfurt, K. P. et al. Development and initial validation of the PROMIS® sexual function and satisfaction measures version 2.0. J. Sex. Med. 12, 1961–1974 (2015).
Fatton, B., de Tayrac, R., Letouzey, V. & Huberlant, S. Pelvic organ prolapse and sexual function. Nat. Rev. Urol. 17, 373–390 (2020).
Gül, M. et al. A clinical guide to rare male sexual disorders. Nat. Rev. Urol. 21, 35–49 (2023).
Vriesman, M. H., Koppen, I. J. N., Camilleri, M., Di Lorenzo, C. & Benninga, M. A. Management of functional constipation in children and adults. Nat. Rev. Gastroenterol. Hepatol. 17, 21–39 (2020).
Rao, S. S. & Patcharatrakul, T. Diagnosis and treatment of dyssynergic defecation. J. Neurogastroenterol. Motil. 22, 423–435 (2016).
Drolet, M., Bénard, É., Pérez, N. & Brisson, M. Population-level impact and herd effects following the introduction of human papillomavirus vaccination programmes: updated systematic review and meta-analysis. Lancet 394, 497–509 (2019).
Yakely, A. E., Avni-Singer, L., Oliveira, C. R. & Niccolai, L. M. Human papillomavirus vaccination and anogenital warts: a systematic review of impact and effectiveness in the United States. Sex. Transm. Dis. 46, 213–220 (2019).
Koff, R. S. Hepatitis A. Lancet 351, 1643–1649 (1998).
Spratt, D. E. et al. Vessel-sparing radiotherapy for localized prostate cancer to preserve erectile function: a single-arm phase 2 trial. Eur. Urol. 72, 617–624 (2017).
Pauls, R. N. Anatomy of the clitoris and the female sexual response. Clin. Anat. 28, 376–384 (2015).
Di Marino, V. & Lepidi, H. Anatomic Study of the Clitoris and the Bulbo-Clitoral Organ 1st edn (Springer International Publishing, 2014).
Jannini, E. A., Buisson, O. & Rubio-Casillas, A. Beyond the G-spot: clitourethrovaginal complex anatomy in female orgasm. Nat. Rev. Urol. 11, 531–538 (2014).
Kinter, K. J. & Newton, B. W. Abdomen and Pelvis, Pudendal Nerve. StatPearls [Internet] https://www.ncbi.nlm.nih.gov/books/NBK554736/ (updated 10 Feb 2023).
Maravilla, K. R. et al. Serial MR imaging with MS-325 for evaluating female sexual arousal response: determination of intrasubject reproducibility. J. Magn. Reson. Imaging 18, 216–224 (2003).
Shafik, A., Shafik, I. A., el-Sibai, O. & Shafik, A. A. Physioanatomical relationship of the external anal sphincter to the bulbocavernosus muscle in the female. Int. Urogynecol. J. Pelvic Floor Dysfunct. 18, 851–856 (2007).
Arias-Castillo, L., García, L. & García-Perdomo, H. A. The complexity of female orgasm and ejaculation. Arch. Gynecol. Obstet. 308, 427–434 (2023).
Alwaal, A., Breyer, B. N. & Lue, T. F. Normal male sexual function: emphasis on orgasm and ejaculation. Fertil. Steril. 104, 1051–1060 (2015).
Djinovic, R. P. Metoidioplasty. Clin. Plast. Surg. 45, 381–386 (2018).
Djordjevic, M. L., Stojanovic, B. & Bizic, M. Metoidioplasty: techniques and outcomes. Transl. Androl. Urol. 8, 248–253 (2019).
Hage, J. J. & van Turnhout, A. A. Long-term outcome of metaidoioplasty in 70 female-to-male transsexuals. Ann. Plast. Surg. 57, 312–316 (2006).
Cristofari, S. et al. Genitourinary vascularized composite allotransplantation for gender affirmation in trans men: an anatomical feasibility study. J. Plast. Reconstr. Aesthet. Surg. 83, 117–125 (2023).
Marque, M. et al. The tube in tube thoracodorsal perforator flap phalloplasty [French]. Ann. Chir. Plast. Esthet. https://doi.org/10.1016/j.anplas.2023.01.003 (2023).
Monstrey, S. J., Ceulemans, P. & Hoebeke, P. Sex reassignment surgery in the female-to-male transsexual. Semin. Plast. Surg. 25, 229–244 (2011).
Elfering, L. et al. How sensitive is the neophallus? Postphalloplasty experienced and objective sensitivity in transmasculine persons. Sex. Med. 9, 100413 (2021).
Canale, D. et al. Genital sensitivity and perceived orgasmic intensity in transgender women with gender dysphoria after gender-affirming surgery: a pilot study comparing pelvic floor evoked somatosensory potentials and patient subjective experience. J. Sex. Med. 19, 1479–1487 (2022).
Kloer, C. et al. Sexual health after vaginoplasty: a systematic review. Andrology 9, 1744–1764 (2021).
CDC. Discussing Sexual Health with Your Patients. CDC https://www.cdc.gov/stophivtogether/library/topics/prevention/brochures/cdc-lsht-prevention-brochure-clinicians-quick-guide-discussing-sexual-health-your-patients.pdf (2022).
Hein, L. C., & Levitt, N. Caring for…transgender patients. Nurs. Made Incredibly Easy 12, 28–36 (2014).
Bauer, G. R., Redman, N., Bradley, K. & Scheim, A. I. Sexual health of trans men who are gay, bisexual, or who have sex with men: results from Ontario, Canada. Int. J. Transgend. 14, 66–74 (2013).
Kenagy, G. P. & Hsieh, C. M. The risk less known: female-to-male transgender persons’ vulnerability to HIV infection. AIDS Care 17, 195–207 (2005).
Rowniak, S., Chesla, C., Rose, C. D. & Holzemer, W. L. Transmen: the HIV risk of gay identity. AIDS Educ. Prev. 23, 508–520 (2011).
Sevelius, J. “There’s no pamphlet for the kind of sex I have”: HIV-related risk factors and protective behaviors among transgender men who have sex with nontransgender men. J. Assoc. Nurses AIDS Care 20, 398–410 (2009).
Nemoto, T., Bödeker, B., Iwamoto, M. & Sakata, M. Practices of receptive and insertive anal sex among transgender women in relation to partner types, sociocultural factors, and background variables. AIDS Care 26, 434–440 (2014).
Dangerfield, D. T. II, Smith, L. R., Williams, J., Unger, J. & Bluthenthal, R. Sexual positioning among men who have sex with men: a narrative review. Arch. Sex. Behav. 46, 869–884 (2017).
Ock, M., Lim, S. Y., Jo, M. W. & Lee, S. I. Frequency, expected effects, obstacles, and facilitators of disclosure of patient safety incidents: a systematic review. J. Prev. Med. Public Health 50, 68–82 (2017).
Weiss, P. M. & Miranda, F. Transparency, apology and disclosure of adverse outcomes. Obstet. Gynecol. Clin. North Am. 35, 53–62 (2008).
Basch, E., Barbera, L., Kerrigan, C. L. & Velikova, G. Implementation of patient-reported outcomes in routine medical care. Am. Soc. Clin. Oncol. Educ. Book 38, 122–134 (2018).
Basch, E. et al. Overall survival results of a trial assessing patient-reported outcomes for symptom monitoring during routine cancer treatment. JAMA 318, 197–198 (2017).
Basch, E. et al. Symptom monitoring with patient-reported outcomes during routine cancer treatment: a randomized controlled trial. J. Clin. Oncol. 34, 557–565 (2016).
Oggesen, B. T., Hamberg, M. L. S., Thomsen, T. & Rosenberg, J. Exploring patients’ perspectives on late complications after colorectal and anal cancer treatment: a qualitative study. Curr. Oncol. 30, 7532–7541 (2023).
The National Academies Collection: Reports Funded by National Institutes of Health (eds Becker, T., Chin, M. & Bates, N.) (National Academies Press, 2022).
Orkin, B. A., Sinykin, S. B. & Lloyd, P. C. The digital rectal examination scoring system (DRESS). Dis. Colon Rectum 53, 1656–1660 (2010).
Serati, M., Espuña-Pons, M., Mouton-Puglisi, A. & Padoa, A. Iron deficiency and sexual dysfunction in women. Sex. Med. Rev. 27, 342–348 (2023).
Gulmez, H. et al. Impact of iron supplementation on sexual dysfunction of women with iron deficiency anemia in short term: a preliminary study. J. Sex. Med. 11, 1042–1046 (2014).
Wiegel, M., Meston, C. & Rosen, R. The female sexual function index (FSFI): cross-validation and development of clinical cutoff scores. J. Sex Marital Ther. 31, 1–20 (2005).
Tirabassi, G. et al. Vitamin D and male sexual function: a transversal and longitudinal study. Int. J. Endocrinol. 2018, 3720813 (2018).
Krysiak, R., Szwajkosz, A., Marek, B. & Okopień, B. The effect of vitamin D supplementation on sexual functioning and depressive symptoms in young women with low vitamin D status. Endokrynol. Pol. 69, 168–174 (2018).
Carrington, E. V. et al. Advances in the evaluation of anorectal function. Nat. Rev. Gastroenterol. Hepatol. 15, 309–323 (2018).
Bardin, M. G. et al. Clitoral blood flow using color Doppler ultrasonography in women with and without provoked vestibulodynia. Int. Urogynecol. J. 33, 1489–1494 (2022).
Heitmann, P. T. et al. Understanding the physiology of human defaecation and disorders of continence and evacuation. Nat. Rev. Gastroenterol. Hepatol. 18, 751–769 (2021).
Wang, X. T. et al. Meta-analysis of oncological outcome after abdominoperineal resection or low anterior resection for lower rectal cancer. Pathol. Oncol. Res. 21, 19–27 (2015).
Moszkowicz, D. et al. Where does pelvic nerve injury occur during rectal surgery for cancer? Colorectal Dis. 13, 1326–1334 (2011).
George, D., Pramil, K., Kamalesh, N. P., Ponnambatheyil, S. & Kurumboor, P. Sexual and urinary dysfunction following laparoscopic total mesorectal excision in male patients: a prospective study. J. Minim. Access. Surg. 14, 111–117 (2018).
Bae, S. U., Varela, C., Nassr, M. & Kim, N. K. Customized Denonvilliers’ fascia excision: an advanced total mesorectal excision technique for anteriorly located rectal cancer. Dis. Colon Rectum 66, e304–e309 (2023).
Yun, S. J. et al. Vitiligo-like depigmentation after pembrolizumab treatment in patients with non-small cell lung cancer: a case report. Transl. Lung Cancer Res. 9, 1585–1590 (2020).
Acknowledgements
The authors thank A. Fenner (Nature Reviews Urology) for providing initial support. D.C.M. is supported by the Office of The Director, National Institutes of Health, under Award Number DP5OD031876. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
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All authors researched data for the article, made a substantial contribution to the discussion of content, and reviewed and edited the article before submission. D.R.D. wrote the manuscript.
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S.E.G. is an investigator on the human papillomavirus vaccine and consultant for Merck. C.R.R. reports speaker training with Takeda. The other authors declare no competing interests.
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Nature Reviews Gastroenterology & Hepatology thanks Marco Romano, Laura Targownik and Christopher Velez for their contribution to the peer review of this work.
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Glossary
- Anodyspareunia
-
Painful receptive anal intercourse.
- Anorgasmia
-
Failure to achieve orgasm or the experience of weakened or diminished orgasms.
- Bottom
-
The receptive partner in anal intercourse; although this term has also been generalized in sexual minority culture to include the receptive partner in oral intercourse.
- Bottom-shaming
-
Judging, demeaning or devaluing someone for deriving pleasure from receptive anal intercourse.
- Bulboclitoris
-
Clitoris and vestibular bulbs.
- Butthurt
-
A colloquialism used to describe someone who is overly sensitive, potentially originating from a sensitive child who is spanked, but now also connotating that people who engage in receptive anal intercourse (RAI) might be sensitive and that RAI is painful, thus minimizing the association of pleasure and RAI.
- Dysorgasmia
-
Pain during orgasm.
- Neoanus
-
A reconstructed or created anus.
- Neoclitoris
-
A reconstructed or created clitoris.
- Neophallus
-
A reconstructed or created phallic structure, typically through metoidioplasty or phalloplasty.
- Neovagina
-
A reconstructed or created vagina.
- Pegging
-
Pleasurable receptive anal intercourse experienced through stimulation by an attachable artificial phallic object on a partner; commonly but not exclusively used in the context of a cisgender heterosexual male receiving anal pleasure from a cisgender woman with a strap-on dildo.
- Rimming
-
Pleasurable receptive anal intercourse experienced through stimulation by the tongue or mouth of a partner.
- Role-in-sex
-
The role a person identifies with during sexual intercourse (for example, top, bottom, versatile, side).
- Sexual and gender minority
-
Individuals who identify as lesbian, gay, bisexual, transgender, gender diverse, asexual, queer or intersex as well as those who do not but whose sexual orientation, gender identity or reproductive development varies from traditional, societal, cultural or physiological norms.
- Shower shot
-
Anorectal douching using an enema attached to a shower.
- Side
-
A person who does not identify with “top”, “bottom”, or “vers” and might not engage in anal intercourse.
- Social determinants of health
-
The environmental conditions in which people are born, reside, learn, work, worship, engage in recreational activities and age that influence health outcomes.
- Top
-
The insertive partner in anal intercourse; although this term has been generalized in sexual minority culture to also include the insertive partner in oral intercourse.
- Vers
-
Or verse, short for ‘versatile’, a person who engages in both the receptive and insertive role in intercourse.
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Cite this article
Dickstein, D.R., Edwards, C.R., Rowan, C.R. et al. Pleasurable and problematic receptive anal intercourse and diseases of the colon, rectum and anus. Nat Rev Gastroenterol Hepatol 21, 377–405 (2024). https://doi.org/10.1038/s41575-024-00932-1
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DOI: https://doi.org/10.1038/s41575-024-00932-1
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