The practice of ASE
Seventeen out of 20 (85%) men had inserted their finger into their anus before – six (35%) were for medical reasons, six (35%) for sexual reasons, three (18%) for both medical and sexual reasons, and two (12%) for cleaning purposes. Currently none were doing this on a regular basis to screen for anal cancer. Only a minority (5 men) felt confident in detecting an abnormal lesion. Four men had found abnormalities themselves and presented to the doctor for further examination (1 skin tag, 1 scarring, 2 haemorrhoids).
Men described how they would conduct an ASE. The location of performing an ASE would either be in the shower, bathroom or bedroom. The positions adopted did not appear to be related to the age of participants and varied (from most frequently used to least): (lying on back or side, squatting, standing, sitting on the toilet, kneeling). The majority of men would use some sort of lubricant in the process (13 men would use KY jelly, 2 use soap) and a minority (4 men) would also use a glove. Four men would use a mirror to also try to visualize the peri-anal area.
Discussion of anal issues
The majority of men felt comfortable raising anal issues within a medical setting. Some men expressed that the ease of raising the issue stemmed from their sexual identity.
In a medical context I have absolutely no problem at all, none whatsover… (62 years old, living with HIV for 7 years)
It’s part of the gay men’s life, you know. (47 years old, living with HIV for 11 years)
A minority of participants stated that comfort levels may alter depending on whether the doctor was their usual HIV doctor and the gender and/or sexual orientation of the doctor.
I’d been seeing my same doctor now for probably 15 years, so, no I don’t feel uncomfortable talking to him. If it was a general GP probably a different story. (49 years old, living with HIV for 29 years)
I think that an HIV doctor, and also a gay doctor, has a much better understanding of what people risk being gay. (55 years old, living with HIV for 32 years)
I always have found those personal things easier to talk about with a female doctor. (47 years old, living with HIV for 28 years)
Some participants recognised that underlying their choice of doctor with whom to discuss anal issues was a trusting relationship.
With another doctor - as soon as I’ve got some sort of relationship - then I think, for me, those things are easier to talk about. (47 years old, living with HIV for 28 years)
Despite the majority of men being comfortable in addressing anal issues with a health professional, only two men reported that their doctor had raised the issue of anal cancer. As a result of the paucity of discussions around anal cancer, the understanding of anal cancer was poor amongst participants.
I don’t know much about it at all other than it is a type of cancer and it’s probably not a good way to die. (56 years old, living with HIV for 15 years)
Participants reported that the majority of doctors would only discuss anal issues if the participant specifically brought the topic up.
It’s more about problem solving [for doctors] (55 years old, living with HIV for 32 years)
Indeed the majority of participants suggested that doctors should be more pro-active in addressing anal health.
Most people are going to find it awkward, so until someone raises it with you, you’re probably never going to do it yourself unless there’s a huge problem, and by then it might be a little late. (39 years old, living with HIV for 13 years)
Many men suggested the manikin was unnecessary for showing them what is meant by the perianal region, but a stronger reaction to the pictures of anal cancer was obvious.
That’s nasty! (47 years old, living with HIV for 21 years)
It should make anyone, you know gay or not, examine themselves (47 years old, living with HIV for 11 years)
Potential barriers for implementing ASE
Despite enthusiasm for considering ASE, there were barriers expressed under the themes of attitudes, knowledge and practice (Table
2).
Table 2
Themes of barriers to anal self-examination (ASE)
Attitudinal barriers | Concern about discomfort with any anal examinations |
| Anxiety about finding an abnormality |
| Preference for a health professional to do an anal examination |
| Too many sensations or sexual connotations with ASE |
Knowledge barriers | Lack of awareness of anal cancer risk |
| Ignorance of how anal cancer presents |
Practical barriers | Inadequate physical flexibility to conduct an ASE |
| Importance of cleanliness before ASE |
Attitudinal barriers
Enthusiasm for ASE was especially evident in younger participants, who saw ASE as simple and who approved of the concept of early detection.
Women do breast checks for themselves and discover their own lumps… there’s no reason why a man can’t do the same thing. (47 years old, living with HIV for 21 years)
Any type of early detection is great, from reports you hear about people like breast examinations… They catch it early and it’s a lot better for them. (47 years old, living with HIV for 8 years)
Everybody should be doing it, no matter what part of the body it is. I mean everyone should be keeping an eye out for any changes… self-examination for me it’s a must. It’s a must. (42 years old, living with HIV for 4 years)
Despite perception of some discomfort, most men conveyed that they would still allow an anal examination if there were clear benefits.
There is something about a digital examination that feels more intimate… and I vaguely feel a little bit uncomfortable with a doctor doing that. But not enough to stop me doing it. (43 years old, living with HIV for 7 years)
However there was agreement that not all men might be comfortable with any sort of anal examinations.
Some are very, you know, “Don’t come near my [anus]” …That’s just something that they’ve got a phobia against or they’ve been brought up thinking no, no one touches that spot, you know… If you go anywhere near them down there and they clench like - - you know, clamp. (47 years old, living with HIV for 11 years)
For men who have never performed an ASE to look for anal abnormality before, they discussed the potential for anxiety if an abnormality was detected. Interestingly, this was always spoken of in the third person, as if to distance themselves from such anxious men.
The only downside is making people slightly paranoid potentially. But ultimately I think most people - particularly people who are in a high risk category it’s probably better to err slightly on the side of paranoia [laughs]. (40 years old, living with HIV for 4 years)
Maybe some people get a haemorrhoid and they get hysterical and think they’re going to die or something because they don’t know what it is. (61 years old, living with HIV for 8 years)
This anxiety seemed to stem predominantly from recognition that following an abnormal ASE further investigation would be required.
The waiting period between the doctor that refers you to somebody that is more the stress period for me, because I’m going “Well the doctor thinks they need to refer it”, then you know that there’s potentially something. (40 years old, living with HIV for 4 years)
The men who had not performed ASE to look for abnormality before preferred anal examinations to be performed only by a medical expert, not themselves. Underlying this ‘hands-off’ attitude was a fear of missing something or the preference for a health professional to decide whether something is normal or abnormal. In addition some men stated that conducting an examination with their own finger would be too difficult as it may lead to too many sensations and had sexual connotations.
I don’t think it’s up to me to decide whether something is normal or not, it’s up to the doctor. (56 years old, living with HIV for 15 years)
I couldn’t do it myself. What if I miss something… [ASE is] not your normal medical procedure. It’s more of a sexual thing for a gay person. It would turn on a whole lot of ranges of feelings and sensations as well. Sexual desires, all that kind of stuff. (49 years old, living with HIV for 29 years)
Knowledge barriers
Two knowledge barriers were noted – lack of awareness of anal cancer risk and ignorance of what to look for during ASE. There was frustration amongst participants that they did not have enough information.
It’s not out there. I can tell you it never crossed my mind that I should be looking for anal cancer…. If you have that knowledge then you can act on that knowledge but if you don’t know, well you just don’t know. (62 years old, living with HIV for 7 years)
When you get to a certain age there’s quite a lot of talk about prostate cancer, not a lot about anal cancer. (61 years old, living with HIV for 8 years)
A result of this lack of awareness may be a tendency to ignore the link between anal symptoms and potential anal cancer.
They would probably brush it off thinking, “Oh, no, it will never happen to me” but in reality that could be quite the opposite. (47 years old, living with HIV for 21 years)
I know of cases where people ignored it… and had been told… “If you’d come three months ago, your chances would have been much, much stronger.” (72 years old, living with HIV for 26 years)
Furthermore, the lack of knowledge led to misconceptions of risk factors, misperception of personal risks and assumptions of an association between anal cancer and other cancers.
A lot of men who would categorise themselves as being active [insertive anal sex] rather than passive [receptive anal sex], they would pigeonhole themselves and say “Well, that doesn’t affect me”. (39 years old, living with HIV for 13 years)
[My risk of anal cancer would] be low because I don’t really have a sexual partner any longer. (78 years old, living with HIV for 31 years)
[Anal cancer] seems to be associated with having partners of different strains of semen from what I’ve read… I’m a great believer in hygiene before and after sex by douching. [Facilitator: You think that helps?] Yes, by cleaning oneself. (69 years old, living with HIV for 28 years)
My grandfather died of bowel cancer… my father died of prostate cancer… but because they’re sort of in the same area, it sort of makes me think maybe I’m more likely to be a candidate for anal cancer. (47 years old, living with HIV for 28 years)
Although men felt comfortable in noticing a change in their anal region, there was no specific understanding of what they should be looking for when they examined themselves.
I never know quite what I’m looking for but I would recognise a change if there was inflammation or change of colour or anything like that. (72 years old, living with HIV for 26 years)
I don’t quite know what I’m looking for – I don’t quite know what the sensation of that difference is. (61 years old, living with HIV for 8 years)
Practical barriers
Whilst largely supportive of ASE, men acknowledged that there may be a few practical barriers to an adequate examination, even for younger participants.
It’s in an obscure spot. It’s not visible… it’s in an enclosed area. So it can be hard to look after if something goes wrong. (47 years old, living with HIV for 11 years)
Whilst a few expressed potential issues with the physical flexibility needed for an adequate examination, the majority (including older participants) believed that flexibility was not a major barrier.
When I was younger, I was quite flexible and reaching around and examining myself was quite - it was easy to do, because I was always constantly checking for warts… the external part of it would be quite easy to detect. But the internal part I find would be a little bit more difficult. (49 years old, living with HIV for 29 years)
Everything’s harder when you get older, really… but I don’t find [ASE] a lot harder. (72 years old, living with HIV for 26 years)
A minority of participants expressed a concern around hygiene prior to ASE. For these men, it was important for them to be completely clean before they would conduct an ASE.
I don’t go anywhere near somebody else’s or my own butt… without it being clean… I mean, not only is it unhealthy, it’s unpleasant and undignified. (55 years old, living with HIV for 32 years)
This is where I probably would get uncomfortable if I knew I hadn’t been to the toilet or wasn’t clean or something. (40 years old, living with HIV for 4 years)
There’s that obsessiveness about being unclean, I think maybe more so being a gay man. (47 years old, living with HIV for 28 years)