Twenty-two men were referred to the research team; of these two declined to participate due to time constraints and twenty men participated in the study. Interviews were an average length of 24 minutes (range 15 to 34 minutes).
The age of the participants ranged from 21 to 53 years, with a median age of 31 (interquartile range [IQR] 27-39) years. The demographics of the participants are shown in Table 1 below.
Anal self-examination was defined as regular based on participants’ perception of whether they were performing ASE regularly or infrequently. Three groups of men emerged in this study: those who were already performing regular anal self-examination, those who infrequently or occasionally performed anal self-examination and those who had never performed anal self-examination. Men who were performing anal self-examination occasionally were not familiar with the term “anal self-examination”, however, after explaining the procedure using pictures of anal self-examination, most participants reported having performed similar examinations previously. Among the three men who had never performed anal self-examination, none knew about performing anal self-examination for health reasons before the interview. These three men, who were HIV-negative, had no previously known abnormalities in their anus and all of them practised versatile anal sex position.
Overall, most participants had performed some form of anal self-examination at least once previously (17 men); among these men, half were regularly performing anal self-examination (11 men) and about a third occasionally performed anal self-examination (6 men).
As part of the interview, men were shown four potential positions that they would be likely to adopt during anal self-examination (supplementary table). Most participants preferred to lie on their side for anal self-examination, while some reported they preferred squatting and standing positions. A couple of men reported performing anal self-examinations while lying on their back with legs raised. The participants reported performing anal self-examination mostly in the shower and toilet for standing and squatting positions, followed by in the bedroom for lying positions.
Four major themes and 12 sub-themes emerged from the study: (1) Reasons for performing anal self-examination, (2) Preferred resources for anal self-examination, (3) Attitudes towards partner anal examination, and (4) Acceptability of anal self-examination (Table 2).
1. Reasons for performing anal self-examination
Reasons for performing anal self-examination varied, but generally involved concerns about symptoms related to sexually transmitted infections (STI). The reasons that men who had ever performed anal self-examination are show in Figure 1.
Most men who regularly or occasionally performed anal self-examination did so for health reasons. Some men regularly checked their anus for signs of STIs, while some were prompted by previous experiences of non-STI anal problems such as haemorrhoids or fissures or specific STI events such as genital herpes, syphilis or genital warts infections. When asked about their main concerns, most men worried about STIs and some men, mostly those who were living with HIV, were concerned about anal cancer. A few men expressed feeling distressed on finding an abnormality, while other men reported they would seek medical advice instead of worrying.
Most men who regularly performed anal self-examination for health concerns felt performing anal self-examination regularly was a way to maintain their anal health.
"I would say like once every month, I try to do a rectal examination myself, just to check that there are no warts, that there’s not anything that I have to worry about.."
— Participant 20, not living with HIV and not taking PrEP, age 30-40
Among the occasional or infrequent anal self-examination users, most had performed anal self-examination as a once off or within a limited timeframe in response to a specific health concern. While the health concern that prompted a period of anal self-examination varied among participants, men in this category described examining their anus in response to symptoms suggestive of an STI or treatment required for anal warts. The time frame of practising anal self-examination varied; men who checked their anus for STI symptoms described performing an exam as a once-off as a way to investigate an unpleasant pain or burning in their anus, while those who were taking anal warts treatment described examining their anus while inserting the medication and checking for the continued existence of warts in the anus for a period of time during treatment.
Around a third of men reported performing anal self-examination for sexual pleasure. These men examined their anus incidentally while pleasuring themselves. The frequency with which these men inserted their finger into their anus for pleasure varied, but all described being able to tell if they felt an abnormality.
"I have done that for sexual pleasure, but not for medical purposes…I’m certain that if I – because I am sexually active, I’m sure I would have noticed if there was something that didn’t feel normal."
—Participant 4, not living with HIV and taking PrEP, age 20-30
A few men performed anal self-examination for hygiene or cleaning purpose.
“So, like even if I’m not having sex now I’ve still been douching to clean up and just keep checking it to make sure that it’s not bigger or smaller or there’s more around it or whatever”.
—Participant 10, HIV negative, taking PrEP, age 20-30
Table 3 provides example quotes relating to the reasons for previously performing anal self-examination. Some men conducted anal self-examination for more than one reason such as checking the anus for anal pathologies and pleasure or for cleaning and pleasure.
2. Preferred resources for anal self-examination
Most men preferred learning from online resources, although some preferred learning from a health professional, and a few preferred learning by practising anal self-examination without any guidance from online, health professionals or friends and partners.
Self-learning through online resources or self-practice
Men who preferred learning anal self-examination through online resources reported accessibility as the main reason for their preference.
“It’s the most easily accessed…. online’s probably the easiest resource cause everyone owns a phone, everyone owns a computer. You know, like it’s readily accessible.”
Participant 2, not living with HIV and not taking PrEP, age 20-30
Men who self-learned without guidance from anyone or any resources described anal self-examination as being easy to learn. These participants reported that self-exploration to teach themselves essentially required the use of “common sense” and knowing their own body helped them to distinguish between normal and abnormal findings (see Table 4 for example quotes).
Learning through healthcare professionals and trusted organisations
Many men indicated that they preferred having a health professional to teach them how to do anal self-examination. The majority of men who preferred a health professional teach them were men who were infrequently practising or had never performed anal self-examination and were uncertain about what to look or feel for during the examination. Their main concern was not being able to tell the difference between normal and abnormal findings and preferred a clinician teach them about anal self-examination.
“Yeah, it doesn’t have to be too in-depth because maybe if things like abnormalities of what to feel for, although I’m pretty sure I could tell what to feel for but just somethings that I might not know. Even just a normal explanation in laymen terms just so I completely understand, rather than trying to wing it myself.”
—Participant 14, not living with HIV and taking PrEP, age 20-30
Several men indicated they would like clinicians to initiate the conversation and educate them about anal self-examination but that once they knew how to perform anal self-examination properly, they would be comfortable to do it themselves. These men felt that while the internet would be helpful to learn how to do anal self-examination, a person would first need to know about anal self-examination and why it should be done before they would think to look up how to do it.
“I think places like Pronto [peer-led community service offering HIV and sexual health screening], and places like here [Melbourne Sexual Health Centre, a sexual health clinic], just during general screenings, I think if either doctors …sort of ask the patients, you know, like, have you – or do you ever do a personal anal examination? I think you’d have so many people who sort of are a bit like me, you know, and don’t really know what the doctors mean. I guess that’s how we become educated.”
—Participant 4, not living with HIV and taking PrEP, age 20-30
3. Attitudes towards partner anal examination
Responses were mixed in terms of men’s comfort levels with partner-assisted examination. Half of the participants (10/20, 50%) reported they were comfortable having their partners perform an anal examination on them, although they would only agree to partner examination if they were in a trusting relationship with a partner or a friend. The other half of the participants (10/20, 50%) were not comfortable having their partners examine their anus.
Willing to have partner anal examination if in a trusted or table relationship
Among those who were comfortable having a partner perform anal examination, trust was the main factor. Some men reported this trust came from regular partnership or friendship, whereas for others it was about a developed intimacy between sexual partners. Nevertheless, these men felt they would not ask a casual partner to examine them for fear it would be awkward. Men who reported being “open” and “liberal” regarding conversations around anal health appeared were more likely to be comfortable with having a partner administer anal examination themselves (see Table 5 for example quotes).
Not comfortable with partner anal examination
Among men who were not comfortable with a partner performing anal examination, some preferred to keep their medical and sex life separate from their partners (see Table 5 for example quotes). They also placed trust in health professionals and would prefer to see a doctor about STI or sexual health-related issues. A few men felt that it was “weird” to ask someone else to do it for them when they could do the examination themselves.
“… I could do it myself yeah it’s a bit weird to ask someone else to do it for you.”
—Participant 16, not living with HIV and not on PrEP, age 30-40
4. Acceptability of anal self-examination for syphilis detection
Most men reported they would be willing to practice anal self-examination for syphilis detection in the future if it was recommended by a health professional, if it was proven effective or if they were already performing regular anal self-examination for health concerns. However, some men still had hesitations citing reasons such as lack of knowledge and wanting more evidence that such screening was helpful before initiating a regular practice (Table 6).
Acceptable to perform anal self-examination if recommended by a health professional
Men who had never performed or infrequently performed anal self-examination reported that they would be willing to start regularly examining their anus for signs of syphilis if it was recommended by a health professional (Table 6).
Most men generally believed that anal self-examination for syphilis detection would be acceptable in the wider MSM community if recommended by a healthcare professional. Some men expressed that any tests or methods that could screen STI quickly would be beneficial to MSM community and MSM would be happy to do whatever it takes to reduce the risk of syphilis infection (Table 6).
Open to perform anal self-examination when proven effective
A few men reported they would need more evidence on the effectiveness of anal self-examination as a screening tool for syphilis before performing a self-exam regularly.
“…Unless they told me the reason to do it, like why am I doing this, I wouldn’t really do it.”
— Participant 8, not living with HIV and taking PrEP, age 31
Already performing regular anal self-examination for health reasons
Whilst men who were already performing anal self-examination regularly found it acceptable to perform anal self-examination for detection of syphilis, a couple of these men raised concerns about being over reliant on their own judgement, particularly if there were some abnormal findings, hence a preference to have an examination by health professionals in the event of developing anal symptoms (Table 6).
Preference for a health professional performing anal examination rather than self-examination
A number of men preferred a health professional to perform anal examination over anal self-examination including those who were prepared to perform anal self-examination if recommended by a health professional. Their concerns centred around a lack of knowledge and confidence in differentiating normal and abnormal examination, uncertainty not knowing what to look for during the examination and personal preference of having a trained professional performing the examination (see Table 6 for examples). Moreover, one participant highlighted having options, such as examination by a health professional, in addition to routine STI screening were important for men who were unable to perform anal self-examination.
“There would probably be a group of gay men who you could sit down and have this conversation with for half an hour [about anal self-examination], who would then go away and just go, “I can’t deal with that.” So, they’re the types of people that would need to be engaging with their GP to do the test, rather than themselves… I think having those two key options is really, really important..”
—Participant 6, living with HIV, age 50-60
Challenges of anal self-examination as a means for syphilis detection
Despite most men expressing a willingness to perform anal self-examination if recommended by health professionals, some men reported potential challenges that could be encountered in implementing anal self-examination for syphilis detection.
A few men suggested that some men who were top only would be apprehensive about performing anal self-examination.
“… it would be interesting to hear people that are tops, how often they would do it, if they’re top only...because I feel they would be more apprehensive about this versus either a bottom or a versatile person doing it.”
— Participant 11, living with HIV, age 20-30
A few expressed concerns of placing a burden on health care services due to frequent presentations whenever MSM had concerning findings on anal self-examination for non-STI related anal problems. On the other hand, one participant counter-argued that men could become complacent with the false sense of security from regular self-examination thinking there were no problems in their anus, hence leading to missing anal pathologies or not performing regular STI screening as recommended (see Table 6 for examples). Although most men generally felt that gay men would be acceptable to performing anal self-examination, some men reported their view that anal self-examination is unlikely to reduce STI rates among gay men (see Table 6 for examples) suggesting the use of anal self-examination as an adjunct to existing measures to reduce STI rates and transmission.