Heterosexual Oral and Anal Sex: Perceptions, Terminologies, and Attitudes of Younger and Older Adults in Ibadan, Nigeria.

Although heterosexual oral and anal sexual behaviors have been reported in sub-Saharan Africa, little is known about how they are understood and perceived, particularly, in West Africa. We undertook a qualitative exploration of local terminologies and sexual scripts associated with heterosexual oral and anal sex in preparation for a quantitative survey. We held focus group discussions (18) and interviews (44) with younger and middle-aged men and women from the general population and female sex workers (FSWs) in selected communities in Ibadan. Most participants had heard of oral and anal sex. Younger adults aged 18-25 years, particularly male participants and FSWs, appeared more informed than older adults in the general population. Sexually explicit movies were the most cited source of information. Oral and anal sexual behaviors were considered sensitive, with different local names, meanings, and interpretations. Participants advised against the use of slang terms in research. We identified six different scripts employed by participants in discussing oral and anal sex practices: protecting sexual relationship, financial reward, an alternative to vaginal sex, pleasure, male dominance and control, and risk, stigma, and disgust.

Introduction

Oral and anal sexual behaviors are associated with several health risks, particularly when performed without barrier protection. Both oral and anal sex are associated with the transmission and acquisition of sexually transmitted infections (STI) in the extragenital sites (Calas et al., 2021; da Cunha et al., 2021). Examples of such STIs include Neisseria gonorrhea, syphilis, Hepatitis, Herpes simplex, Chlamydia trachomatis, Human immunodeficiency virus (HIV) and human papillomavirus (HPV) (Calas et al., 2021; da Cunha et al., 2021; Stannah et al., 2020). Furthermore, oral and anal sex are independently associated with the occurrence of oral and anal cancers, respectively, especially in cancers caused by the persistence of high-risk HPV infections in these anatomic sites (Drake et al., 2021; Wong et al., 2021).

In Nigeria, sexual risks behaviors are commonly reported among younger adults and sex workers including condomless penile–vagina, oral, and anal sex (Folayan et al., 2015; Keshinro et al., 2016; Ochonye et al., 2019). These sexual behaviors have been associated with higher risk of STIs and HIV particularly in younger adults and sex workers (Folayan et al., 2015; Keshinro et al., 2016; Ochonye et al., 2019). In 2019, the prevalence of HIV in women aged 20–24 years was 1.9%, three times higher than men in the same age group (0.3%), and above the national average of 1.4% (Federal Ministry of Health, 2019). Sex workers, men who have sex with men and people who inject drugs account for 3.4% of the Nigerian population, but comprise 32% of new HIV infections in the country (Avert, 2020).

Although anal and oral sexual practices are more common in same sex relationships, they are also prevalent in heterosexual relationships, especially among young people (Boladale et al., 2015; Morhason-Bello et al., 2019). In past decades, heterosexual oral and anal sexual behaviors have been increasingly reported among men and women in the general population and in key populations such as female sex workers (FSWs), long-distance drivers, and women working in bars and entertainment centers in sub-Saharan Africa (SSA) (Cherie & Berhane, 2012; Kerwin et al., 2014; Morhason-Bello et al., 2019; Shayo et al., 2017; Watson-Jones et al., 2007). A recent systematic review of 103 articles published in SSA found that oral and anal sex were most common in younger adults and sex workers, and that a substantial proportion did not use any form of protection (Morhason-Bello et al., 2019).

In contrast to the increasing number of quantitative surveys, there has been limited qualitative research to explore knowledge, perceptions, and attitudes toward anal and oral sex in SSA. The qualitative studies that exist have generally been conducted outside of Nigeria and focus on understanding terminologies and perceptions of anal sex (Duby et al., 2016a, 2016b; Mavhu et al., 2008; Ndinda et al., 2008; Wamoyi et al., 2015). For example, anal sex was misunderstood by people in some communities in South Africa to be vaginal sex from behind (Ndinda et al., 2008), or was perceived to be foreign to African culture or exclusive to men who have sex with men (Ndinda et al., 2008; Wamoyi et al., 2015). Five studies (Beckham et al., 2015; Duby et al., 2016a, 2016b; Mavhu et al., 2008; Stadler et al., 2007; Veldhuijzen et al., 2011), documented that anal sex was a sensitive topic for open discussion, and individuals involved in such practices often used slang or euphemistic terms to describe it. To our knowledge, there are no qualitative studies that examine meaning, interpretations, and terminology of oral and anal sex in men and women in West Africa. Locally contextualized qualitative research is crucial to designing culturally sensitive public health prevention and sexual health care programs.

To understand local knowledge, perceptions, and terminology, we drew on sexual scripting theory (Frith & Kitzinger, 2001; Metts & Spitzberg, 1996; Simon & Gagnon, 1986). Originally developed by Gagnon and Simon (1973), sexual scripting theory explains how cultural, interpersonal, and intrapersonal/intrapsychic “operating syntax” (scripts) guide individual, dyadic, and community sexual behaviors (Gagnon & Simon, 1973; Metts & Spitzberg, 1996; Simon & Gagnon, 1986). Cultural scripts exist at the level of collective life. For instance, cultural “scripts” may include that oral and anal sexual behaviors are not regarded as “sex” or considered to be safer than penile–vaginal sex (Dotson-Blake et al., 2012; Duby et al., 2016a, 2016b). Culturally scripted expectations of heterosexual sex shape how people respond or act when sexual behaviors aside from penile–vaginal sex are discussed or practiced within the community (Simon & Gagnon, 1986). For instance, some religious organizations believe that oral and anal sex are not sexual and therefore cannot be used to define the virginity of women (Dotson-Blake et al., 2012; Duby et al., 2016a, 2016b). Such institutionalized beliefs influence interpersonal and individual scripts by shaping the perceptions, interpretations, and attitudes of people belonging to that religion or community. Gender power negotiation, risk taking, and motivation for decision making in sexual encounters are influenced by cultural or institutional values and norms (Morrison et al., 2015; Sakaluk et al., 2014; Simon & Gagnon, 1986; Wiederman, 2005). Yet Bourdieu (1977) observed that people still engage in behavior considered deviant according to dominant norms, by employing a range of tactics to cover-up or protect themselves.

Interpersonal scripts exist between two (or more people) and comprise desires, feelings, and experiences (Metts & Spitzberg, 1996). Interpersonal scripts demonstrate how group dynamics modify perceptions and influence individual behavior (Simon & Gagnon, 1986). Interpersonal scripts tend to be gendered, and both genders adapt and craft interpersonal scripts to carefully manage how they present to others. Scripts surfaced in single gender groups may be adapted or censured in mixed-gender discussion. Gendered sexual scripting involves an imbalance of power in the dyadic context, making it harder for women to influence decisions that involve both partners and control the behavior of their partner (Wiederman, 2005). Sexual scripts in Africa often include that male aggression and dominance in sex is acceptable while female demand for equity in decision making, preference, and control over her own body is perceived as an affront and a sign of disrespect (Bridges et al., 2016; Metts & Spitzberg, 1996).

We undertook a qualitative study in Ibadan, Nigeria in order to prepare for cross-sectional surveys of HPV prevalence and risk factors for HPV infection in adolescent and adult women and FSWs (the Sexual Behavior and HPV Infection in Nigerians in Ibadan [SHINI] Study). We explored knowledge, perceptions, local terminologies, motivations, and beliefs as well as risks associated with different types of sexual behaviors, with specific attention to heterosexual oral and anal sex. We focused on people reporting heterosexual sexual encounters, because of the dearth of information in this group in Nigeria, and the general lack of attention to the public health implications of oral and anal sex relative to penile–vaginal sex in the country.

Method

Participants

We conducted focus group discussions (FGD) and in-depth interviews (IDI) to obtain information from male and female younger adults (18–25 years) and older adults (26–45 years) and also from brothel-based FSWs (18–45 years) in Ibadan Southwest and Ibadan Southeast Local Government Areas (LGAs) of Oyo State, Nigeria. The communities were purposively selected due to their relatively high population of youth and the presence of social activity points such as hotels, bars, pub and clubs, cinema houses, and brothels. Within each LGA, brothels with more than 20 FSWs were selected with the help of officials of Oyo State Ministry of Health and the Society for Family Health. The FGDs focused on knowledge, definitions/meanings, and motivations for different sexual behaviors among homogenous participants (supplementary Box 1). The IDIs sought information on personal experiences concerning oral and anal sex, including motivations and perceived risks (supplementary Box 2).

Potential participants among the general population and FSWs were recruited separately by gender-matched, trained research assistants. The FGD participants from the general population were recruited in the community from tertiary educational establishments, vocational centers, youth clubs, markets, artisanal groups, and other institutions/facilities in both LGAs to provide a wide perspective on the research topic. Research assistants informed potential participants about the objectives of the study, and they were provided with an information leaflet that explained the aims and procedures of the study. The contact details of potential FGD and IDI participants that agreed to join the study were recorded for follow-up. These contact details were kept in a safe locked cabinet with access restricted for the purpose of the study. In each LGA, separate FGDs were conducted for male and female participants in the general populations. Within each gender subgroup, separate FGDs were conducted for the married and unmarried participants. There were also separate FGDs for participants who spoke English or who spoke only Yoruba (Table 1). In the two population groups, the number of participants per session of FGD ranged from 6 to 10 people.

Table 1

Sampling matrix for the community FGD and IDI, and the selected sociodemographics of the participants

Study site and type of data collection	Educational status	Population subgroup	Gender	Mean age in years (range)	Total number of participants
Southeast LGA FGDs	Formal education	Younger adults (unmarried)	Male	20.9 (18–25)	8
			Female	20.8 (19–25)	6
		Adults (married)	Male	34.8 (28–42)	8
			Female	37.3 (28–45)	7
	No formal education	Younger adults (unmarried)	Male	21.9 (18–25)	9
			Female	20.9 (18–24)	7
		Older adults (married)	Male	40.4 (32–45)	8
			Female	38.2 (30–45)	10
Southwest LGA FGDs	Formal education	Younger adults(unmarried)	Male	19.7 (18–22)	7
			Female	19.3 (18–25)	10
		Older adults (married)	Male	41.1 (33–45)	7
			Female	40.4 (33–45)	8
	Formal education	Younger adults (unmarried)	Male	20.8 (18–25)	6
			Female	22.0 (20–24)	7
		Older adults (married)	Male	36.6 (26–45)	10
			Female	37.8 (28–45)	10
Southeast LGA IDIs	Formal education	Younger adults (unmarried)	Male	22.0 (19–24)	3
			Female	20.0	1
		Older adults (married)	Male	34.0 (28–42)	3
			Female	33.0 (30–36)	2
	No formal education	Younger adults (unmarried)	Male	21.7 (18–24)	3
			Female	21.0 (19–23)	2
		Older adults (married)	Male	37.7 (28–45)	3
			Female	36.0 (32–40)	2
Southwest LGA IDIs	Formal education	Younger adults(unmarried)	Male	20.7 (18–22)	3
			Female	22.0	1
		Older adults (married)	Male	33.7 (31–37)	3
			Female	43.0 (40–45)	3
	No formal education	Younger adults (unmarried)	Male	22.7 (21–25)	3
			Female	23.7 (23–24)	3
		Older adults (married)	Male	32.7 (29–36)	3
			Female	30.0	1

FGD focus group discussion, IDI In-depth-interview, LGA Local government area, Younger adults– 18–25 years, Older adults – 26-45 years; One FGD was conducted for each population group

The FSWs living and/or working in the selected brothels were invited to take part in one of two FGDs (one in each LGA) (Table 2). Two members of the research team visited the selected brothels, met with the managers and the chairladies of the FSWs working in the brothels to discuss the research objectives and sought their approval. After obtaining written approval from the brothel leadership, the female research assistants individually discussed the objectives of the study with the FSWs and also gave out study information leaflets. FSWs agreeing to participate were enrolled in the study.

Table 2

Sampling matrix for the brothel FGDs and IDIs, and selected sociodemographics of the participants

Study site	Type of data collection	Marital status	Mean age in years (range)	Total number of participants
Southeast LGA	FGD	Married	30.0	1
		Unmarrieda	26.3 (20 – 34)	9
	IDI	Married	32.0	1
		Unmarriedb	35.0	1
Southwest LGA	FGD	Married	30.0	1
		Unmarriedc	26.6 (21 – 29)	8
	IDI	Married	NA	-
		Unmarriedd	26.3 (23 – 29)	3

FGD -focus group discussion; IDI- In-depth-interview; LGA – Local government area; NA – Not available (Declined to give her age)

aSingle – 6FSWs and 3

bSingle

cSingle-6 FSWs and divorced – 2 FSWs

dSingle- 2FSWs and divorced – 1FSW

Individuals willing to share their personal experiences were invited to participate in an IDI. Participants were recruited from the FGDs, as well as other interested people in the community and sex workers from brothels not included in the recruitment described above. Individual potential IDI participants were provided an information leaflet and those willing to participate were scheduled for the interview.

Measures and Procedure

The topic guides for FGD and IDI (Supplementary boxes 1 and 2) were primarily designed for this study in English and translated to Yoruba language. In order to ensure quality and retention of the original content, the Yoruba copies were translated back into English by an independent individual not involved in the design of the tool. The topic guides for FGD covered the following: knowledge, terminologies, interpretations, stigma, and belief as well as motivation for engaging of different sexual behaviors. The IDI topic guide also covered personal experiences of practicing vaginal, oral, and anal sex; and stigma and beliefs around health risks associated with these sexual behaviors. Focus group facilitators were trained in facilitating discussion on sensitive behaviors. The topic guide was piloted in a different community to allow adaptation and refinement and identify further training needs of fieldworkers.

During the FGDs data collection, a trained, gender-matched moderator and a note-taker facilitated the sessions. Written or witnessed informed consent was obtained from individual potential participants before each session began. The consent also covered permission to record and analyze results and to publish the research findings. After a brief introduction, participants who provided consent were given numbers for identification (R1, R2…Rn) by the moderator. Participants were informed that there would be no right or wrong comments or views expressed during the discussions. FGDs/interviews were conducted in English (8 FGD/19 IDI); Yoruba (8/20) and “pidgin” English (2/5).

The moderator introduced the discussion themes, each participant was encouraged to express his/her views freely, and they were assured of confidentiality. The moderator probed for specific issues that were not spontaneously raised in discussion. Demographic information on individual participants was collected at the end of each FGD. The IDIs were conducted in the participant’s preferred venue by a gender-matched research assistant and the IDI was conducted in the participant’s language of choice. Each FGD session and each IDI were audio-recorded and generally lasted between 40 and 65 min. The note-taker documented the key findings from each FGD and IDI session, including the non-verbal cues that were observed. The data collection took place between August and December 2016.

Data Analysis

Audio files and field notes were transcribed verbatim. Yoruba and “pidgin” English transcripts were translated to English. One author (IMB) read all FGD and IDI transcripts while KM and AJ read two randomly selected transcripts. The data were imported into Nvivo 11.0 Pro software (QSR International Pty Ltd. Cardigan UK) for coding.

At the first stage, three coders (IMB and two researchers) generated the preliminary (parent) codes. Two experienced qualitative researchers (KM and AJ) reviewed the codes and offered suggestions to improve the emerging “parent” codes. IMB and two other coders generated “child” codes from further reading of transcripts and discussions. Information from the notes of the FGDs and IDIs and the reflective diaries of coders were used to further refine the emergent themes through an iterative and inductive process (Srivastava & Hopwood, 2009). The links between emerging themes were explored to reveal contextual meaning of the final themes that were identified. The analysis was conducted using a thematic content analysis framework (Vaismoradi et al., 2016). The identified themes from the FGDs and IDIs were summarized with headings and key messages were illustrated using direct quotes from the study participants.

Results

Sociodemographic Characteristics of Participants

Eighteen (18) FGDs and 44 IDIs were conducted in the two LGAs: 16 FGDs and 39 IDIs were among the general population, and two FGDs and five IDIs were conducted with the FSWs. In the 16 FGDs among the general population, 60/128 participants were younger adults (30 each were males and females) while 68/128 participants were older adults (33 males and 35 females). Nineteen younger adults (12 males and 7 females) and twenty older adults (12 males and 8 females) participated in the IDIs among the general population. Most of the FSWs participating in the 2 FGDs (17/19) and 5 IDIs (4/5) were unmarried. The summary description of selected socio-demographic variables is presented in Tables 1 and 2. The mean ages of younger adult and adult male participants were 21.40 years and 36.0 years, respectively. Similarly, the mean ages younger adult and adult females were 21.1 years and 36.5 years, respectively. The mean ages of married and unmarried FSW participants were 30.7 years and 29.3 years, respectively. A half of the FGDs and IDIs were conducted among younger unmarried adults and those without formal education. The majority of FSWs were unmarried (Table 3).

Table 3

Local names or slang terms for oral and penile–anal sex

Oral and penile–anal sex definitions	Examples of slang terms
Slang term when a man gives oral sex to a woman (i.e., when a man/boy uses his tongue, mouth, or lips to touch or stimulate the external genitals of a woman/girl)	‘lick plate,’ ‘clean up,’ ‘wash wash,’ and ‘go south’
Slang term when a woman gives oral sex to a man or boy, i.e., when a woman uses her tongue or mouth to touch or lick or suck the penis	‘blow job (BJ),’ ‘chop or eat banana or plantain (‘dodo’), ‘eating carrot,’ ‘hold microphone to sing,’ ‘licking soft sweet stick,’ ‘lollipop,’ ‘suck straw,’ and ‘gbe se enu’ (put it in your mouth)
Slang term for oral sex that is used interchangeably to describe oral sex that is given by man/boy or woman/girl	‘sucking,’ ‘sukky,’ ‘kiss it,’ ‘ice cream,’ ‘yoghurt,’ and ‘collabo’
Slang term for penile–anal sex	‘back side,’ ‘bend down and sow,’ ‘backyard sex,’ ‘chopping from the back,’ ‘daudau’ (penile thrusting from behind), ‘doggy style,’ ‘gba eyin wole’ (penetration from behind), ‘hanging up,’ ‘load from the back,’ ‘monkey style,’ ‘olosho’ (sex worker’s style), ‘room,’ ‘redeemed,’ ‘sex through yansh,’ ‘shoki,’ ‘smash from the back,’ ‘table sex,’ ‘touching of toe,’ ‘wheel barrow’ and ‘yodi (project out your buttock or anus)’

Knowledge and Sources of Information Oral and Anal Sexual Practice

Knowledge of oral sex

Most FGD and IDI participants had heard of oral sex; however, not all of them were able to give an accurate and complete definition. Most participants described oral sex as a form of sexual activity involving use of the mouth and/or tongue. The most common description given by both male and female participants was oral stimulation of the penile shaft by a female. Only younger adult males mentioned that females could receive oral sex. For example, a younger adult male in a FGD described cunnilingus as well as fellatio:

What I knew of oral sex is when a man or woman is using their tongue or mouth to stimulate either the vulva or vagina or penis [Unmarried younger adult male with no formal education, Ibadan southwest FGD, aged 18 years, R3]

Generally, discussion of oral sex meaning was underpinned by assumptions of heterosexuality, but a few adult men, and younger unmarried adults also defined oral sex within same sex relationships.The dominant script for oral sex was that it was not a sexual act in itself, but a modern method of foreplay before engaging in penile–vaginal sex. In this script, “oral genital contact” between heterosexual partners was viewed as similar to other forms of sexual fondling meant to stimulate erotic feelings.Other descriptions of oral sex included ejaculation of seminal fluid into the mouth of a woman, the exchange of open mouth-to-mouth kisses (deep kisses), breast fondling with the mouth, or licking of the anal verge of a sexual partner.

It could be man to woman, woman to woman, and that’s when they say that the person is having oral sex. [Married adult male with formal education, Ibadan southeast FGD, aged 45 years, R1]

For a female, who is also not in the mood when she and her boyfriend are together, in this case, when they are romancing themselves, the man will put his mouth on the woman’s vagina to make her to be in the mood, then he might also put her breast in his mouth and suck it. [Unmarried younger adult female with no formal education, Ibadan southeast FGD, aged 18 years, R3]

Sources of information on oral sex

The two most frequently mentioned sources of information on oral sex by the general population participants was watching movies, including “porn,” followed by learning from sexual partners. In contrast, most FSWs said they learnt about oral sex from their sexual partners followed by watching “porn” movies. Women in both formal and casual heterosexual relationships explained how their male partners used pornographic films to introduce oral sex to them:

We all learnt oral sex from blue film (pornographic film). We have been watching such movies inside. My husband bought one blue film, and said you, you just sleep "borogidi" (like log of wood, i.e., Lying motionless on the bed) (*laughs by all participants*). He said you just sleep, and your body does not move. So, he brought one blue film. When I watched the film, I screamed, said ehnnn!!! I cannot even do it and I don't want to see this film inside my house again. (*laughs by everyone*). [Married adult female with formal education, Ibadan southwest FGD, aged 39 years, R3]

At one of the IDI sessions, a FSW explained how she learnt oral sex through a customer’s request and through discussions with her friends:In addition, a married woman also shared a similar experience of learning oral sex from a friend.One sex worker described an unusual source of information: overhearing accusations or insults leveled at others.There were a few participants, mostly younger FGD participants who had no formal education, who had not heard or learnt about oral sex.

I learnt about oral sex from friends and from my customers; some men do come here and request for oral sex. [FSW, Ibadan southeast IDI, aged 23 years]

I heard about it from a friend that we were together, she narrated how she gave oral sex to her boyfriend when he had problem of ejaculation during sex. [Married female adult with no formal education, Ibadan southeast IDI, aged 40 years]

I also overheard about oral sex during a misunderstanding between two close friends. They were accusing each other of engaging in oral practice. [FSW, Ibadan southwest IDI, aged 35 years]

Knowledge of anal sex

Although not all participants had heard about anal sex, most were able to define anal sex as a form of sexual intercourse that involved the anus or anal cavity. Younger adults and FSWs were able to offer a more comprehensive explanation of the meaning of anal sex compared with older adults. Generally, the dominant script for anal sex among participants with no formal education was that anal sex was practiced between two men. For example, a participant with no formal education described anal sex as being common among men who have sex with men:

Anal sex basically happens among men to men, it is more common among men who used to have sex with men. They must perform anal sex to satisfy themselves. [Unmarried younger adult male with no formal education, Ibadan southeast FGD, aged 18 years, R3]

Other younger adults with no formal education and older women believed that it was impossible for anyone to insert a penis into the anus of another person, describing such sexual acts as “barbaric” or unacceptable. In contrast, unmarried younger adults, adult males, sex workers and those exposed to a “Western education” tended to adhere to wider-ranging scripts around anal sex, giving a detailed description of anal sex within heterosexual and same sex sexual relationships. A few of the participants also mentioned mouth to anal contact or stimulation aside penile–anal penetration.

Some younger adults and adult married men said they thought anal sex may be more pleasurable than penile–vaginal sex.Cultural scripts about anal sex held by married women included doubt about whether anal sex could be pleasurable. A participant reported hearing about anal sex from others:Anal sex was also mistakenly described as “penile–vaginal sex” from behind by some young women. For example,

From my own view, I think anal sex means having sex through the anus and it is very common to people that are called gay. Some guys do practice anal sex with some ladies because I think they enjoyed it more than vaginal sex. [Unmarried younger adult male with formal education, Ibadan southwest FGD, aged 22 years, R4]

They said a man will put his penis at the anus of maybe a man or a woman. [Married adult female with formal education, Ibadan southeast FGD, aged 44 years, R3]

Anal sex is having a man insert his penis into the vagina from behind. [Unmarried younger adult female with formal education, Ibadan southwest FGD, 25 years]

Sources of information on anal sex

Pornography and other sexually explicit movies, followed by friends or sexual partners were the most frequently mentioned sources of learning anal sex, particularly, among the younger adults and FSWs. The younger adults and sex workers freely shared how they learnt about anal sex while the older married adults were reluctant to disclose their sources of information. A young woman described how differences in repertoires between generations could be attributed to “blue films.”

Before now, during the time of our mothers and fathers, they don’t engage in such (anal sex), but now that everybody is now watching blue film, and they see how everything is done, they also want to do the same. [Unmarried younger adult female with no formal education, Ibadan southeast FGD, aged 20 years, R3]

In addition to learning anal sex from watching pornographic films, most FSWs also mentioned learning anal sex when they joined the sex work business or from clients requesting it.Rather than discussing the sources of learning about anal sex, some older adults expressed concern about watching pornographic movies, believing them to encourage people to practice anal sex, “a sexual act that is against religious injunction.” Reflected in such discussions was a traditional script of anal sex as immoral. Among older adults, especially married women, interpersonal and intrapsychic scripts about anal sex drew more on hearsay than experience. However, a traditional script of anal sex as “dangerous” and against God was pervasive even among those with experience of it:A male adult participant described how he heard about anal sex from an incident in the community in which two young men were warned against it by community leaders.

I have never heard of it before until when I found myself in this job. [FSW, Ibadan southwest FGD, aged 33 years, R4]

I used to watch pornography videos. I developed much interest in these sexual activities (oral and anal sex), which is not good at all, and it is against the will of God, so watching pornography video is dangerous. [Married adult male with formal education, IDI, aged 28 years]

Concerning the male-to-male sex, something happened to one of my people, a boy called another boy for sex, but the other boy disagreed leading to a serious disagreement. The matter was taken to the landlord association meeting. The boys were warned seriously not to try anything funny again. [Married adult male with no formal education, Ibadan southeast FGD, aged 35 years, R3]

Local Slang Terms within Sexual Scripts

There were marked generational and gender differences in the awareness and use of slang terms to describe oral and anal sex, especially, in the general population. Unmarried younger adult men and FSW mentioned slang words more often than women and younger adults who felt they were impolite. The most frequently mentioned slang words to describe anal sex among the general population participants were “backside,” and “bend and sow.” “Blow job” was the most frequently used slang term to describe oral sex. None of the participants mentioned slang terms to describe oral contact by one partner with the anal rim of another partner.

Slang terms were largely used to describe oral and anal sex in the context of heterosexual relationships. Most participants did not differentiate penile–anal sex slang terms between homosexual and heterosexual relationships even when they were prompted. A number of phrases were used to describe anal sex including words to differentiate from vaginal sex from behind:The anal canal was sometimes described as a room especially by participants with no formal education in the general population.

…what I see about those who go through the back is that for instance, [it is not just back], it is the anus, yes, because if it is back, it can be the vagina also, but it is not the vagina we are talking about. We are talking about the place through which the woman defecates. The man can also say that I gave her from the “bakashi” (buttocks). [Married adult male with no formal education, Ibadan southwest FGD, aged 43 years, R7]

You see if we are talking about anal sex, we can call it monkey style, that was even common some 20 years ago or more than that, if it is through the place where the woman excretes, they can say that, “mogba oju ibuwo” (enter a room), there is no one that does not know. [Married adult male with no formal education, Ibadan southwest FGD, aged 35 years, R8]

Functions of Slang Terms for Oral and Anal Sex in Sexual Scripts

Slang terms fulfilled three key functions in sexual scripts: to communicate between friends in coded ways; as a show of sexual superiority, and to profile people as being “in the know” or otherwise. Male participants in particular talked about how slang terms performed certain communication purposes within groups. Slang terms were used to tease people about their sexual past, to mock women, to display that they were modern, or to hide discussion of oral or anal sex from other individuals, such as parents.Slang words were also used by male participants among friends and peers to share and boast about their sexual experiences and to suggest sexual prowess.Most FSWs reported communicating with their male clients during sexual negotiations using slang words. The ability to use and understand the slang terms for different sexual acts including oral and anal sex was one of the tools that sex workers used to differentiate the regulars from the new customers. Regular or frequent customers of sex workers were called “roskos” while the new customers were called “magas”; the former were familiar with slang terms while the latter were not. New customers were usually billed higher than regular customers. A sex worker offered her own understanding of how clients are profiled in the brothel.In another discussion, a sex worker added that the use of slang terms is also common among students and clubbers. Her account suggested that slang terms were employed to convey belonging and identify other members of a marginalized group:

There is something we call blow job. […] If you really want to code it and you don’t want somebody to know what you are talking about, you can call it BJ, yeah, through “BJ.” [Unmarried younger adult male with formal education, Ibadan southeast FGD, aged 18 years, R3]

Let’s say a man has already had done something with a lady, then maybe you want to explain what happened between each other to one of your friends. You may say that the lady has already eaten my banana. [Married adult male with formal education, Ibadan southeast FGD, aged 33 years, R8]

Customers that are frequent in the hotel will know and understand slang terms for different sexual styles. There is no way you wouldn’t know them in the hotel unless you don’t come around. [FSW, Ibadan southeast FGD, aged 29 years, R5]

I for one, if I hear anybody outside saying he wants to suck or washy-washy, skirt and blouse, plate etc., I will know easily that the person belongs to our team. I will understand without any problem because an outsider may not know that (slang terms), except the clubbers. [FSW, Ibadan southwest FGD, aged 22 years, R1]

Views on the Use of Slang Terms in Sexual Scripts and Whether They Should Be Employed in Research Settings

One of the aims of the study was to determine which words should be used to describe these behaviors in the SHINI study. There were contrasting views on the use of slang or local words to describe types of sexual activities in the community. Generally, young participants, especially young men, and FSW believed that slang terms were acceptable and understandable, but older adults, particularly women, thought that the use of slang words was unacceptable, embarrassing and sometimes offensive when discussing sexual behaviors.There was also a concern that religious people might be offended by slang terms:Several participants expressed concern that sexually related slang terms could potentially promote immorality, especially among young people.Most educated young adults considered slang words as a modern method of communication or expression, especially students, clubbers, “big-men” in the society and FSWs.Most participants agreed that slang words could sometimes be very confusing to people that are not familiar to such terms and cited examples where a slang phrase could have another meaning.:Although most younger adults and FSWs knew different slang words for oral and anal sex, they advised against using such words to frame research questions about oral or anal sex. They believed that slang words could be ambiguous, might not elicit appropriate responses, and might provoke negative responses from interviewees/participants. However, most participants were of the view that the use of simple definitions to describe oral and anal sex would be well accepted by the community:

the slang for oral and anal sex just sounds embarrassing. People can even ask that what kind of slang terms are these? [Married adult female with formal education, Ibadan southwest FGD, aged 36 years, R5]

Sex slang term will be offensive in the midst of the religious people; you cannot utter all those sex slang words in Church or Mosque. But in the midst of the people with the same set of mind, you can say whatever you want to say at times, even at the influence of alcohol, you are free, you will be saying many things. [Married adult male with formal education, Ibadan southeast FGD, aged 33 years, R8]

Sex related slang words are not at acceptable all because it is something that is very bad in the society and most of the younger ones must not be aware of these names. [Unmarried younger adult male with no formal education, Ibadan southeast FGD, aged 19 years, R7]

Nowadays slang word are very common and if it is used it will not be a strange thing. [Unmarried younger adult male with no formal education, Ibadan southeast FGD, 19 years, R4]

People use them (sexually related slang) on a daily basis. Customers ask for it now. [FSW, Ibadan southeast FGD, aged 29 years, R5]

Yodi—projecting of the buttock or anus—is a common slang term that has different meaning. It can mean piles (haemorrhoids) and it can also mean big buttocks. So do not use the slang term. [Married adult female with formal education, Ibadan southwest FGD, aged 44 years, R1]

I think if you use oral sex, I think everybody knows what oral sex is, everybody knows what sex is rather, so if you use oral sex, it would be more understandable than talking about blow job. What is the meaning of blow job? You will be looking at the questionnaire as if the questionnaire should give you the answer itself. However, if you use oral sex, they will be like ok, it oral sex. You will try and meditate on it and get the answer but if you use these slang words, it may not easy for people to understand the message being passed across. [Unmarried younger adult female with formal education Ibadan southeast FGD, aged 21 years, R4]

Scripts of Oral and Anal Sexual Practice

Participants with experience of oral and/or anal sex were asked to reflect on motivations and feelings about doing so. We identified six different scripts employed by participants in discussing oral and anal sex practices: protecting sexual relationship, financial reward, an alternative to vaginal sex, pleasure, control, and stigma.

Oral/anal sex to protect the sexual relationship.

Most younger and older women including FSWs talked about having oral/anal sex to satisfy the request of their sexual partners or clients and to prevent them from losing their partners to other women. In this script, oral/anal sex was a “performance” which sometimes took effort. Some unmarried women said that they sometimes pretended to enjoy the practice, despite their internal disgust, or that they practiced oral and anal sex simply to satisfy their partner’s request.

Maybe you are in love with someone, this is what he wants (oral or anal sex) and it is something you can’t do no matter what, but because you don’t want him to break up with you, the fear of breaking up and losing him will make you do that thing. [Unmarried younger adult female with formal education, Ibadan southeast FGD, aged 19 years, R5]

The “performance” also sometimes necessitated enduring pain. One FSW recounted how she endured pain during penile–anal sex in order to satisfy her partner.

…in the process of having fun (vaginal sex) with my guy, he requested for anal sex, and I said no problem. We used lubricants with all other things we know in the process, but I had to endure the pain to satisfy him. [FSW, Ibadan southeast IDI, aged 27 years]

Oral/anal sex brings financial reward. Oral or anal sex for financial gain was a common script in all groups, especially in FSW. Most FSW observed that they made more money from oral and anal sex than vaginal sex. A participant described complying with a customer request for oral sex despite her reservations because the high sum of money was difficult to refuse. She felt uncomfortable doing this, but her friends encouraged her just to consider the financial benefit.

My first experience was when a customer requested for oral sex. I initially declined by telling him that I’ve never done it before. Then, he said he was going to give me good money if I could cooperate with him. He was the one that taught me. I discussed the different styles I had with the man with my friends. I also discussed the pleasure and my fear…. But they (my friends) said “forget about it”…it is about money. [FSW, Ibadan southeast IDI, aged 25 years]

Some participants also referred to a cultural script of rich men using financial reward to coerce young girls into oral and anal sex with them.

Some people do engage in oral sex and anal sex because of money, and when these so-called rich men want to enjoy themselves, they will ask our teenage girls to do something like this. These girls are usually from broken homes. Poverty is real in our country. Anything they ask them to do, they will do it just to get money to survive themselves. [Married adult female with formal education, Ibadan southeast FGD, aged 44 years, R3]

A different perspective was offered by some married men, who said that people engaged in anal sex in order to gain spiritual power to protect their wealth.

Some are using that thing (anal sex) to protect their wealth. [Married adult male with formal education, Ibadan southeast FGD, aged 34 years, R2]

Oral/anal sex as an alternative where penile–vaginal is problematic.

Most unmarried younger adults and a few married women observed that some women and their sexual partners engaged in oral and anal sex instead of vaginal sex in order to protect the virginity of female partners and avoid the embarrassment of unwanted pregnancy.During the FGDs among younger adults, oral or anal sex were described as an alternative way of sexual intercourse during menstruation.

I think anal and oral sex is safer because if you are not really ready to marry, you can have an oral and anal sex. You cannot get an unwanted pregnancy from anal or oral sex. [Unmarried younger adult male with formal education, Ibadan southeast FGD, aged 25 years, R4]

With what I have watched maybe when the lady is in her menstruation period, they do oral sex. [Unmarried younger adult female with no formal education, Ibadan southwest FGD, aged 22 years]

Oral/anal sex as pleasurable.

Some participants described how oral/anal sex could enhance pleasure. Oral sex was said to easily allow orgasm and some men preferred penile–anal sex to penile–vaginal sex because it provided more sexual pleasure due to the tight anal opening. Oral sex was described as a good foreplay before penile–vaginal sex by some married women. A married woman explained how oral sex increased sexual urge, drive, and performance during vaginal sex.

I think they (men) derive pleasure and enjoyment. When they do such (oral sex), the urge will arouse, and they will be able to perform very well (vagina sex) either with their husband or with the wife. I think enjoyment, pleasure, and urge that they derive from oral sex is the magic. [Married adult female with formal education, Ibadan southwest FGD, 39 years, R3]

Oral/anal sex as abusive and controlling.

A few participants described how anal sex was used by men to punish or subjugate a female partner, often in the context of substance abuse.

A young man suggested that:

Some people like to disgrace their partner (girlfriend) by demanding for anal sex to hurt her. After, they will be laughing at her…this usually happen after a bottle of alcohol or use of recreational substance. [Unmarried younger adult male with formal education, Ibadan southeast FGD, aged 20 years, R3]

Some women also described how they endured anal sex because their partner threatened to leave them if they did not go along with it.

[…] I told him that I will not be able to do this again, that was the reason why I back out. He told me, do I want him to start going to other ladies?. I was not ready to lose him, so I tried it with him again, but the pain I experienced was just too much to bear. [Unmarried younger adult female with no formal education, Ibadan southwest FGD, aged 21 years, R6]

Oral/anal sex as stigmatizing, disgusting, and dangerous.

Scripts reflecting stigma and disgust were also evident. This was sometimes couched in terms of religious rulings (what is normal and allowable) and sometimes in terms of public ridicule in the community.

If there are people engaging in such things like oral or anal sex, people may develop hatred for them because it’s not really normal; they might not want to associate with such people known to practice oral and anal [Unmarried younger adult female with formal education, Ibadan southwest FGD, aged 18 years, R10]

All the three religions in Nigeria, they all consider people who engaged in such acts as devilish people because if you look at it too, it is not acceptable. So, the three religious bodies will totally condemn the act too; they dislike people who engage in such acts. [Married adult male with no formal education Ibadan southeast FGD, aged 45 years, R3]

A few participants also expressed their personal disgust.

There is no enjoyment in both anal and oral sex, it is irritating to me because it is very bad, and God is against. [Married adult male with no formal education, Ibadan southeast FGD, aged 45 years, R8]

Some participants, mostly women, talked about fears of acquiring STIs including HIV and HPV infections, sustaining genital or other related injuries and catching other diseases such as mouth odor and cancer. They opined that acquisition and transmission of infections could arise from licking an “unhygienic penis,” inadvertent swallowing of seminal fluids, penetration of anus and possible trauma to their mouth or anus.

There are many diseases you can contract through oral sex. For example, if someone suck in sperm and allow it to enter your stomach and blood, you can contract HIV infection, and other diseases. [Married adult female with no formal education, Ibadan southeast IDI, aged 40 years]

Receptive anal sex by women was believed to be associated with fecal incontinence. FSWs expressed fear of having fecal incontinence with associated embarrassment, shame, and a large financial cost to manage the condition.

White men have treatment for anal sex and Nigeria does not have that. I don’t want to have a leaking buttock and I’m not ready for the use of diaper for the rest of my life. [FSW, Ibadan southwest IDI, aged 32 years]

The perception of oral/anal sex as risky and dangerous was sometimes sufficiently strong to outweigh the desire to protect the relationship. Some married women explained that they had rejected oral and penile–anal sex with their husband because of fear of contracting infections or diseases.

So as far as I am concerned, I don't engage oral sex because even though my husband wants it. I don't accept it from him because he might have other women outside. […] I don't want to contact any disease from him. [Married adult female with formal education, Ibadan southwest FGD, aged 36 years, R5]

Discussion

This is the first in-depth qualitative study to explore the perspectives of younger and older adults, and FSW on oral and anal sexual behavior in West Africa. Although most participants had heard of oral and anal sex, knowledge was generally better in younger adults and FSWs than in older adults. There were more slang words for oral sex than for anal sex, and participants felt more comfortable discussing oral sex than anal sex. The sources of information on both sexual behaviors were similar, primarily sexually explicit movies and sexual partners. Views on the acceptability of using slang terms in the community to describe sexual behaviors differed across population groups; only younger and older adults, and FSWs would readily accept slang/colloquial terminologies for oral and anal sexual behaviors. Participants adhered to a range of scripts in describing oral and anal sexual practices, including pleasure, dominance, and disgust. These scripts surfaced in all participant groups but with some differences. For instance, financial reward was more common among FSWs while concerns about health risks (including fecal incontinence) were most common among women in the general population.

In this study, younger adults and FSWs engaged in more robust discussions on the meaning of oral and anal sex than older adults from the general population. Increasing access to sexually explicit movies on different platforms likely provided higher exposure to these behaviors in younger adults compared with older (Arulogun et al., 2016; Lim et al., 2017; Rothman et al., 2015). In spite of awareness of oral and anal sex by many participants, some defined them incorrectly. For example, oral sex was defined by some participants as an exchange of erotic messages between lovers or condomless penile–vaginal sex. Similarly, anal sex was referred to by some as penile–vaginal sex from behind. Misperceptions and lack of knowledge need to be considered by researchers while designing their studies to avoid eliciting incorrect responses. Asking direct question about oral and anal sex might not convey the intended meaning to the participants unless these terminologies are clearly defined. Misconception about the definition of oral and anal sex can also drive misinformation and may put people at risk of STIs, HIV, and HPV-associated morbidities.

In this study, younger adults and FSWs engaged in more robust discussions on the meaning of oral and anal sex than older adults from the general population. Increasing access to sexually explicit movies on different platforms likely provided higher exposure to these behaviors in younger adults compared with older (Arulogun et al., 2016; Lim et al., 2017; Rothman et al., 2015). In spite of awareness of oral and anal sex by many participants, some defined them incorrectly. For example, oral sex was defined by some participants as an exchange of erotic messages between lovers or condomless penile–vaginal sex. Similarly, anal sex was referred to by some as penile–vaginal sex from behind. Misperceptions and lack of knowledge need to be considered by researchers while designing their studies to avoid eliciting incorrect responses. Asking direct question about oral and anal sex might not convey the intended meaning to the participants unless these terminologies are clearly defined. Misconception about the definition of oral and anal sex can also drive misinformation and may put people at risk of STIs, HIV, and HPV-associated morbidities.

Participant discussions of slang words reflected a subculture phenomenon which bordered on identity, and this has been found elsewhere (Duby et al., 2016a, 2016b). People who use slang words have something in common and they understand such language within their clique (Selikow, 2004). This may be the reason why younger adults and FSWs more readily accepted slang words as a means of communication and openly discuss their experience of oral and anal sex at ease. Some sex workers shared how they profiled customers to negotiate the price of sex. Customers who communicated that they understood the slang terms for oral and anal sex were usually charged less than those who were clearly naïve to such activities.

The scripts for oral and anal sex were similar to previous qualitative studies conducted among adolescent and adult women in Tanzania, USA, and Canada (Armstrong et al., 2012; Reynolds et al., 2015; Vannier & O’Sullivan, 2012; Wamoyi et al., 2015). The six scripts that emerged from our study were as follows: protection of sexual relationships; financial rewards; alternative to penile–vaginal sex; sexual pleasure; male dominance and control; and stigmatization, disgust, and danger. The gender and age group of participants in the community influenced which scripts they discussed and how. Protection of sexual relationships as a script for engaging in oral and anal sex was talked about by the unmarried younger adults and FSWs. The scripts relating to protecting a relationship and dominance/control reflected gendered roles and expectations in a patriarchal society (Hindin & Muntifering, 2011), specifically male dominance in sexual spheres.

The FSWs gave a deeper insight into the role of financial inducement to encourage people to accept oral and anal sex. They explained the significant financial price that is often placed on oral and anal sex by customers to incentivise them to allow oral and anal sex, even when they despise it. A qualitative study in South Africa also showed that FSWs will negotiate for high price from clients to allow condomless sex or oral or anal sex (George et al., 2019). In Ethiopia, FSWs (18–39 years) reported that they engaged in anal sex with fee-paying clients in several contexts: when they needed money for personal needs, when coerced by clients (particularly when they are both drunk), and for fun (Mazeingia et al., 2017). Men/boys mentioned sexual pleasure and adventure as a script for engaging oral and anal sex. This finding is consistent with the results of a qualitative study among long-distance drivers in the Morogoro region of Tanzania which found that most truck drivers mentioned better sexual pleasure as their main motivation for anal sex (Mtenga et al., 2015).

Fear of acquiring infections and other diseases, physical injury, stigmatization, and breaching the religious teachings, as well as personal and community disapproval emerged as a common script. Participants associated a risk of acquiring sexually transmitted infections such as HIV and HPV with both oral and anal sex. Oral sex was also reported to be associated with the risk of cancer. The fear of stigma and breaching of religious teachings might partly explain the culture of silence around oral and anal sexual practice. Even in the brothels where discussions about sexual practices appeared to be more acceptable than in the community, sex workers sometimes denied practicing oral and anal sex when an unfamiliar person requested it or asked about it.

The strength of this qualitative study includes the enrollment of different population subgroups with wide ranging sexual experiences and attitudes. The triangulation of focus group discussions and in-depth interview contributed to richer descriptions of phenomena, allowing for contrast and comparison between individual views and those generated via group dynamic. The study also provided the opportunity to seek the input of people in the community in the preparatory stages of the survey design, and participants made recommendations as to how the questions about oral and anal sex should be framed to enhance acceptability and clarity. This study also provided information on other form of penetrative sexual behaviors apart from the penile–vaginal sex on perception, meaning, and personal experiences. This information can be useful in designing health interventions for sexual risk behavior and public health prevention programs.

There are several limitations to our study design. There is a risk of social desirability bias due to the sensitive nature of oral and anal sex in the community. Fear of negative reaction from others may have resulted in some participants self-censoring their views, and editing or limiting their personal stories. The study did not include men who have sex with men, lesbians, bisexuals, long-distance drivers, people working at bars or entertainment venues, clients of sex workers, and street-based sexual workers who may have different perspectives about oral and anal sex. It is important to note that this study was conducted before the advent of global pandemic SARS-CoV-2 infection. It is not clear whether and how the pandemic has altered perspectives on oral and anal sex, but it seems plausible that public health measures and regulation of social distancing, wearing of face mask, and hand washing against SARS-CoV-2 infection might affect how people feel about intimate behavior (Lopes et al., 2020).

Conclusion

This formative study provides insights on different scripts of oral and anal sex among younger and older adults in the general and FSWs. The study focused on critical aspects of oral and anal sexual behaviors that need to be understood in a community, particularly when related scientific research is being contemplated. Although oral and anal sex were known as specific sexual behaviors, they were still considered sensitive topics by the participants. The use of clear and culturally acceptable definitions of oral and anal sex instead of slang or colloquial terms was advised whenever the research questions are to be designed to improve the quality of responses and cooperation of people in the community. The perceived script for and against the practice of oral and anal sex were similar to findings in a number of previous studies. We recommend that researchers keep track of evolving meanings, interpretations, and attitudes toward oral and anal sexual behaviors in SSA. Information on these emerging sexual behaviors is vital in formulating policy and programs that can mitigate against any associated health risks.

Below is the link to the electronic supplementary material.

Supplementary file1 (DOCX 19 kb)