Table 1 Selected data from qualitative studies reporting on heterosexual oral and anal sex in sub-Saharan Africa by year of publication
Author; Year | Country | Study design | Sampling; Data collection methods | Study population | Gender (M/F); Age (yrs) | Summary of Key findings on oral sex | Assessment of risk of bias |
Gathece et al. 2000 [133] | Kenya | Mixed methods | Purposive sampling; NS Focus group discussions and In-depth interviews | FSW (KAP) | F: 30.5 | Participants said that there was no need to use condom during oral sex because they felt that oral sex is “safer” than vaginal sex. | high-risk of bias |
Author; Year | Country | Study design | Sampling; Data collection methods | Study population | Gender (M/F); Age (yrs) | Summary of Key findings on Anal sex | Assessment of risk of bias |
Stadler et al. 2007 [100] | South Africa | Qualitative | Purposive sampling; Focus group discussion | Adult women in community (GP) | F; NS | Some of the local terminologies of anal sex that were mentioned by participants included: “pata pata”, “matanyula” and “dog style”. Participants had open discussions on anal sex. They mentioned pornographic films and television as sources of information of anal sex. The reported reasons for engaging in anal sex that were discussed included: a form of partner punishment and coercion, sexual experimentation and partner desire or pleasure. Some of the misconceptions that emerged during discussion were: anal sex is safer than penile-vaginal sex, anal sex was regarded as a form of contraception and it could prevent STIs/HIVs. | low risk of bias |
Mavhu et al. 2008 [122] | Zimbabwe | Qualitative | Purposive sampling; 65 In-depth interviews | Adolescent and Adult in the community (GP) | M and F:18–40 | Participants were uncomfortable with “anal sex” as a question. They preferred anal sex to be referred to as “sex at a place where wastes (faeces) comes out” or “sex at backside”. Some referred to anal sex as “doggy style”. They described anal sex as “homosexual do”. | low risk of bias |
Ndinda et al. 2008 [101] | South Africa | Qualitative | Purposive sampling; 11 Focus group discussions | Adult men and women in community (GP) | MandF; NS | Participants were reluctant to talk about anal sex. They largely used proxy names in Zulu to describe anal sex. There was poor understanding about the meaning of anal sex. They expressed shock and disbelief when the facilitator told them the meaning of anal sex as “having sex in the faecal passage”. Some participants felt that anal sex is practiced only by MSM. They expressed shock and disbelief when the facilitator told them the meaning of anal sex as “having sex in the feacal passage”. Some participant felt that anal sex is practiced only by MSM. | low risk of bias |
Ambaw et al. 2010 [66] | Ethiopia | Mixed methods | Purposive sampling; 6 Focus group discussions | University students (GP) | M and F: 17–45 | Participants interpreted sexual intercourse to mean heterosexual and vaginal sex. They believed only “whites” (ferenges) accept anal sex as a form of sexual intercourse | low risk of bias |
Veldhuijzen et al. 2011 [90] | Kenya and Rwanda | Mixed methods | Purposive sampling; 7 Focus group discussions and 4 In-depth interviews | FSW in Kigali only (KAP) | F; 22–30 | Some FSWs had strong negative perceptions about clients requesting anal sex. They believed that anal sex was mostly requested by non-Rwandans. The most common reported reason for engaging in anal sex was a financial incentive. Some participants said that anal sex practices are associated with alcohol use. Some FSWs reported that their clients do not use condoms for anal sex. | low risk of bias |
Duby et al. 2014 [102] | Kenya, Tanzania and Uganda | Qualitative | Purposive sampling; 40 Focus group discussions and 54 In-depth interviews | Adult men and women in community/clinics (KAP) | M and F; NS | Participants demonstrated a good knowledge of anal sex, but they were reluctant to discuss their personal experiences. They also regarded anal sex as a taboo. Reported reasons for engaging in anal sex that were discussed included: preserving virginity, contraception, financial incentives, as an alternative when vaginal sex was not feasible (e.g. pregnancy and menstruation), to satisfy their male partner’s pleasure, adventure and novelty. Participants had the misconception that anal sex is safer than vaginal sex, is associated with lesser risk of HIV/STIs and hence there is no reason to use condoms. | low risk of bias |
Beckham et al. 2015 [103] | Tanzania | Qualitative | Purposive sampling; 3 Focus group discussions and 30 In-depth interviews | FSW (KAP) | F; 20–40 | Participants had open discussion about anal sex including their personal experiences with clients. The main reported reason for engaging anal sex was receiving higher financial incentives than for penile-vaginal sex. Clients paid more for requesting unprotected anal sex. | low risk of bias |
Mtenga et al. 2015 [124] | Tanzania | Qualitative | Purposive sampling; 24 Focus group discussions and 81 In-depth interviews | Adult men and women in community (KAP) | M and F; NS | Truck drivers and their female partners said heterosexual anal sex is increasingly being practiced in Tanzania. Reasons for engaging in anal sex by men included: seeking better sexual pleasure than vaginal sex, to avoid pregnancy, to prove to their female partners that they are sexually strong and for sexual adventure. Women mentioned receiving greater financial gains with anal sex compared to vaginal sex, that anal sex helped to retain their sexual partners, that it could prevent pregnancy, was an alternative during menstruation and fattening their buttocks to improve their beauty to suitors as reasons for practicing anal sex. Both men and women said a barrier method is not needed during anal sex because the sexual act is safer than vaginal sex, sexual pleasure will be reduced and there is a fear of losing the condom inside the anus. | low risk of bias |
Wamoyi et al. 2015 [104] | Tanzania | Qualitative | Purposive sampling; 4 Focus group discussions and 16 In-depth interviews | Adult men and women in community/clinics (KAP) | MandF; 20–30 | There was culture of silence about anal sex and participants used proxy names for the practice. Participants believed that anal sex was mostly practiced by foreigners, young people, FSWs and Arabs. Reported reasons for engaging in anal sex that were described by participants included: adventure, ‘trending’, financial incentives and male partner desire. Women felt that anal sex was associated with delivery complications, and anal incontinence. Male participants reported that engaging in anal sex could cause blockage of the anus and urinary system, and cancer. Both male and female participants believed that anal sex is risky and there was a need to use condom during anal sexual act. | low risk of bias |
South Africa; Uganda; Zimbabwe | Qualitative | Purposive sampling; 88 In-depth interviews | Adult women in community (GP) | F: NS | Some participants expressed “shock”, “disbelief”, “disgust”, “embarrassment” and “denial” about anal sex. Some believed that anal sex should not be openly discussed. There were misconceptions that the back side vaginal sex and anal sex were the same sexual act by the participants until it was explained by the researcher with annotated diagram. A number of participants preferred to use alternative name for anal sex e.g. “hidden part”, “down there” and “where faeces comes out”. Women reported engaging in anal sex in order to satisfy their partners’ sexual pleasure/ They considered anal sex to be safer than vaginal sex and as an alternative sexual act when vaginal sex was not feasible. Some engaged in anal sex for better financial gains. | low risk of bias | |
Mazeingia et al. 2017 [125] | Ethiopia | Qualitative | Snow ball Sampling; 18 In-depth interviews | FSW (KAP) | F:18–39 | Participants engaged in anal sex with their clients for financial gains, for personal sexual pleasure, due to coercion by clients and to satisfy their lovers (husband or boyfriends). | low risk of bias |
Shayo et al. 2017 [120] | Tanzania | Mixed methods | Purposive sampling; 20 Focus group discussions | Adolescent and Adult in the community (GP) | F:> = 15 | Heterosexual anal sex was perceived to be more culturally acceptable especially among the younger population and it is regarded as part of love making. Some women said men force them to practice anal sex against their wish while other women engage in anal sex to protect their sexual relationships. Some women suffered discrimination among their peers for refusing anal sex. A number of participants believed that anal sex is safe without using any barrier methods. Lubricants such as “jelly” were believed to enhance anal sex pleasure and to minimise risk of injury. | low risk of bias |