Bryan Kutner is telling me how he got into studying butt stuff over coffee. “So,” Kutner says, “I was counseling cisgender men and trans folks in public sex venues — bathhouses basically — for an HIV/STI prevention project, and people would often share intimate details about their sex lives.” One night, a guy in his 50s commented, offhandedly, that bleeding after anal sex was normal. This was the second guy of the same age saying the same thing, and it baffled the public health worker. How could gay men in their 50s, he wondered, who’ve been sexually active for 30 plus years, not know that bleeding is unnecessary. “I thought, ‘Wait a second. If bleeding is regular for these guys then a medical provider needs to conduct an anal exam, to find and treat whatever is causing the bleeding.’” It struck Kutner that we’ve done a somewhat fair job of educating people about HIV. But could it be, he wondered, that that same public health effort inadvertently reinforced the notion that anal sex is inherently harmful? Could we be conflating anal sex with disease in such a way that we’ve trained people to expect and accept other sexual health problems, like bleeding or pain, that are preventable? “It’s almost like our HIV prevention campaigns have colluded with a taboo about anal sex. Maybe that’s inadvertent, like a natural consequence of repeated public health messaging, ‘Hey, think about HIV when you have anal sex.’ But, in other cases, that conflation of anal sex with harm is conspicuously informed by stigma toward anal sex. Remember that ‘It’s Never Just HIV’ campaign?”
While Kutner pondered the ramifications of these bathhouse conversations, he received a call from a friend as she walked down 8th Avenue after a gynecological visit. “She was in tears. She’d been in the stirrups and the doctor was nearly done with the exam and my friend asked, “Would you check a little lower? I think I felt a bump or something.” The doctor did look a little lower and saw a wart somewhere near her anus. The doctor’s response was accusatory, “Are you having anal sex? You shouldn’t be doing that. It’s dangerous.”
The doctor then froze the wart, one of a few options — and certainly a painful one given the location. “It struck me that my friend did the very thing we encourage people to do: ‘When you have a medical question, ask your doctor,’ right? But that resulted in a slap on her hand and an all-or-nothing message that she shouldn’t be having anal sex. It’s the opposite of harm reduction. Just telling someone not to do something, expecting somehow that a warning alone is going to scare people into changing behavior. Well, my friend never saw that doctor again and it disrupted the continuity of her health care to boot. But she didn’t stop having anal sex. She just stopped talking about it with her doctor.”
These two experiences got Kutner thinking that people, in general, may need basic information about anal health so they can advocate for themselves, and that providers specifically may need skills to broach this topic with their clients, to encourage disclosure by framing anal sexuality in terms of pleasure and health, rather than just harm. Kutner had been a public health trainer in the harm reduction movement for several years, so he developed a new training curriculum and piloted it through the Harm Reduction Coalition. The training on physiology and health went so well that he added another day focused on how to communicate information. “I based the training in motivational interviewing, one of the better researched interventions when it comes to helping me consider behavior change. With the help of all these public health workers who’ve attended, we now have little mantras that embrace the diversity of people who have anal sex. Like, ‘Everyone has an ass, so everyone has the capacity to enjoy anal sex.’ It’s really beautiful the way people frame this not in terms of gender, but in terms of the diversity of human sexuality, in a sex-positive way.”
Kutner, eventually decided it was time to get more training himself, so went back to school, first for an MPH in epidemiology and then a PhD in clinical psychology. He says he landed on this topic for my dissertation, thinking it might be useful to understand more clearly the possible relationships between devaluation of anal sexuality, the concerns and questions people harbor, and how this might affect our HIV prevention efforts. “In some ways, at least for queer men, we’ve placed anal sex at the center of the HIV epidemic, but we know so little about how people think and feel about it, outside of the focus on HIV.”As he prepared to train others, to his surprise, Kutner found there was so much to learn and convey in trainings. “If you gently stroke the top of your hand with your finger, see what sensations you notice,” he says, “Now flip your hand over and gently stroke your palm. You naturally feel a difference.” That Kutner says is an easy way to communicate the sensitivity of the anus, the opening before the anal canal. “It’s a part of the body with lots of nerve endings packed into a small area. That may be a hard concept to communicate as a health worker, but it’s a little easier with visuals and little tricks of the trade people share in trainings.”
There’s also the prostate, “Contractions around the prostate produce a sensation of orgasm, and typically these contractions contribute to ejaculation. But pressure internally from a toy, object, penis, or hand, or pressure externally against the perineum — aka the ‘taint’— can also produce this orgasmic sensation, even without ejaculation.” He adds, “Pelvic floor muscle exercises, like Kegel exercises, may also aid discovering this sensation, by building the ability to stay in the plateau phase of the sexual response cycle, riding the rise of orgasm without ejaculating — basically a multiorgasmic experience. It’s the p-spot in ‘male’ anatomy, akin to the g-spot in people with ‘female’ anatomy.” Kutner recommends a few books on the subject Multiorgasmic Man and another The Ultimate Guide to Prostate Pleasure.” And then of course, there’s Anal Pleasure and Health by Jack Morin which is a go to source because it’s so comprehensive.”
Kutner continues, “When I first started, people thought the training was all about men’s anal sexuality. But at a population level, there aren’t that many men who have sex with men, maybe 2-4 percent. Women make up a much bigger part of the world’s population, so if even a minority of women are having anal sex, it’s likely to outnumber men who have anal sex with other men. This is a woman’s health issue too – or, really more to the point, a health issue that isn’t about gender binaries but about the diversity of how human beings have sex.” At first, Kutner struggled to find accurate, science-based information about anal sexuality beyond men’s sexuality. “There was very little written about physiological sources of anal pleasure in relation to the clitoris. I kept searching online and one day in 2009 found an obscure blog post and YouTube video from the Museum of Sex. I didn’t know the clitoris had legs — and, apparently, we didn’t discover that until 2009!” There’s a lot more information out there than there used to be. “Still, there’s very little I’ve seen about lesbian and transgender anal sexuality – they’re both a very neglected area of research, I think. Most of what I’ve found, in general, is from a cisgender perspective, and mostly about penetration, which is just one aspect of sexual activity.”
On that note, Kutner shares some more of what surprised him as he learned more. The legs of the clitoris extend into the pelvic floor musculature and seem in part to be responsible for pleasure and possibly orgasm through anal stimulation, even when the visible clitoris is not directly stimulated.” Kutner notes, “The clitoris has legs and bulbs that extend deeper into the body than just the visible part under the hood.”
Kutner recounts how a trans man once described how hormone therapy enhanced his experience of anal sex, bestowing him with a sensation that he remarked, wassimilar to the way cisgender men describe satsifcation from prostate stimulation.
“There’s so much to learn,” Kutner says seriously as this is generally an understudied area of sex research. “I’m not exactly a sex researcher myself — as in I’m researching sociobehavioral phenomenon but not conducting direct experimental or observation studies of physiology and sexual response. This is all just stuff I’ve picked up by reading and talking with health providers and educators.”
Kutner’s been surprised by a lot since embarking on this field of study. Since early 2016, he’s been conducting his dissertation, a mixed-methods study on anal pleasure and health. “One thing I’d never considered is just how the omission of basic information about anal sexuality can affect people,” he says, “I interviewed cisgender guys as a lead up to developing quantitative measures for the online survey.” Guys asked him questions he’d never considered, “like whether someone can ejaculate directly from the ass — as in literally cum or ejaculate sexual fluid from the ass.” Kutner knows that’s not happening from an internal physiological process, “as far as I can tell: it’s lube, precum or semen from someone’s penis, not from the rectum.” But that’s not what his study participants said. “They encouraged me to look online for “creaming” videos because it’s a thing.” He laughs at his own naivete, “I didn’t know it was a thing AT ALL. And that’s amazing in itself. Here we are, 35 years into an epidemic spread in large part through anal sex, and people still haven’t been given accurate, specific responses to their questions about anal sex. And, at least in my case, I didn’t even know some of the questions they had!” If there’s shame in learning any of this, Kutner believes it lies, “in our neglect of such an obvious area of study.”
Another preliminary finding from the qualitative interviews Kutner found, is just how woven together experiences of devaluation are. “It’s not just that people stigmatize anal sexuality, all on its own. It’s racism, xenophobia, sexism, and other forms of human devaluation intersecting with people’s experiences of anal sex.” This in and of itself did not surprise Kutner, but, people shared quite painful experiences. Kutner pauses, “Some of these guys grew up thinking all gay men were supposed to enjoy anal sex, so syllogistically as they came of age desiring other men they thought they should bottom even if they didn't like it, even if it was painful and not pleasurable.” It didn’t occur to them that they could decline anal sex. They also didn’t know how they could learn how to find pleasure in it. Which to Kutner, “Sounds awfully similar to women’s sexual experiences catering to men’s desires rather than holistically to their own desires too.”
Kutner was also struck by how, at least for the men he interviewed, anal sex is intimately associated with experiences of racism and sexism. For example, one black man shared that even though a white sex partner would never consider himself to be racist, once in bed it became quickly apparent that his fantasies about anal sex were indeed racialized — and in ways that were not mutually pleasurable. Men of color, in particular, experienced being objectified by their race in ways that seemed to potentiate a partner’s pleasure even while it inhibited their own pleasure and, at times, lead to physical and psychological discomfort. Kutner says, “It’s a strange paradox that anal sex is obviously pleasurable to many people, but how it’s practiced is still mediated by social processes that make it less enjoyable and, at times, appear to increase psychological and physiologicalharm — and that appears to be experienced by men of color in very different ways than white men.”
Even with these painful experiences shared in research interviews, for the most part the people he’s surveyed are interested in hearing more about the positive aspects of anal pleasure. “They’re hungry to have their questions answered, and to hear more directly about anal sex.” That is what Kutner hopes to finally understand upon completing his dissertation, how to leverage these interests in anal sex to promote more engagement in HIV services. “That’s one of the problems we have with the epidemic in the U.S. We have all these interventions available — ARVs, PrEP, PEP, behavioral interventions — but can we find new ways to engage people?”
Bryan Kutner has worked in public health for over 15 years, first helping to launch the Harm Reduction Coalition's Oakland training calendar, then offering case management services for people living in supportive housing. In 2001, he began training for the University of California San Francisco AIDS Health Project, traveling throughout the state to facilitate workshops for HIV service providers and to collaborate with the California Department of Public Health on policies and procedures related to HIV counseling and testing. Bryan continues to consult with a handful of domestic and global NGOs to develop training programs for mental health, supportive housing, sexual health, and HIV prevention projects. He earned an MPH in Epidemiology from Columbia University, is nearing completion of a PhD in Clinical Psychology from the University of Washington, and is a member of the Motivational Interviewing Network of Trainers, a group dedicated to the dissemination and implementation of evidence-based practice. His survey is available at tinyurl.com/uwHealthStudy.