Abstract
Objective and Design Forced anal examinations are used to prosecute sexual and gender minorities (SGM) in at least seven countries under the presumption that decreased sphincter tone, estimated by a finger inserted into the anal canal, can detect persons practicing receptive anal intercourse. In a cross-sectional analysis of the baseline data from a longitudinal study, we aimed to determine factors associated with sphincter tone and the accuracy of sphincter tonality to detect persons engaging in receptive anal intercourse.
Setting Clinicians in Chicago, Houston, and Milwaukee, USA conducted digital anal rectal examinations (DARE) on 838 participants, 94.0% of whom were cisgendered males. Clinicians used the Digital Rectal Examination Scoring System to score sphincter resting tone (RT) and squeeze tone (ST). On a separate survey, individuals reported their preferred position for anal intercourse: i.e., either always/mostly insertive anal intercourse, always/mostly receptive anal intercourse, or both receptive and insertive anal intercourse. Multivariable regression assessed factors associated with decreased sphincter tone while area under the Receiver Operating Characteristic curves (AUC) estimated the accuracy of sphincter tonality to detect receptive anal intercourse.
Results 11.3% had decreased RT (95/838) and 6.3% had decreased ST (53/838). The accuracy of DARE to detect any receptive anal intercourse was little better than random guessing (AUC 0.53, 95% CI 0.51 to 0.55, and AUC 0.51, 95% CI 0.49 to 0.53, respectively. RT and ST decreased with age regardless of sexual behavior (ptrend<0.01 for both). Compared to individuals having always/mostly insertive anal intercourse, individuals having always/mostly receptive anal intercourse was associated with decreased RT, but not ST, while those equally preferring both insertive and receptive anal intercourse were not associated with decreased RT or ST.
Conclusions Decreased sphincter tone is uncommon among SGM who prefer receptive anal intercourse. Given virtually no accuracy, a finger inserted into the anus has no utility to detect individuals practicing receptive anal intercourse and thus should not be used as such.
Trial registration NCT04090060
What is already known on this topic To gather evidence for prosecution of sexual and gender minorities, forced anal exams are used in multiple countries. The examination includes inserting the index finger into the anal canal to detect decreased sphincter tone which is considered evidence of receptive anal intercourse. We found only two small studies (n= 58 and n=24) assessing factors associated with decreased sphincter tone and none assessing the accuracy of sphincter tone to detect sexual and gender minorities having receptive anal intercourse.
What this study adds Our study suggests that a finger inserted into the anal canal is not useful to detect a history of receptive anal intercourse. As such, the sexual practices of individuals cannot be known using a forced anal examination.
Competing Interest Statement
All authors have completed the ICMJE uniform disclosure form and declare: no support from any organisation for the submitted work except for AGN who received National Institutes of Health funding that was paid to his employing educational institution; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years except for AGN, EYC, and MWR who received National Institutes of Health funding that was paid to their employing educational institutions; no other relationships or activities that could appear to have influenced the submitted work.
Funding Statement
This research was supported by the National Cancer Institute of the National Institutes of Health under award numbers R01CA215403 and R01CA232892. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. This work was also supported by the Medical College of Wisconsin. The study sponsors had no role in study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication. The study authors had full access to the data and take responsibility for its integrity and accuracy.
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The Human Protections Committee of the Medical College of Wisconsin gave ethical approval for this work (PRO32999 and PRO33000).
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Data Availability
Fully de-identified datasets and data dictionary will be shared with properly trained investigators requesting such on the study website (https://mindyourbehind.org) within one year of study completion after assessment of institutional policies, Medical College of Wisconsin Human Research Protections Program rules, as well as local, state, and federal and tribal laws and regulations. Further information is available from the corresponding author upon request.