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Open in a separate window Note. Of all 81 study participants, only those quoted in the text are included in this table.

First same-sex sexual experiences Participants reported on their first same-sex sexual experiences and how old they were at the time. Sixteen participants indicated that their first same-sex sexual experience occurred before the age of 16; 44 participants were aged 16—19; and 17 had their first experiences after age 20; this data was missing from four respondents.

Most participants who were able to recall when they first experienced same-sex attractions reported that they experienced such attractions prior to their first same-sex sexual encounter.

More than three-quarters of participants described first same-sex sexual experiences that involved anal intercourse. Participants commonly described these experiences as painful. A smaller group of men described them as both painful and pleasurable. Six participants reported that their first same-sex sexual experience, beyond being painful, involved serious anorectal trauma.

Four of these participants reported bleeding during or after the encounter, and one reported having hemorrhoids piles at the time of first RAI. This participant, who had his first same-sex sexual experience at age 16, described several unexpected consequences, one of which was the disclosure of his sexual behavior to his mother: So around 11 a.

It was pain from behind. It was painful but I ignored it. The pain alerted me to go to the toilet, I felt like defecating. I went to the toilet and defecated, and as I was busy, blood dripped in the toilet. Afterwards I told my friend, and my friend explained to me what was happening. After some time I felt better and I took a bath and came home; when I got there I told myself that the pain would not happen again.

As Tlotliso goes on to explain, he eventually needed to seek medical intervention: On Monday, when I went to the toilet again, the same thing happened and my mom was at home. When I got there, the doctor told me to climb on the bed and he inspected me and when he was done he told my mother that I am being naughty and that I know what I did and that I will tell her what I did.

So my mother asked me what I did and I told her. This quotation illustrates a range of negative outcomes that could possibly have been prevented had Tlotliso received some advance education about how to avoid or address such outcomes. Attributions for Painful Receptive Anal Intercourse Participants were asked about subsequent same-sex sexual experiences i.

Twenty-one participants referred in their interviews to personal experiences with painful RAI, and we focus here on these descriptions. Additional participants made reference to anal sex as painful, though they were not necessarily describing personal experiences i. Partner characteristics The gay-identified men in our sample tended to have more same-sex sexual experience than their bisexual- or straight-identified counterparts.

It gets difficult because you have to tell him what to do, where to penetrate, what not to do, things like that. Sizwe shared the following story about a negative sexual experience: But he was my boyfriend, my steady boyfriend, so like I had to just, you know, end the relationship because of that sex.

Okay, what was painful about the sex? He was so controlling to me and he wanted whatever he wanted. Lutendo and Tumelo shared similar accounts. The experience, that person he controlled me over and he was just doing it and he was rushed, he was rough and rushed. Was it something that you felt needed to be reported? And did you tell him? Interviewers generally did not probe for specifics about the type of lubricants referred to in these instances, however.

Although it was the lack of lubricant in the context of sexual encounters that participants discussed in relation to painful RAI, participants also commented more generally on the limited availability of lubricants in their townships. Unlike condoms, which were widely available for free, lubricants generally needed to be purchased at venues located outside the townships such as pharmacies and adult shops. Alcohol consumption Participants linked alcohol consumption to painful RAI in several ways.

RAI was painful to some participants when they were sober, and was less painful when they were drunk. As Dingani explained, in describing how sex differed whether he was sober or drunk: When a guy is too rough, you can feel the pain and ask him to stop.

As Tumelo explained, when describing how drinking affected his sexual behavior, the numbing effect of alcohol during a sexual encounter could sometimes have consequences later: You feel them tomorrow. This quotation again illustrates that there could be multiple, mutually reinforcing reasons for painful RAI forgetting to use lubricant as a result of alcohol intoxication.

Finally, a few participants noted that RAI could be painful when their partners were drunk, either because they would have difficulty reaching a climax or became more aggressive. These strategies are discussed in further detail below. A small number of participants used strategies that would not fall into either of these categories. For example, although a larger number of participants had generally discussed alcohol use as a context for painful RAI, two participants reported using alcohol purposefully to prevent the pain associated with RAI.

Setting sexual boundaries Several participants described setting personal boundaries regarding what they would and would not do sexually as a response to experiences of painful RAI and to avoid anal pain.

These actions included abstaining from anal intercourse; having non-penetrative sex; and having rules about sex acts or sexual positions one would or would not perform. Dingani explained how he would communicate his boundaries to his sexual partners: When you are having sex do you negotiate what type of sex you want and do you also give the other person a chance to voice what he wants?

Yes, we talk about it first. You speak about frozen; which other positions do you negotiate? So I will tell him to think of something. Kabelo described a similar negotiation process, explaining that he would make assessments about what type of sex to engage in on a case-by-case basis: When you are with a man would it be clear from the start what type of sex you will have and how is it clear what type of sex you will be having?

How big it is…? It depends on the guy, whether he is rough or gentle. If he is rough, you can tell him that he is too rough and you can try a second option. And most of the time they agree?

The above example illustrates that boundary-setting might happen not only case-by-case, but from moment to moment, as needed to ensure a pleasurable sexual experience.

This example also illuminates the overlapping factors that could structure the experience: Some participants set sexual boundaries specifically related to lubricant use, saying that they would not engage in anal intercourse if lubricant was not available. As Kabelo also explained: Have they done it by force to you without lubricant? Sexual boundaries were not always respected, however, particularly from sexually abusive partners.

For example, Mosegi described how what began as a consensual sexual encounter ended in rape when he withdrew consent during an attempt at intercourse that was painful: Some other guy, we agreed to each other, we went to his place and then he was beating me because, how can I put it?

He could not like penetrate it to me. And then he was busy like trying to force himself on me. And so why did he end up beating you up?

Because I was telling him he could not enter me…He started to beat me and hit me with a bottle…I was scared of him…He tried to force himself on me. And then I was like, I became relaxed anyway for him to do his job. Lubricant use The majority of participants indicated that they regularly used lubricants during anal intercourse to make penetration easier and reduce pain.

As Masopha explained, I would say to gays, the lubricants are the best things since sliced bread. Like initially the sex was painful and like it was unbearable, and there were cuts and there was this and there was this. But because of the lube, then the sex it is more easy and bearable I think.

Use of commercially available water-based lubricants such as KY Jelly, Durex Play, and Assegai, was most commonly reported.

Some participants reported using oil-based lubricants such as jojoba or baby oil and Vaseline; Remicaine gel which contains lidocaine ; plain yogurt; and saliva. For Lesedi, such alternative lubricants were used when commercial lubricants were unavailable: Most participants understood the importance of water-based lubricants as an HIV risk reduction tool when used alongside latex condoms, explaining that lubricants decreased friction and reduced the likelihood of condom breakage.

Mareka also referred to the ability of lubricants to both increase comfort during RAI and prevent condom failure: Because I have experienced that the condom—it breaks when you are not using lubrication.

Participants attributed painful RAI to various factors and coped with it in different ways, but there were some clear commonalities in their descriptions. The ways in which these men are already coping with this issue also suggest several opportunities for effective sexual health and HIV prevention educational interventions. Their responses to painful RAI can also be optimized so that they yield the greatest health benefits i.

The qualitative nature of this study provides more nuanced information about some issues that have been raised in the few previous studies of painful RAI. This experience differential in some cases led to intercourse that was painful for the receptive partner. MSM engaging in RAI therefore may have an important role as far as expressing their preferences to partners during anal sex; many were quite capable of articulating their likes and dislikes to the study interviewers and could potentially be empowered to do the same during sexual encounters.

Gendered power dynamics appear to play an important role, but further study is needed to better understand the way in which such dynamics shape sexual encounters and relationships. Although we make comparisons to other studies with some caution, given that participants in this study were not asked directly about painful RAI, we note that no participants in this study reported limiting their behavior to insertive anal intercourse in response to pain in the receptive role, although this has been found among MSM in the U.

Perhaps some Black South African MSM are unlikely to switch their sexual roles to manage sexual pain given the importance of sexual role to overall sexual and gender identity.

A few studies have considered the relationship between sexual role preferences and gender expression in MSM e. Several strengths and limitations of this study should be noted. Given the sampling approach, the participants in this study are not necessarily representative of Black South African MSM, and findings are not generalizable to other populations of MSM.

However, more feminine, gay-identifying MSM were best represented in the sample and it was their voices that were dominant on the issue of painful RAI; the perspectives of MSM engaging in insertive AI should be solicited as part of future studies of this topic.

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Open in a separate window Note. Of all 81 study participants, only those quoted in the text are included in this table. First same-sex sexual experiences Participants reported on their first same-sex sexual experiences and how old they were at the time.

Sixteen participants indicated that their first same-sex sexual experience occurred before the age of 16; 44 participants were aged 16—19; and 17 had their first experiences after age 20; this data was missing from four respondents.

Most participants who were able to recall when they first experienced same-sex attractions reported that they experienced such attractions prior to their first same-sex sexual encounter. More than three-quarters of participants described first same-sex sexual experiences that involved anal intercourse.

Participants commonly described these experiences as painful. A smaller group of men described them as both painful and pleasurable.

Six participants reported that their first same-sex sexual experience, beyond being painful, involved serious anorectal trauma. Four of these participants reported bleeding during or after the encounter, and one reported having hemorrhoids piles at the time of first RAI.

This participant, who had his first same-sex sexual experience at age 16, described several unexpected consequences, one of which was the disclosure of his sexual behavior to his mother: So around 11 a. It was pain from behind. It was painful but I ignored it. The pain alerted me to go to the toilet, I felt like defecating. I went to the toilet and defecated, and as I was busy, blood dripped in the toilet.

Afterwards I told my friend, and my friend explained to me what was happening. After some time I felt better and I took a bath and came home; when I got there I told myself that the pain would not happen again. As Tlotliso goes on to explain, he eventually needed to seek medical intervention: On Monday, when I went to the toilet again, the same thing happened and my mom was at home.

When I got there, the doctor told me to climb on the bed and he inspected me and when he was done he told my mother that I am being naughty and that I know what I did and that I will tell her what I did. So my mother asked me what I did and I told her. This quotation illustrates a range of negative outcomes that could possibly have been prevented had Tlotliso received some advance education about how to avoid or address such outcomes. Attributions for Painful Receptive Anal Intercourse Participants were asked about subsequent same-sex sexual experiences i.

Twenty-one participants referred in their interviews to personal experiences with painful RAI, and we focus here on these descriptions. Additional participants made reference to anal sex as painful, though they were not necessarily describing personal experiences i. Partner characteristics The gay-identified men in our sample tended to have more same-sex sexual experience than their bisexual- or straight-identified counterparts. It gets difficult because you have to tell him what to do, where to penetrate, what not to do, things like that.

Sizwe shared the following story about a negative sexual experience: But he was my boyfriend, my steady boyfriend, so like I had to just, you know, end the relationship because of that sex. Okay, what was painful about the sex? He was so controlling to me and he wanted whatever he wanted. Lutendo and Tumelo shared similar accounts. The experience, that person he controlled me over and he was just doing it and he was rushed, he was rough and rushed. Was it something that you felt needed to be reported?

And did you tell him? Interviewers generally did not probe for specifics about the type of lubricants referred to in these instances, however.

Although it was the lack of lubricant in the context of sexual encounters that participants discussed in relation to painful RAI, participants also commented more generally on the limited availability of lubricants in their townships. Unlike condoms, which were widely available for free, lubricants generally needed to be purchased at venues located outside the townships such as pharmacies and adult shops. Alcohol consumption Participants linked alcohol consumption to painful RAI in several ways.

RAI was painful to some participants when they were sober, and was less painful when they were drunk. As Dingani explained, in describing how sex differed whether he was sober or drunk: When a guy is too rough, you can feel the pain and ask him to stop. As Tumelo explained, when describing how drinking affected his sexual behavior, the numbing effect of alcohol during a sexual encounter could sometimes have consequences later: You feel them tomorrow.

This quotation again illustrates that there could be multiple, mutually reinforcing reasons for painful RAI forgetting to use lubricant as a result of alcohol intoxication. Finally, a few participants noted that RAI could be painful when their partners were drunk, either because they would have difficulty reaching a climax or became more aggressive. These strategies are discussed in further detail below. A small number of participants used strategies that would not fall into either of these categories.

For example, although a larger number of participants had generally discussed alcohol use as a context for painful RAI, two participants reported using alcohol purposefully to prevent the pain associated with RAI. Setting sexual boundaries Several participants described setting personal boundaries regarding what they would and would not do sexually as a response to experiences of painful RAI and to avoid anal pain.

These actions included abstaining from anal intercourse; having non-penetrative sex; and having rules about sex acts or sexual positions one would or would not perform.

Dingani explained how he would communicate his boundaries to his sexual partners: When you are having sex do you negotiate what type of sex you want and do you also give the other person a chance to voice what he wants? Yes, we talk about it first.

You speak about frozen; which other positions do you negotiate? So I will tell him to think of something. Kabelo described a similar negotiation process, explaining that he would make assessments about what type of sex to engage in on a case-by-case basis: When you are with a man would it be clear from the start what type of sex you will have and how is it clear what type of sex you will be having? How big it is…? It depends on the guy, whether he is rough or gentle. If he is rough, you can tell him that he is too rough and you can try a second option.

And most of the time they agree? The above example illustrates that boundary-setting might happen not only case-by-case, but from moment to moment, as needed to ensure a pleasurable sexual experience. This example also illuminates the overlapping factors that could structure the experience: Some participants set sexual boundaries specifically related to lubricant use, saying that they would not engage in anal intercourse if lubricant was not available.

As Kabelo also explained: Have they done it by force to you without lubricant? Sexual boundaries were not always respected, however, particularly from sexually abusive partners. For example, Mosegi described how what began as a consensual sexual encounter ended in rape when he withdrew consent during an attempt at intercourse that was painful: Some other guy, we agreed to each other, we went to his place and then he was beating me because, how can I put it?

He could not like penetrate it to me. And then he was busy like trying to force himself on me. And so why did he end up beating you up? Because I was telling him he could not enter me…He started to beat me and hit me with a bottle…I was scared of him…He tried to force himself on me. And then I was like, I became relaxed anyway for him to do his job. Lubricant use The majority of participants indicated that they regularly used lubricants during anal intercourse to make penetration easier and reduce pain.

As Masopha explained, I would say to gays, the lubricants are the best things since sliced bread. Like initially the sex was painful and like it was unbearable, and there were cuts and there was this and there was this. But because of the lube, then the sex it is more easy and bearable I think. Use of commercially available water-based lubricants such as KY Jelly, Durex Play, and Assegai, was most commonly reported. Some participants reported using oil-based lubricants such as jojoba or baby oil and Vaseline; Remicaine gel which contains lidocaine ; plain yogurt; and saliva.

For Lesedi, such alternative lubricants were used when commercial lubricants were unavailable: Most participants understood the importance of water-based lubricants as an HIV risk reduction tool when used alongside latex condoms, explaining that lubricants decreased friction and reduced the likelihood of condom breakage.

Mareka also referred to the ability of lubricants to both increase comfort during RAI and prevent condom failure: Because I have experienced that the condom—it breaks when you are not using lubrication. Participants attributed painful RAI to various factors and coped with it in different ways, but there were some clear commonalities in their descriptions.

The ways in which these men are already coping with this issue also suggest several opportunities for effective sexual health and HIV prevention educational interventions.

Their responses to painful RAI can also be optimized so that they yield the greatest health benefits i. The qualitative nature of this study provides more nuanced information about some issues that have been raised in the few previous studies of painful RAI.

This experience differential in some cases led to intercourse that was painful for the receptive partner. MSM engaging in RAI therefore may have an important role as far as expressing their preferences to partners during anal sex; many were quite capable of articulating their likes and dislikes to the study interviewers and could potentially be empowered to do the same during sexual encounters.

Gendered power dynamics appear to play an important role, but further study is needed to better understand the way in which such dynamics shape sexual encounters and relationships. Although we make comparisons to other studies with some caution, given that participants in this study were not asked directly about painful RAI, we note that no participants in this study reported limiting their behavior to insertive anal intercourse in response to pain in the receptive role, although this has been found among MSM in the U.

Perhaps some Black South African MSM are unlikely to switch their sexual roles to manage sexual pain given the importance of sexual role to overall sexual and gender identity. A few studies have considered the relationship between sexual role preferences and gender expression in MSM e. Several strengths and limitations of this study should be noted.

Given the sampling approach, the participants in this study are not necessarily representative of Black South African MSM, and findings are not generalizable to other populations of MSM. However, more feminine, gay-identifying MSM were best represented in the sample and it was their voices that were dominant on the issue of painful RAI; the perspectives of MSM engaging in insertive AI should be solicited as part of future studies of this topic.

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  1. Although it was the lack of lubricant in the context of sexual encounters that participants discussed in relation to painful RAI, participants also commented more generally on the limited availability of lubricants in their townships. Most participants who were able to recall when they first experienced same-sex attractions reported that they experienced such attractions prior to their first same-sex sexual encounter. Participants who were able to exert or share control in sexual situations were best able to avoid the experience of painful RAI.

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