New York-based doctor Evan Goldstein said that while anal sex is an important part of many gay men’s lives, injury is usually inevitable at some point — even if precautions are taken.
So for those gay men that bottom, anal fissures, small tears in the lining of the anal canal, are a reality. Don’t let the word small fool you either, just because the tear is small, the pain can be enormous.
Things like passing a hard stool can cause the tear. But it is often the case that the tear is associated with the trauma of anal intercourse. Symptoms include pain, discharge, bleeding or the development of a skin tag.
Goldstein, through his medical practice Bespoke Surgical, provides some numbers and insight into how gay men prepare, or don’t prepare, for anal sex.
His recent survey of 600 Americans showed most gay men prefer to be a top (39 percent); followed by versatile (33 percent) and then bottom (29 percent). He found that 39 percent of gay men have anal sex a couple times a week; 24 percent engage a couple times a month and 13 percent have anal sex every day.
“The issue with our culture and community is that most people don’t learn the right way to ‘bottom,’” said Goldstein, 42, a gay man who lives in New York City’s Upper West Side with his partner Andrew Yu and their twin five-year-old boys.
Goldstein’s data show that 41 percent of gay men have experienced tearing or other damage from anal sex.
“We want injury prevention — the right way to engage — to gradually get somebody to the point where they can receive,” Goldstein said. “It’s the bottom who needs to learn positioning and engagement and its incumbent on the tops to engage the correct way so injury doesn’t happen.”
Goldstein said education about anal sex is key, whether it’s preparation, diet and hygiene, positions, transitioning from being a top to being a bottom, sensations while bottoming (the good, the bad and the ugly, he said), anal ailments, treatments, aftercare and cleanliness.
As part of his practice he, not surprisingly, recently taught a class, ‘The Art of Bottoming’ at an event in NYC.
Goldstein’s top tips for injury prevention for bottoms include:
- Investing in an anal kit with three gradual dilators to allow “complete neuro-muscular control with precise relaxation.”
- Use of anal plugs in a stepwise fashion over four to six weeks. “With minimal use, a few times weekly for five or so minutes, one can achieve the desired outcomes,” he said.
- Implementing anal toys, such as anal plugs, into foreplay with lots of lubricant, not only lubricates the entire anal canal — minimizing injury — but also “truly dilates the anal sphincter,” which allows penile penetration.
- Proper positioning is key for entry and throughout the initial stages the bottom needs to be in continued control. “The first step is best achieved with the bottom on top, allowing the bottom to control how deep and fast they’re being penetrated,” he said.
- If you are a petite bottom, be cautious of both length and girth. Two places of common friction and potential injury is the over distension of the external skin and the underlying muscle. If one takes something beyond any of those capacities, tears can occur, limiting engagement.
Goldstein hits a lot of the same notes as those of Dr. Elie Schochet, a colon and rectal surgeon at Holy Cross Hospital in Fort Lauderdale.
Schochet is well known in the community (he’s been at Holy Cross for almost a decade). He’s also known for his previous “Happy Hiney Health” lectures at The Pride Center, where Schochet talked about South Florida’s (and the gay community’s) above average anal cancer rate and everything from removing foreign objects from patient’s anal canals to treatment for constipation, diarrhea, hemorrhoids and STDs.
Schochet said there are several myths associated with anal fissures.
“[One of the top myths is that] you can work through the pain,” Schochet said. “Anal fissures overlie the anal sphincters. When they're in spasm, nothing is getting in or out without significant pain that may shoot to the back, or legs, or torso,” he said.
Schochet suggests “heat and patience” to reset the sphincters, such as a hot shower just before a bowel movement to help pain and spasms.
Schochet said other myths are that hemorrhoid cream will help, and that you can ignore an anal fissure if it doesn’t hurt.
“Sometimes fissures will stop hurting, but not heal. Any fissure that doesn’t heal with basic measures needs to be evaluated by a specialist for possible biopsy,” he said.
Goldstein gives his patients a variety of options if they think they have an anal fissure.
“Whether you have one is always a tough question,” Goldstein said. “The reality is we’ve all been at that stage — irritation and mild bleeding. It’s different if you have ridiculous anal pain, a large amount of blood, swelling in the area, things persisting,” he said.
Goldstein said the… um… bottom line is that if you’re seeing a positive trajectory in two to three days, you can wait and watch. If there is worsening or persistent pain — see somebody.
“Acute fissures can heal without anal fissure surgery with an appropriate bowel regimen, as well as with the use of topical creams, suppositories, and refraining from intercourse,” Goldstein said. “However, most anal fissures that become chronic and non-healing will require surgical intervention,” he said.
Goldstein said he began his practice (with offices in New York and Los Angeles) because he saw a need for nonbiased, nonjudgmental care for the gay community — both preventative work and surgical correction.
Bespoke’s website, bespokesurgical.com, has lots of information about all things anal. Goldstein also has a large presence on social media (Facebook, Instagram) where you’ll find “Tales from the Tail” — real examples of patient problems and how they were corrected.
Contact Schochet at the Holy Cross Medical Group Colorectal Surgery Practice by calling 954-772-4553 or at medicalgroup.holy-cross.com.