Everything you wanted to know about bottoming but were too afraid to ask.


When it comes to having safe and pleasurable anal sex, it’s important to know all the facts. With that in mind, we asked Dr. Joseph Terlizzi, a New York-based colon and rectal surgeon, for the lowdown on how gay and bi men can prepare, how to do the deed, and how to stay safe post-coital. Check out his expert advice on how to make anal sex more pleasurable:  

How To Prepare for Bottoming (Along With Some Common Mistakes)

While maintaining anal hygiene is important, people tend to be too fastidious when it comes to cleaning up before anal intercourse. Common mistakes I see patients make include using chemical wipes (the perfumes and preservatives make them irritating) and wiping too much (friction can lead to abrasions). This causes the skin around the anus to become inflamed, leading to thickening and ultimately itching or discomfort with sex. In fact, chemical wipes and over wiping are the most common causes of anal itch (if you haven’t experienced this…trust me, you don’t want to). So forget the harsh scents and chemicals — before sex, simply clean the outside of the anus well in the shower or bath with plain water or a very gentle soap.

It’s also helpful to consistently eat a high fiber diet that includes foods such as whole grains, broccoli, and beans — as this regulates bowel movements and decreases the likelihood of soiling during sex. Fiber helps bulk up stool and decreases liquidity, further minimizing the chance of a mess. In general, men should consume 30-40 grams of fiber per day, and women should consume 25-30 grams of fiber per day.

Due to the common fear of excrement rubbing off on one’s partner, many people perform enemas (whereby they inject liquid into the rectum) before engaging in anal sex. While enemas may seem like a logical way to avoid an embarrassing interaction, I strongly advise against them. Enemas increase your risk of acquiring infections, including gonorrhea, chlamydia, hepatitis and even HIV. In fact, rectal biopsies have found that individuals who performed enemas with tap water or soap suds show deterioration in their intestinal lining, resulting in increased susceptibility to pathogens. Additionally, among subjects who performed 50 or more enemas in their lifetime, there is a trend for increased risk of anal dysplasia (which can lead to anal warts and anal cancer). If you don’t feel like you need to go to the bathroom (we’re talking number two here, people), the rectum is likely empty, and you will be ready for anal sex.

If you just read this paragraph, rolled your eyes, and still plan to use enemas, there are steps you can take to mitigate the risks. First, it’s important to lube up so that you don’t damage the anal wall. Second, keep in mind that after the enema is about 1.5 inches inside, you won’t feel sharp pain — that’s because your rectum doesn’t have this type of pain receptor. Therefore, it’s important to choose an enema that has a smooth nozzle to prevent cuts and nicks. Make sure to use warm water so that your sphincters don’t tighten, but don’t make it so hot that you will burn yourself (I’ve seen several patients burn their rectum from hot enemas!). Ensure that there is no soap in the enema, as this can cause more irritation. Most importantly, only use a small volume of water (you can try the little bulbs that are sold in drug stores to clean out your ears). The human colon is 5 feet long and you don’t have to clean the stool out of the entire colon! If you try to clean high up, the water will mix with the stool. This can fill the rectum with liquid stool, running the risk that you will have a messy experience.

Getting Down to Business

Now for the fun part.

Step 1: Foreplay.

If your anus is too tightly contracted when you are first penetrated, you’ll run the risk of tearing skin or damaging your sphincter. That’s why it’s important to relax your anus before penetration using various foreplay techniques and to keep your anus relaxed and well-lubricated while bottoming.

Toys present an excellent way to prepare and relax before intercourse, but they can easily cause trauma if used incorrectly, and even spread infections if shared. Passing them back and forth between partners without thoroughly washing them can spread STIs. Be careful, too, that the toy is not larger than your partner’s penis or strap-on — and if you’re new to anal, start small and work your way up. Opt for softer latex toys that are much less likely to cause trauma than ones made with more rigid materials. I don’t recommend butt plugs that get wider at the base. If you decide to use one, make sure that you’re careful that the wide base does not tear anal muscle fibers.

Rimming can provide some lubrication and helps the anus relax before sex. That said, rimming can put both partners at risk for STIs, so be careful. Dental dams may be used as a protective barrier to minimize the risk of infection, but can obviously be awkward to use.

Step 2: Condoms.

Adequate water or silicone-based lubricants with condoms offer the best protection during anal sex, as these lubricants reduce friction during the act and won’t degrade the latex condom the way oil-based lubes can. Condoms are the best barrier against STIs, though their efficacy can vary depending on the type of infection. It’s impossible to understate the importance of condoms in minimizing your risk of STIs: among men who used condoms during every instance of anal intercourse, rates of HIV infection were reduced by 70 percent compared to men who never used them. Condoms are unfortunately less effective for STIs like herpes, HPV, and syphilis, which can be spread by skin-to-skin contact. It’s important to put the condom on before his penis has any contact with your anus, as STIs can be spread even before penetration.

While I can’t overemphasize the importance of using condoms, I strongly recommend PrEP for those who choose to go bareback (even if you only ditch the condoms every once in a while). When taken correctly, Truvada for PrEP reduces the risk of contracting HIV from sex by up to 99 percent. Even if you are consistently using condoms, PrEP can serve as a valuable backup if you are at even a minor risk for HIV exposure. It is very important that you get your PrEP from a healthcare professional who is comfortable prescribing the medication, who you can find by using our Lighthouse doctor search function. I have heard of individuals getting Truvada on the streets and this is a terrible idea. First, there is no way to ensure that what you’re taking is safe. Second, it is important that your doctor checks your kidney function and other lab tests every few months. If you’re worried about cost, don’t be; the company that makes the medication has an assistance program, so most people pay nothing for PrEP!

Step 3: Penetration.

After foreplay, lubricate the outside of the anus and your partner’s penis. It’s important not to stimulate the bottom’s penis while attempting penetration. During penetration, if the bottom’s penis is stimulated, he is likely to experience the bulbocavernosus reflex, or the involuntary contraction of the anal sphincters. This reflex is more pronounced in uncircumcised men, and will make bottoming more painful and difficult.

Gently allow penetration to the point of minimal discomfort. It may be more comfortable for the bottom to control penetration by sitting on their partner’s penis. Within a minute, the sphincter will relax and the penis can be slowly inserted fully.

Once the sphincter is fully relaxed, intercourse should not be painful and stimulation of the bottom’s penis will no longer cause difficulty with anoreceptive intercourse.

Post-Coital Cleaning

After anal sex, shower normally with a gentle soap. Clean the outside of the anus very gently — do not attempt to scrub. Do not use enemas, including soap suds or Fleets. Get tested for STIs every three months if you are having anal intercourse with more than one partner, and every six months if you are monogamous. You can easily find a gay-friendly or gay-identifying doctor through Lighthouse to avoid negative discrimination or stigma.

What If Bottoming Still Isn’t Blissful?

If you are unable to enjoy anal intercourse, there could be a few factors at play.

When bottoming hurts, it could be that your anus is anatomically too tight or you are unable to relax, which is oftentimes a psychological response. Many people have had negative bottoming experiences in the past or simply have a fear of the unknown, rendering them unable to relax their anus and enjoy safe and pain-free anal intercourse. Some people are simply tighter than others — and some penises are larger than others — which can make anal intercourse more painful.

For either problem, I suggest trying dilators. Available in medical supply stores, dilators provide a safe and secure way to become more comfortable with anal sex. Start small, leave the dilator in place for 10 minutes three times a day, and use the same size for a week. Increase to the next size on a weekly basis until you reach the size of your partner’s penis.

Dilators help with psychological fears by preparing you more for what to expect, giving you total control over your body, and erasing any fear or embarrassment in the eyes of a partner. Physically, they allow the sphincter to accommodate a penis over time and should help bottoming get easier

If for any reason anal sex remains painful or you notice the appearance of lumps, bleeding, or an ongoing itch, see a healthcare professional immediately for a thorough anorectal examination.

Find Bottom Friendly Medical Support

Despite the fact that both men and women have been engaging in anal sex since the ancient Greeks (and probably long before that), there remains, in many circles, a stigma attached to it. But it’s paramount that people who are having anal sex feel comfortable discussing it with a knowledgeable and respectful healthcare provider. That’s why at Lighthouse, we work to connect patients with LGBTQ-affirming healthcare providers who have the training and experience necessary to provide holistic and nonjudgmental care. Because when it comes to bottoming — or any part of your sex life — no subject should be taboo.

Interested in learning more? Make an appointment with Dr. Terlizzi today. 

Citations

Noor, S. W. & Rosser, B. R. S. Enema Use Among Men Who Have Sex with Men: A Behavioral Epidemiologic Study with Implications for HIV/STI Prevention. Archives of Sexual Behavior 43, 755–769 (2014).

Schmelzer, M., Schiller, L. R., Meyer, R., Rugari, S. M. & Case, P. Safety and effectiveness of large-volume enema solutions. Appl Nurs Res 17, 265–274 (2004).

Richel, O., De Vries, H. J. C., Dijkgraaf, M. G. W., Van Noesel, C. J. M. & Prins, J. M. Risk Factors for the Presence of Anal Intraepithelial Neoplasia in HIV+ Men Who Have Sex with Men. PLoS ONE 8, e84030 (2013).

Politch, J. A., Mayer, K. H. & Anderson, D. J. HIV-1 is undetectable in preejaculatory secretions from HIV-1-infected men on suppressive HAART: AIDS 30, 1899–1903 (2016).

Rodger, A. J. et al. Sexual Activity Without Condoms and Risk of HIV Transmission in Serodifferent Couples When the HIV-Positive Partner Is Using Suppressive Antiretroviral Therapy. JAMA 316, 171–181 (2016).

Podnar, S. Clinical elicitation of the penilo-cavernosus reflex in circumcised men. BJU Int. 109, 582–585 (2012).

Goldstone, S. E. The ins and outs of gay sex: a medical handbook for men. (Dell Pub, 1999).

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