Input:
 The prompt for the above section of the story could be:

Write a paragraph discussing the use of antibacterial soaps for cleaning sex toys. Address the common misconception that these products are more effective than regular soap for cleaning sex toys, and provide information on the correct way to use antibacterial soaps to ensure their effectiveness. Discuss the potential risks associated with using antibacterial soaps that contain triclosan, and provide reassurance that regular soap is just as effective for cleaning sex toys.

Response: Some people use antibacterial soaps for their toys. While  these products can be useful, most people dont use them correctly. The most common antibacterial ingredient is triclosan, which must be left on the surface for two minutes to have the desired effect. If you dont soap up and let the toy sit for two minutes before rinsing it off, you might as well use any regular soap. When exposed to UV light, triclosan converts to dioxin, a dangerous chemical, and in any case, research has shown that regular soap is just as effective as the antibacterial kind. Simply wash with soap and hot water for 15 seconds and youll be all set.


Input:
 The prompt for the above section of the story could be:

Write a chapter on anal sex and strap-on fucking, specifically focusing on the prostate. Discuss the benefits of receptive anal sex for men, including the potential for intense prostate stimulation and the feelings of vulnerability and intimacy that can come with it. Provide information on how to prepare for anal sex, including the importance of using lube and taking things slowly. Discuss different positions for anal sex and their potential effects on prostate stimulation, and provide tips for how to make the most of each position. Also, address any concerns that heterosexual couples may have about pegging, and provide reassurance that it is a normal and healthy sexual activity. Finally, discuss the potential for women to experience physical gratification from strap-on play, and provide tips on how to achieve this.

Response:
**CHAPTER** **12**

**ANAL SEX AND STRAP-ON FUCKING**

For many men, the preferred method of giving the prostate a little rubdown is to be on the receiving end of anal sex with a cock or a strap-on dildo. A number of anal sex positions angle the cock or dildo so that it slides over the prostate with each in-and-out motion, giving a hands-free massage. Even in other positions in which the prostate is not in perfect alignment with the cock, it still gets some pressure (since there is pressure in all directions when you are being filled up) and some jostling (since the whole pelvis may be jostled by the thrusting motion).

If your ass is ready for this level of stimulation, and you have a trusted partner with an appropriately sized cock or dildo, anal sex offers an entirely different experience from  prostate massage with fingers. In fact, some even prefer it over finger play. By virtue of being thicker than fingers, cocks and (many) dildos apply more pressure in all directions, including pressure on the prostate—which can add to your pleasure. Because the force is not all concentrated behind a small fingerpad, the stimulation is broader over the surface of the prostate. This lesser concentration might leave some wanting, but for others for whom the very direct, focused pressure of a finger massage is too much, the broad in-and-out strokes of a cock or dildo sliding over it may be just the ticket. And the bouncy, jostling motions of fucking can really feel amazing on the gland.

The prostate is not the _only_ thing that makes receptive anal sex pleasurable for a man. But for many men who love anal sex, the prostate is a significant part of the pleasure they experience, even though some may not realize that what they are feeling is their prostate.

Some men first discover their prostate gland accidentally, before they have even heard about it, while exploring anal sex. One fellow describes his experience of this: "My playmate liked to use her strap-on and I quickly discovered that some positions felt _much_ better than other ones. I didnt realize that this was my prostate at first. In fact, I dont exactly recall when I made the connection[...]."

Though many men feel amazing prostate stimulation while getting fucked, its not going to happen for every man, every time. The same is true for women: not all women feel their G-spot activated every time they have vaginal sex. Remember from chapter 7, Find It: Locating the Gland, that it is possible  to press directly over your partners prostate and not have him feel anything remarkable. Some men simply may not feel a great deal of prostate sensation during anal sex. Of course, we believe that it is possible to learn to tune in to the prostate through practice.

DISCLAIMER: For the sake of simplicity, we use the terms _dildo_ and _cock_ interchangeably in this chapter. Some of you will be playing with a flesh cock, others with a manufactured cock—but really, if we spent the whole chapter saying "cock or dildo" it would get a little tedious, wouldnt it?

**A Different Way of Doing the Same Thing**

Some male–female couples are happy to explore anal play with fingers and toys but feel that anal intercourse is a different matter. For some, this is because strap-on fucking is seen as too closely resembling anal intercourse between gay men, or sex with the man playing the "womans role."

If you are having these concerns, first wed invite you to consider: Is there any real difference between using a toy by holding it in your hand versus attaching it to your pelvis or thigh? Either way, you are creating the motion of the toy. We invite you to look at it as a different way of doing the same thing: pleasuring the prostate. If issues about masculinity are coming up, we recommend that you check out chapter 13, Real Men Dont, for an in-depth discussion of these concerns.

#  **TECHNIQUE**

Anal intercourse inherently involves a lot of in-and-out motion. This is different from finger massage, which consists of smaller movements. Because of the emphasis on motion, it is imperative that you use lots of lube. If you dont use enough, there will be too much friction and it will likely become uncomfortable very quickly.

Anal sex is often perceived as a pinnacle sex act. Often when someone gets the idea to have anal intercourse the impulse is to say, "Okay, great! Put it in my ass right now!" A severe ass pounding is the stuff of many a fantasy, but no matter how hot that fantasy is for you, it is important that you dont rush into it before you are ready.

It is highly unrealistic to expect to have pleasurable anal sex during your first attempt at anal penetration. Weve heard lots of stories about painful, entirely pleasureless anal sex experiences. This is where many of them come from: eager newbies who rush to anal intercourse before theyve learned how to warm up. Ideally, you should only attempt anal fucking after youve practiced penetration with reasonably sized objects—and liked it—several times. This is one of the best ways to ensure that you get the pleasurable experience you are hoping for.

The ass doesnt do well with a zero-to-60 approach, especially for beginners. So for best results, take the time to get the ass ready. By way of a warm-up, give yourself a gentle prostate massage with your fingers. This awakens the prostate early in the session, so that by the time you get to anal  sex it will be perked up and eager to revel in the persistent strokes of the cock over it. The more stimulation the prostate gets _before_ intercourse, the more it will be able to generate sensation _during_ intercourse, since it will be that much more swollen and aroused. Once you are warmed up, open your ass slowly, moving from smaller to larger objects and allowing plenty of time for it to adjust between insertions. Use fingers or small toys before you take on that fat purple dildo!

Sometimes people rush anal sex because thats what theyve seen in porn movies. While those movies can be lots of fun, they dont show sex the way it really works. Using porn for sex ed is like learning gun safety from watching an action film. In porn movies you almost never see any warm-up before anal sex, or anyone applying lubricant. Both of these steps happen before the cameras are turned on, to convey a fantasy about the immediacy of anal sex. So feel free to use these movies as inspiration, as long as you remember to do it differently in the bedroom.

##  **Riding the Curve**

If you are working with a curved cock, you are at an advantage. The curve allows the cock to reach up and around the top of the prostate on each instroke, so that it tugs downward on the prostate during the outstroke. This mimics the "come-hither" motion that is so popular in finger massage. Make sure that the inside of the curve is always facing the prostate. If the cock curves downward, favor rear-entry positions, and if it curves upward, favor face-to face positions.

Of course, if you are using a strap-on dildo, you can simply  rotate the dildo in the harness so that it points up or down, according to your needs. Sometimes, with all the motion of fucking, the dildo migrates a little off to one side or the other, rotating in the harness so that the curve no longer leans toward the prostate. This is less likely to happen if you have a harness that holds the dildo snugly in place (with the appropriate size O-ring—see chapter 11, Toys). But even with a well-fitted ring, it can sometimes shift if its a very vigorous fuck.

The trouble is, when you are inserted and the top half of the dick is buried in his ass, it is often difficult to tell which way the curve is facing without pulling out. The bases of dildos are usually round, so looking at the base wont help. For this reason, a dildo with a nonrounded base is your friend—you always know which way the curve is facing just by looking at the base of the dildo.

If you are using a toy with a circular base, there is a simple solution: put on the harness with the dildo, angle the toy the way you want it, and draw a line or a small mark on the base of the toy with a permanent marker to indicate which end is up. Flip the toy around and mark the other side too, for positions in which you want it curving in the opposite direction. (Do this in advance so the ink has time to dry completely.) To check whether it is still facing the right direction during penetration, all you have to do is glance down at your mark and adjust if necessary.

##  **Finding the Angle**

Often when you ask someone how to touch the prostate during anal sex, they simply say, "Just point toward the front of the  body." This is true: when you are aiming for the prostate, you are always aiming toward the front of the body. However, there are a few pitfalls that you can watch out for.

If you didnt know better, you might "point toward the front of the body" in such a way that you direct your cock straight into the prostate, so that all the force of each stroke impacts the prostate head-on. As we mentioned in chapter 9, Prostate Massage, most men find poking sensations to be unpleasant, and this is likely to feel like a lot of poking.

Depending on the preferences of your partner, you may be able to do some nice things with this angle: it might feel good to have the head of a cock apply very gentle head-on pressure if its only small, quick, jostling stokes (almost like a vibration) or very subtle pressure-on, pressure-off strokes. But any hard or forceful pressure you apply directly to the prostate is likely to feel like a poke: uncomfortable and overstimulating.

So dont jab it with the head of your cock like a battering ram breaking through a fortress door. Instead, use your cock to slide across it. This means changing the angle so that the force of the stroke is not directed _into_ the prostate, but _along_ it. You want the cock to apply a grazing pressure as it slides in and out over the prostate. This tends to work best with long strokes: all the way past it on the instroke so the head of the cock is beyond the prostate, and all the way past it again on the outstroke so that the head of the cock drags down along the whole surface of the gland.

Though these are long strokes, they dont need to be deep strokes. You need only go just past the prostate so that you can come down over it again on the outstroke (about 5 inches  deep). If you have a longer cock, you may find that it is not necessary to insert it all the way. In fact, you may be better off not inserting it to its full length on each stroke. Which brings us to our second pitfall: hitting the first curve of the rectum.

As we described in chapter 5, Penetration 101, the rectum is not a straight line. Rather, it has a gentle _S_ curve. In the book _Anal Pleasure and Health_ , Jack Morin points out that if you angle the penetrative object too strongly toward the front of the body and then plunge deep, the tip of the object is likely to slam into the first curve during the instroke. This will be painful, especially if there is force behind it.

This is especially relevant when you are shooting for the prostate, which necessitates a forward angle to your fucking. To avoid hurting your partner by poking into the first curve of the rectum, be sure that when changing from shallower to deeper strokes you go softly at first; if you do hit the first curve, there wont be force behind your thrust. Take a moment to adjust the angle, gently feeling your way. Check in with him, or watch for signals of discomfort. The new angle will be less dramatically pointed toward the front of the body, so it may not deliver as much sensation to the prostate. However, switching from shallow to deep strokes and back again can be a nice change, and is a good way to give the prostate a break so that it doesnt get overstimulated.

##  **Pivot**

For variety, stop the in-and-out motion and do a little up-and-down pivot with your hips. For this, you use your cock like a seesaw. Insert about 4 inches of the shaft so that the cock is  contacting the whole surface of the prostate, and gently move your hips in a subtle up-and-down motion. As your hips go up, the head of your cock will point down, putting pressure on the prostate. This mimics the "come-hither" curl that you would do with your fingers to milk the prostate.

This one works well in rear entry or missionary (with his ass is propped up on a pillow and you on your knees), or if hes in a sling and you are standing. For rear entry, you are pressing the head of the cock downward against the prostate by pivoting your hips upward. Likewise, in missionary positions, you are pressing the cock up into the prostate by pivoting your hips downward. Note that this is not a big motion. You dont lift your hips up or down more than an inch or so at a time.

In many positions, the receiver can create this effect himself: you insert to the right depth and he rocks his hips, curling toward the pubic bone and then unfurling the tailbone to nestle the head of the cock against the area he favors. This way, he can very specifically line you up to where he wants you.

##  **Circle Hips**

In a glorious union of the in-and-out stroke and the up-down pivot, you can move your hips in a circular motion as you fuck him. Basically, you just fuck him in and out while moving your hips upward on one stroke and downward on the other. Note: we are not talking about a circle that involves moving your hips right to left. That might feel good for the prostate too if you get the right angle, but the circle were describing is the up-down motion. The idea is that you are dragging the  head of the cock dramatically across the surface of the prostate with every outstroke.

Lets say hes lying on his back, his ass propped up with a pillow and his knees pulled in to his chest. You are kneeling, penetrating his ass. Now imagine a clock on your right hip: point to 12:00 and trace your finger clockwise around the clock. This is the motion that your hips will follow—instroke, pivot down, outstroke, pivot up. Now, remember the seesaw? As you are pulling out and simultaneously moving downward (3:00 to 6:00), the head of your cock seesaws up and strokes across the surface of the prostate.

This can be a tricky motion and may take some practice—definitely slow it down and build from lesser to greater speeds. Also, it really doesnt have to be a big motion: just enough to reach beyond the prostate, stroke along it on the outstroke, and push in again. If you were entering him from behind, you would simply move your hips in a counterclockwise motion (if the clock is on your right hip)—but you are always dragging across the prostate on the outstroke so you contact it from top to bottom (going with the natural flow of the glands it contains) and to avoid poking it.

##  **Switch It Up**

As always, variety is good. Vary the speed, rhythm, length of stroke, and depth of stroke. After a few prostate-focused strokes, change the angle and go deeper for a few strokes that dont focus so strongly on the prostate. Occasionally backing off from the gland not only prevents it from getting bored or overstimulated, but also allows the prostate to enjoy the  contrast between right-on-it strokes and just-gliding-past-it strokes. It gives the gland a chance to recharge and to crave the attention, so when you return to it, it will be eager for more.

**REMEMBER THE SWEET SPOT**

In many positions, you can reach with your hand to apply pressure to his perineum and massage his sweet spot while you fuck him. This applies pressure to the prostate from two directions simultaneously, and the dual approach can feel really amazing. There is a sense of unification of the pleasure, activating a wider range of nerves.

In missionary positions, simply reach down with your thumb. In rear entry, you might externally rotate your hand (so the thumb points away from your body), then press into his perineum with the pads of your curled fingers. Just be careful not to dig your nails into his skin!

#  **POSITIONS**

Positions make a big difference in how much prostate stimulation you get. Experiment with different positions and different angles and discover with your partner what works best for the unique pairing of your bodies.

##  **Rear Entry**

Rear-entry positions are especially good for pleasuring the prostate. Lots of people have mentioned that they feel it the most in these positions. When you enter him from behind, it is  very easy to direct the cock toward the front of the body. The head of the cock is ideally situated to slide across the prostate on the in-and-out strokes. And as a bonus, you can give him a reach-around! Rear-entry positions dont favor eye contact, but if you want to see your partners face, you can position yourselves in front of a mirror.

_**On all fours (doggy style)**_

• He is on his hands and knees and you are behind him.

• Great freedom of motion for him. He can move his hips back and forth to meet the thrusts, rock his hips up and down, and adjust easily to get the right angle.

• Easy to line up the height. He can spread his legs wider or bring them together to adjust the height of his ass so it lines up with your cock.

_**Doggy style with head down**_

• He is on his elbows and knees, with his face lowered to the bed so that the torso-to-thigh angle shifts from 90 degrees to 45 degrees.

• Changing the angle of the torso to the legs produces a subtle internal shift that positions the prostate closer to the surface: the prostate moves dorsally (toward the spine) and posteriorly (toward the anal opening).

• Have him lie over a pile of pillows so he wont have to work so hard to support himself with his arms. Some companies like Liberator make cushions that are specifically designed for sex. Theyre firm enough to give plenty of support, and the washable cover makes clean-up easy.

_**On his belly**_

• He lies flat on his belly, with you lying on top of him (between his legs) or kneeling upright (straddling his legs).

• Prop his ass up with a pillow for better accessibility.

_**Spoons**_

• Both partners lying on their sides, his back to your front, like two spoons nestled together in the silverware drawer.

• For better access, he can draw his top knee up so his thigh is perpendicular to his torso.

_**Bent over**_

• He is standing up and bending over, with his hands or elbows bracing him against the wall or a piece of furniture.

##  **Missionary**

Missionary positions have the receiver lying on his back and the giver approaching him from the front. These positions tend to be very comfortable for the receiver, letting him relax and lie back. Also, since he doesnt need his hands to hold himself up, he can use them to jerk off.

_**On his back**_

• When he is flat on his back, his asshole is not easily accessible. It becomes more accessible with a pillow under his hips: this makes it easier to get to his anus, and also allows for better angles.

• You can lie or kneel between his legs.

• He can bend his legs with his feet flat on the bed, or he can draw them up toward his chest. You can also put them over your shoulder, though this can be tiring.

• Position his legs at right angles to the body to soften the curves of the rectum, making it straighter and easier to penetrate without hitting the curves.18 Bring his legs up closer to his chest to compress the pelvic area, adding to the pressure on the prostate. 19

**Illustration 28. Holding His Legs Up**

**WHAT TO DO WITH HIS LEGS**

In missionary positions, you have greater access if his legs are drawn up, but that generally means either the receiver needs to hold them up with his hip flexors (which can be tiring) or one of you has to hold them up with your hands. Here are a few ways of doing it:

• He uses his arms to hold his own legs up, with his hands or (if he is flexible) his elbows wrapping behind the knees, or his hands holding his feet.

• You drape his legs over your shoulders.

• He pulls his knees to his chest, then you lie over them, putting some of your weight on the back of his thighs, with your hands on the bed at either side.

• He wraps his legs around your torso and puts his feet behind your mid-back. You slip your hands _under_ his calves (supporting them) and _over_ his thighs. Use your hands to pull his thighs toward you, your forearms to support his calves, and your elbows to keep his feet tucked behind you. (See Illustration 28.)

• You can improvise a seated sling position with a yoga strap. Connect the ends so that it forms a loop. He puts the loop around both of his legs, just above the knees. He lies back and pulls his knees to his chest. Then he grabs both pieces of the looped strap from between his knees and puts them behind his neck, so that his legs are supported. This can put a lot of strain on his neck; it helps if he has a pillow under his head and he positions the strap low on the neck. To help distribute the force evenly over the back of the neck, place a folded towel or small pillow between his neck and the straps. (See Illustrations 29–30.)

**Illustration 29. Improvised Portable Sling, Step 1**

**Illustration 30. Improvised Portable Sling, Step 2**

_**Off the side of the bed or other furniture**_

• Position him on the edge of a bed or a desk, and stand or kneel (as your height dictates) on the floor.

• Dont do this on any furniture that may not safely hold his weight!

**SLINGS AND SWINGS**

Slings are immensely popular for anal sex, because they allow positioning that is both greatly comfortable and easy-access. A sling is, essentially, a little sex hammock that you hang from the ceiling. They are often made of leather but can be found in some other sturdy materials as well. The receiver lies on his back in the sling, with his ass hanging slightly off the edge and his knees pulled up toward his chest. You can also buy leg loops to attach to either side so the receiver can relax his legs.

This laid-back and fully supported position is ideal for anal sex because it really lets you relax fully, so your pelvic musculature can release and the ass can open more easily. The height of the sling can be adjusted before you get in it so that your ass is perfectly positioned to line up with your partners pelvis when they are standing. They only need to point the cock inward and upward, and the prostate is right there waiting! Slings are spendy, generally ranging from $250 to $500, depending on the material, but its a good investment. If you get a nice one and take good care of it, itll last for years.

_**Cowboy (Receiver on Top)**_

• You lie down on your back and he climbs on top of you, straddling your cock.

• He can face toward or away from you. (This choice may depend on the shape of the cock—whether it curves upward or downward.)

• He can control the motion by bouncing up and down or gyrating on the cock.

• He can easily get it where he wants it by adjusting the depth and angle.

• Cowboy positions help him feel in control and help you feel assured that you are not going to hurt your partner.

• You can stroke him if he is facing toward you.

#  **PEGGING: STR AP-ON SEX FOR GUY–GIRL COUPLES**

_Pegging_ is a recently coined term for an increasingly popular sexual practice: strap-on sex for male–female couples, with the man on the receiving end of penetration. Certainly, not every hetero couple is doing this, but an increasing number are trying it out, as shown by the emergence (and marketability!) of a number of products for this kind of play.

In 1998, a sex ed video on this subject titled _Bend Over Boyfriend_ came out, and over the years it has sold well, generating a sequel. "Bend over boyfriend" or BOB for short has become a common term for this kind of sex. More recently, in 2009, Tristan Taormino released an educational video titled _Expert Guide to Anal Pleasure for Men._ In 2012 she came  out with her follow-up, _Expert Guide to Pegging: Strap-on Anal Sex for Couples_.

Anecdotally, sex shop workers have reported an increase in guy–girl pairs shopping for butt toys for him, including strap-on harnesses and dildos. There are even "beginner strap-on kits" at sex shops that market to these pairs.

Some couples have a strong sense of reservation at the idea of pegging: they may have enjoyed experimenting with fingers and handheld toys, but strap-on sex feels like another ball game entirely. There is a feeling that anal intercourse is just _different_ from other forms of anal play—too close in its association with the stigmatized realms of homosexuality or dominance and submission.

These concerns are common and its often best to just talk it over openly with your partner. The way we see it, if she is making him feel good with her fingers, or with a toy held in her fingers, its no different to do so with a toy attached to her pelvis. Inherently, the act is the same: she is pleasuring him (and hopefully enjoying herself too).

If you can get past the hang-ups, strap-on sex can be a way-hot experience for both the lady and the fellow shes givin it to. First, it requires a great deal of trust for him to let her in this way, so it can foster deep feelings of intimacy; he is entrusting her with a part of himself that not a lot of men share with others, allowing himself to be vulnerable.

Then theres the excitement of trying something new together, of exploration and discovery. Plus the psychological turn-on of doing something naughty and taboo: the neighbors would flip if they knew, and that just makes it even hotter!  (Actually, the neighbors are probably doing it too.)

Also, the role reversal can be an eye-opening and memorable experience. Each partner gets to experience the other side of what they are used to: he gets to experience being on the receiving end of penetration, and she gets to be on the giving end. For that matter, quite a few women who have tried strap-on harnesses for the first time say that they now get how much work and responsibility fucking someone can be—and they dont even have to worry about their erections getting soft or reaching orgasm too soon!

And, of course, there is the actual physical pleasure it gives him, from the anal attention and the prostate. Many men find that receiving strap-on sex is an entirely different experience from other forms of anal play, and they appreciate the unique sensations it offers their prostate.

But this doesnt have to be all about him! Many women can get clitoral stimulation during strap-on sex if they position the base of the dildo over the clit. Some can even climax this way. There are also double dildos available that penetrate both partners simultaneously, so she can get vaginal stimulation while she fucks him.

Some eroticize the idea of power exchange that is suggested by penetration and play it up with fantasy and dominance/ submission role play. For others, there is no suggestion of power exchange, and the approach can be playful and sensual instead: no D/s dynamic here; just some sweet lovin for his whole body—no parts excluded.

Certainly, any kind of penetration can be delivered with a tone of dominance, but it is not inherently so. You may find  that you and your partner like it both ways, and you can vary your approach nightly as the mood strikes you.

##  **Finding Your Rhythm**

Many women are not used to the fucking motion of the hips, so wielding a strap-on can be a bit awkward at first. Definitely dont build up a huge "Im going to take your ass like a bandit" fantasy in advance of your first attempt at wielding a strap-on. You may find that you are not able to be as smooth in practice as you were in his and your shared fantasy.

When youre new, expect a learning curve. Many women, when they take on the role of the penetrator, are using muscles that they may not normally use in this way, so it may take some practice before you can fuck as smoothly as your boyfriend, who has probably had years of experience. Dont try to give him a fast and riotous pounding right away. If you are trying to move faster than your unpracticed muscles can coordinate, your strokes will be erratic and the angle will be changing with each stroke—which will feel about as good to his prostate as a flopping fish. Instead, take it slow and learn how to get a steady rhythm going. Once youve got that down, you can increase your speed. For each new position, start slow again and allow your muscle memory to develop through practice.

When you first enter him, hold the base of the dick in your hand to guide it in. You can hold still and have him back up onto it, or you can instruct him to "bear down" to open his sphincters. (See chapter 5, Penetration 101.) Dont shove all the way in right away—after the head pops in, hold still for a  spell and let his ass get used to it before you work your way in deeper.

##  **How She Can Get Off on Strap-on Play**

Some women really love strap-on fucking their men—and not just because its hot to watch him enjoy himself or because its a hot fantasy to bend him over. As mentioned above, some women can experience real physical gratification from the act. All that thrusting and banging against his ass can give her some very nice friction on her clit—enough friction for some women to climax.

To maximize this sensation, wear the harness low, and position the dildo so that the base sits over the clit and the shaft extends out as if it were, itself, an extension of the clit. If you find the friction to be too much, try wearing panties under the harness. This softens the friction while also decreasing the likelihood that your genitals will come in contact with the ample quantity of lube which you are, of course, generously applying to the dildo.

Different positions work better for different women, but definitely try a position that lets you get in touch with the thrusting motion. If you have never come this way before, try really slowing down your strokes and tuning in to the way your clit feels. You might even practice by grinding on a pillow, or on his thigh. Dildos that maximize this effect are those with more to rub against—try one with a pair of balls attached, providing a larger surface area to grind on. Get one that is firm enough to allow easy fucking, but not so firm that it hurts to press into it.

And of course, there are plenty of dildos on the market that work for strap-on style sex but that penetrate the giver as well as the receiver. For info on these, as well as general tips for purchasing a strap-on harness, read up on toys in chapter 11.


Input:
 The prompt for the above section of the story could be:

Write a chapter on the societal pressures and beliefs that can prevent men from exploring their prostate. Discuss the idea that receiving penetration is in conflict with masculinity, and how this belief can limit men. Address the common misconceptions that only gay men enjoy anal penetration and that penetration is an act of dominance. Also, discuss the idea of the "Act Like a Man" Box and how it can limit men's expression of their true selves. Finally, provide reassurance that there is nothing wrong with enjoying prostate play and that it does not make a man any less masculine.

Response:
**CHAPTER** **13**

**REAL MEN DONT**

#  **DOES IT MAKE ME LESS OF A MAN?**

Many people have the idea that receiving penetration is in conflict with masculinity. The basic story goes like this: _Real_ men dont get fucked—thats for women, fags, and sissies. Because receiving penetration is usually viewed as the womans role in sex, a man may be worried that he isnt fulfilling the mans role if he takes a turn catching instead of pitching.

Thanks to the common (though incorrect) belief that the only men who like to receive anal penetration are gay men, many people think that if a man likes to be penetrated, he must secretly be gay. And it is also a common belief that being gay = being feminine = not very masculine.

Further, some people view penetration as an act of  domination, so a man may worry that he is being dominated if he lets his partner penetrate him—again, not a very "manly" thing to do.

All this contributes to the idea that if a guy opens his ass to some love, it makes him less of a man. To be clear, we think this is nonsense. But many men have a very real fear that if they receive penetration, they forfeit their masculinity. Needless to say, this can be a major roadblock to exploring and enjoying the prostate!

While not all men or their partners experience these concerns as a barrier to enjoying prostate play, it happens often enough that its worth taking a closer look at these issues. In this chapter, we explain where these ideas come from, how they limit men, and why they arent true.

#  **THE "ACT LIKE A MAN" BOX**

What does it mean to be a " _real_ man," anyway? Although theres a lot of variation in how people define masculinity, some trends are pretty common. One of the best ways to describe these patterns is the "Act Like a Man" Box, which we first heard about in Paul Kivels book _Mens Work: How to Stop the Violence That Tears Our Lives Apart_.

When people are asked to name the characteristics of a "real man" they usually come up with a pretty consistent list:

_tall_ | _drinks alcohol_
---|---
_strong_ | _watches and plays sports_
_muscular_ | _plays poker with his buddies_
_25–45 years old_ | _doesnt show emotions other than anger, excitement_
_able-bodied_
_heterosexual_ | _stoic_
_cisgender_ _20_ | _violent_
_competitive_ | _always wants sex_
_dominant_ | _has lots of sexual partners_
_cop_ | _sex is about scoring_
_firefighter_ | _has a big penis_
_mechanic_ | _gets hard when he wants to_
_lawyer_ | _stays hard_
_businessman_ | _gives his partner an orgasm (or multiple orgasms)_
_CEO_
_caretaker_ | _ejaculates when he wants to_
_competent_ | _sex is focused on intercourse, blow jobs (receiving), possibly anal (giving)_
_leader_

Now, the point needs to be made that not everyone shares these values or thinks highly of this kind of masculinity. Different cultures, communities, and families have different expectations around how they think men are supposed to act, and not everyone is in favor of this particular version of what it means to be a "real man." In fact, quite a lot of people would disagree with the valuation that emerges from the list  above. Based on these characteristics, hes not necessarily a very nice guy!

But whats important about this list is that it shows how prevalent this particular "real man" ideology is. These ideas and images are so pervasive that even people who dont agree with them are still familiar with them. In fact, lots of people who dont agree that men should be violent and stoic still picture such a man when they hear the expression "a real man." So even if a guy didnt hear these messages from his family while growing up, odds are that hes absorbed them to some degree, simply because of how prevalent they are in the larger culture.

In communities where the "real man" ideal is in effect, it is a standard that men are measured and judged against. The degree to which a man conforms to these expectations is understood as an indicator of his value as a person. Other men may praise him for having these characteristics, or pass judgment on him for lacking them. And plenty of women learn these ideas, so sometimes they reinforce them too. Men absorb these ideas and judge themselves accordingly, even if they may not agree with these values rationally. This is called internalized judgment.

#  **OUTSIDE THE BOX IS A SCARY PLACE**

When people are asked to come up with some of the names that men get called when they dont meet the expectations of being a "real man," the responses are also pretty consistent:

 _gay_
_fag_
_girl_
_sissy_
_weak_
_punk_ _21_
_loser_
_bitch_
_pussy_
_wimp_
_maricón_ _22_
_poof_

Its easy to see that its a scary place outside the Box! Men who are perceived in these ways are subject to serious harassment, ostracism, and physical violence. Even if youve never been on the receiving end of this kind of treatment, we would bet that almost every man has seen it or heard about it happening to another person, especially when they were young. Its not surprising that so many men are concerned about keeping their masculinity points up.

Fortunately, more men than ever are realizing that although staying in the Box may keep them safe in some ways, it also limits them and keeps them from exploring and expressing their genuine selves.

**IT ISNT JUST GUYS**

Some men with female partners might discover that while none of these beliefs are getting in their own way, their partner is having difficulty letting go of them. After all, it isnt just guys who can get caught up in the "Act Like a Man" Box. Quite a few women discover that theyve absorbed judgments about how men, especially their partners, should behave. They might think that theyve let go of the Box mentality but find that its coming up during or after prostate play. The Box can be really hard to shake, especially since many of us start learning its traits when were really young. Plus, sometimes when we try something new or challenging, our worries or anxiety bring old fears back to the surface even if we think weve shed them.

#  **WHY THE BOX IS NONSENSE**

##  **You Cant Win**

One of the characteristics of the Box is that its very much an either/or. Even if you have many of the characteristics that are inside the Box, lacking any one of them can be taken to mean that you arent a "real man." But its almost impossible to have all the traits all the time. In fact, for all men, there will be a part of their lives when they are excluded from the Box because the "real man" image paints a picture of a man around age 25–45 years old, so any man outside that age range cant make the cut. Likewise, men with disabilities can never be in the Box. And some guys are simply not going to be tall or muscular.

To make it even harder, sometimes the Box is contradictory. For example, one element of the "real man" myth is that a "real man" works with his hands. Another is that he runs the company and makes big money. So a mechanic might feel hes not a "real man" because hes not in big business. And a CEO might feel hes not a "real man" because he doesnt work with his hands.

##  **The Box Leads Men to Be Inauthentic**

Because it can be scary to be seen as "not a real man" and to catch the judgment and shaming that comes with that, one of the ways men often respond to situations in which they arent fulfilling the expectations the Box creates is to act the role in the hope that no one will notice. This is why Kivel calls it the "Act Like a Man" Box. Sometimes men "perform" masculinity to avoid the harassment that men sometimes get when they arent in the Box.

Unfortunately, this sometimes means not being true to oneself. A lot of men hide their feelings, since emotions other than anger are outside the Box, which often means they dont develop the ability to talk about how they feel. Other men might be interested in something other than sports, cars, and drinking with their buddies but either never try it or hide it from prying eyes. How guys dress, talk, work, and play is influenced by their perception that if they dont follow the rules, people will know that they arent "real men." They may behave a certain way not because it is what they really want, but because they feel that they have something to prove.

##  **The Box Values Performance over Pleasure**

What do you suppose would happen if men had the choice between an 8-inch cock with limited sensation and a 4-inch cock with added sensation? Were pretty certain that some men would opt for less sensation if it meant having a bigger cock, and therefore being more "manly."

When youre stuck in the Box, fulfilling the expectations of being a "real man" is more important than experiencing pleasure, and sex is all about scoring and proving that youre macho. It becomes more important that a man should "perform" well than that he should enjoy himself. And if hes having sex with a woman, her enjoyment and her orgasms are sometimes not for her sake so much as a way to prove how good he is at what hes doing.

In the Box, its all about the cock and what you do with it: "get it up, get it in, get it off." This is so central that some people have the expectation that men should get all their sexual pleasure from their penis, to the exclusion of the rest of their body. Despite the fact that men have sensitive spots all over, theres still a widespread belief that the penis is the only thing to pay attention to. Weve heard men say things like "My cock is all I need to get off," as if it would be an offense to the sovereignty of the cock if other parts of his body added to his pleasure!

Plenty of men get stuck trying to fit themselves into a sexual script that might not always feel right to them. Theres no limit to the ways in which we can have sex, and when you restrict yourself to the kinds of sex that fit into the Box, you miss out on a lot of amazing fun.

While we respect everyones right and ability to enjoy whatever sexual pleasure they wish—within the bounds of the consent and well-being of everyone involved—weve noticed that theres a big difference between "I tried it and didnt like it" and the more defensive "Ill never do that." Unfortunately, it means that a lot of men choose the Box over their own pleasure.

#  **PICKING AND CHOOSING FROM THE BOX**

Many men find, with time and consideration, that while some elements of the Box may fit who they are, others do not, and they realize that they resent having these expectations put upon them. But how to get free of it?

A lot of people think that in order to get rid of the Box a man needs to reject _all_ those expectations and be none of the things the Box requires a man to be. However, by doing this he gets out of one box and right back into another: the Anti-Box. You might know some of these guys—they dont allow themselves to feel or express anger, they dont ever speak up for what they want, and they tend to be pretty passive. Before, they felt they had to be everything that the Box is, and now they feel they have to be nothing that the Box is. Theyre still in a box, its just the opposite box!

Instead, we think the way to get free of the Box is to reject the either/or-ness of it: let go of the idea that you have to be all or none. You can pick and choose! You can be some of the things in the Box—you dont have to be _all_ of them.

This also means that you can start creating your own definition of what it means to be a man. You dont have to try to meet the expectations of the Box. Ultimately, your sense of value as a person—no matter where you fall on the gender spectrum—comes from within you. No one can give it to you—you have to find it within yourself. And no one can take it away either—its always available inside you, even if you lose contact with it at times.

As you free yourself from the Box, consider whether you are spending time with people who are really stuck in the Box mentality—friends, co-workers, family members, romantic partners, and playmates. If there are people in your life who try to force you into this box, or any box, maybe they arent people you want to spend so much time around. Also, its important to ask yourself how much of this judgment might actually be coming from within you. Have you internalized these messages?

#  **BACK TO PROSTATE PLAY**

Now that weve talked about the Box and how masculinity standards are created and reinforced, lets go back to the three main pillars of the idea that receiving penetration will make you less of a man and see how it all ties in together.

Remember the names that men sometimes get called when they dont meet all the requirements of the Box? You may have noticed that they all fall into three categories: youre female, gay, or a loser. Some terms even carry connotations of more than one category. Consider, for instance, that the word _fag_ connotes both gay and feminine, and the term _sissy_ connotes  both feminine and weak. The insulting associations between femininity and male homosexuality are so deeply intertwined that its sometimes difficult to even distinguish between them.

We think this says some interesting things about how the Box defines both women and gay men. A big part of how people define what it means to be a "real man" is by putting down women and gay men, and by viewing the world in terms of dominance and submission or win–lose. In many ways, sexism and homophobia are the bricks that make up the Box and shame is the mortar that holds them together.

##  **"Penetration is the womans role"**

Receiving penetration is sometimes thought of as the womans role in sex. And since a big part of being a "real man" means that you dont do anything womanly, then of course receiving penetration doesnt fit. Some men fear that if they get penetrated, they are being feminized—turned into a sissy.

Of course, the negative judgment about a man taking on the womans role only works if you think theres something wrong with being a woman. Many men have internalized this judgment without ever considering that it is based on the idea that women are inferior and therefore men should not be like them. Ask yourself: do you really believe that women are inferior? Whats so wrong with women that it should be a terrible thing for men to resemble them?

Also, the idea that in sex men have one role and women have another is very restrictive. "Men should do all the giving and women should do all the receiving"—these roles work fine if your sex life consists only of fucking with the man  controlling all the motion. But a lot of people with very satisfying sex lives have roles that are more blurred: for example, sometimes the woman hops on top and controls the motion, or fucks back on him from underneath. Sometimes the woman gives a blow job while the man sits back and receives. Who is playing what role then? Its not always an either/or.

Its also worth thinking about how it can still be a womans role if a man is doing it. In some ways, its similar to how women used to be attacked for wearing pants (i.e., "mens clothes"). In our view, if a woman is wearing pants, theyre a womans clothes. Similarly, if a man gets penetrated, its _his_ hot sex!

The belief that only certain people ever enjoy or engage in a particular sexual practice holds a lot of people back from trying something they might enjoy. Wed much rather have people decide what they want to do based on their (and their partners) consent, pleasure, and well-being than on someone elses opinion of what they should do.

##  **"Only gay men like to be penetrated"**

Two popular myths are: 1) All gay men like to take it up the ass, and 2) Only gay men do this. These myths gave birth to another: Any man who wants to be penetrated must secretly be gay. Or even that being penetrated will actually make you gay!

This is one of those things thats more about perception than reality. Lots of heterosexual men enjoy anal play. After all, its not as if gay and bi men are born with extra parts that straight guys dont have! There are responsive nerves that  will work for you whether you are doing this with a man, a woman, or by yourself.

While were willing to bet that the percentage of straight men who enjoy penetration is smaller than the percentage of gay men, thats likely to be because gay men are generally more open to the idea of it since it is discussed more openly, and because they have probably had at least a few experiences with a partner who knew how to do it and what it was like. But this simply means that lots of straight guys havent had the chance to try it out! Its also worth noting that recent research has shown that when men sleep with other men, anal sex is not always so pivotal as many people think: many men who sleep with men actually dont like to be anally penetrated, and their play focuses on other acts such as blow jobs.

The important thing to know is that _whether_ you like anal penetration is about what kinds of sexual stimulation work for you; _who_ you want to do it with is about your sexual orientation. While there can be some correlation between the two, one doesnt imply anything about the other. If youre gay and you dont like anal play, youre still gay. If youre straight (or bi or any other sexual orientation) and you enjoy it, that doesnt make you gay.

_**"Do you have toys that are**_
_**made for men?"**_
_**"Yes. We have cock rings,**_
_**sleeves, and anal toys—"**_
_**"Do you have toys that are**_
_**made for straight men?"**_
_**"Yes. We have cock rings,**_
_**sleeves, and anal toys."**_

**—CONVERSATION WITH A**
**MALE SHOPPER AT GOOD**
**VIBRATIONS**

And just to be clear, in our view, theres nothing wrong with any sexual orientation. But while were on the subject,  wed like to point out that the idea that a straight guy is less of a man if he takes it up the ass, because thats a gay thing to do, is based on homophobia, in the same way that concerns about assuming the womans role stem from sexism. To get out of the Box and be able to fully enjoy yourself and your prostate explorations, you may have to root out absorbed views like this that you may not agree with!

##  **"Penetration is an act of dominance"**

The idea that being penetrated is a bad thing shows up in some interesting ways. For example, if you are in trouble, some people will say "Youre fucked!" or "Youre screwed!" The idea that penetration is an act of dominance is almost certainly tied in to sexism and the notion that the womans role is inferior. Plenty of men have absorbed these ideas at a subconscious level. Even if a man doesnt think it is an act of dominance when he penetrates his (male or female) partner, he may still hesitate to switch roles because he is afraid that it will mean losing his masculinity if he takes a turn catching instead of pitching.

Certainly, penetration can be done in a spirit of dominance, but it isnt true that penetration is _always_ an act of dominance. And just because it is sometimes viewed or performed that way doesnt mean it has to happen like that between you and your partner. Its all about how you do it, rather than anything inherent in the act of penetration.

First, lets investigate this idea of domination. What does it mean for one partner to dominate the other? As typically understood, it means that the dominant partner imposes their  will on the other, who submits even if its not what they want. Notice how this poses sex as a win–lose activity, where there can only be one winner and the other person loses. Lets not forget that many of the terms for men who dont fit inside the Box carry connotations of losing or submitting: _loser_ , _weak_ , _wimp_ , _punk_ , _bitch_.

Its not surprising that this polarity comes up around anal penetration, because theres a common myth that anal play always hurts the receiver and only feels good for the giver, and the receiver only does it because the giver wants it. We suspect this is also why some straight guys may fear that their female partners want to penetrate them not for mutual pleasure, but as some kind of passive-aggressive payback.

Of course, we know that this is not true: receiving penetration can actually feel really, really good—and often the receptive partner is the one who suggests it! How can they be losing when they are getting exactly what they want?

Instead of the win–lose mentality, where one person is dominant and the other person submits, we propose that sex can be a total win–win, where both the receiver and the giver: a) want to do it, b) enjoy it, and c) want their partner to enjoy it just as much.

_"When we moved to strap-on anal sex with him as the receptive partner, we were careful at first to be certain that neither of us saw this as an act of dominance. Satisfied that we did not see his penetrating my vagina as an act of dominance, we proceeded with hedonistic abandon."_

Now that weve dispelled the myth that penetration is inherently an act of domination, wed like to talk about fantasies. Many people are turned on by thinking about or acting out a situation of dominance and submission or force/coercion in sex. Doing this in your sex life is not the same as wanting it to happen in real life: you can enjoy these fantasies while being perfectly clear that you would never want to force someone or be forced in actuality.

Along those lines, some people enjoy settling into a submissive frame of mind when they get penetrated, as part of a mutually agreed upon BDSM role play. For them its just a fantasy, and both partners are clear that it doesnt say anything about their real-life relationship. Its like a hat that you put on for a while and you can take off anytime.

If fantasies of dominance and submission (D/s) are a turn-on for you and your partner and youd like to incorporate that into your prostate play, by all means go right ahead! (Just be sure to establish a safeword.) Violet Blues book _The Ultimate Guide to Sexual Fantasy_ has lots of great tips for exploring fantasies.

And, if youre not into that, then you dont have to go there. Its possible to enjoy prostate play without having any of those feelings at all.

When you start experimenting with prostate play, if you notice that the issue of dominance is getting in the way of enjoying yourself, take a break from doing it with a partner and spend some time with solo exploration. Going solo is a great way to set aside any partner expectations or concerns about how the play might affect your relationship and find  out what you enjoy before bringing another person into the mix. It will let you explore the physical sensations of prostate play at your leisure, without the complications of attending to a partner.

#  **ITS UP TO YOU**

Whether or not you would like to explore your prostate is up to you. Ultimately, we respect each persons ability to make this choice. But if you think that being penetrated makes a man less of a man, take some time to explore why youre letting that get in the way of enjoying yourself. There are many ways to be a man, and prostate play fits right into that for a lot of men.

Plenty of men—and lots of women—dont enjoy being penetrated for any of a number of reasons. The difference is between choosing not to do something because it doesnt feel good and believing that you cant do something because a "real man" supposedly wouldnt. Its a question of whether your decision is based on what works for you or on externally defined rules that are imposed on you.

Dont be discouraged if you have these concerns relating to masculinity: a lot of newbies to prostate play have to sort through these concerns before they can relax and enjoy themselves. Ironically, this also means (at least in our experience) that many of the men who get into anal penetration are among the most secure in their masculinity: because theyve examined themselves, faced their fears, and worked through it.

We hope that you can find a definition of masculinity that  opens doors for you rather than closing them. Our hope is that however you choose to define your masculinity, you can find ways to enjoy the many pleasures that sex can bring, including prostate play.


Input:
 The prompt for the above section of the story could be:

Write a chapter on prostate health, focusing on common prostate conditions such as prostatitis and benign prostatic hyperplasia (BPH), and prostate cancer. Include information on the symptoms, causes, and treatments for these conditions. Also, provide tips for maintaining prostate health, such as keeping the urethra healthy, wearing a condom, peeing after sex, and eating a healthy diet. Finally, discuss the controversy surrounding prostate cancer screening and the possible benefits and drawbacks of screening.

Response:
**CHAPTER** **14**

**PROSTATE HEALTH**

Prostate conditions are fairly common. Its been said that "if you live a normal male lifespan, odds are at some point you will experience a prostate problem."23 Some of these health concerns are more annoying than dangerous, while others can pose a serious threat. Fortunately, the best tool you have to maintain your prostate health is information, so read on for a description of the most common prostate conditions and what you can do about them.

#  **PROSTATITIS**

Prostatitis is a class of diseases with four types. We will describe the three most commonly diagnosed categories.

The literal meaning of the term _prostatitis_ is "inflammation of the prostate." In its simplest form, prostatitis is an infection of the prostate by a microorganism that has traveled up the urethra and into the microscopic ducts and glands of the prostate. This is called Type I: acute bacterial prostatitis. There is a sudden onset of symptoms including pain in the prostate/perineum/lower back, pain and difficulty with urination, plus fever and chills. This form of prostatitis is the easiest to diagnose and treat. Signs of inflammation are found in the prostatic fluid and, if a culture is done, bacteria (or other likely-culprit microorganisms) are found as well. Most of the time, a complete course of antibiotics resolves the infection.

For some men, prostate infections become chronic. Many of the symptoms are the same, notably frequent and painful urination. But instead of coming on suddenly with fever and chills, symptoms appear gradually and ebb and flow over time, with periodic flare-ups. This is called Type II: chronic bacterial prostatitis. This most often occurs when a case of Type I: acute bacterial prostatitis is not fully cured and comes back. It can also occur in cases of recurrent urethral infection, or in patients with a history of repeated use of urethral instruments, such as sounds and catheters. There is inflammation and bacteria in the prostatic fluid, yet unlike Type I, the condition is not consistently cured by antibiotics. Doctors do not know why the antibiotics are sometimes ineffective. In some cases, multiple rounds of cultures and different types of antibiotics may clear the infection, but when that doesnt work, the prostate lives in a chronic state of inflammation.

A third category of prostatitis is even more trying. It is the most commonly diagnosed form of prostatitis, and also the hardest to cure—Type III: chronic pelvic pain syndrome. In this type, the patient has the usual pelvic pain and urinary symptoms, and occasionally sexual symptoms such as pain during ejaculation. In some cases, inflammation of the prostate is detected by finding inflammatory products (a nice way of saying pus) in the prostatic fluid or urine. In others, signs of inflammation are not found; inflammation may still be present but is not detected. Either way, no bacteria are found, and the cause of symptoms is unclear.

Cases such as these have historically been diagnosed as "nonbacterial prostatitis" because the symptoms are so similar to those of chronic bacterial prostatitis (Type II). This is so even though it is not clear that the prostate is the origin of symptoms in Type III cases. In this way, the term _prostatitis_ became, in the words of one urologist, "a wastebasket of clinical ignorance, used to describe any condition associated with prostatic inflammation or prostatic symptoms."24 It has been suggested that the syndromes which are lumped into the category of "prostatitis" may actually be several different diseases with similar symptoms.25

In 1995, the National Institutes of Health (NIH) held a convention to redefine the categories of prostatitis. They pointed out that in some cases of prostatitis the cause was unknown and that "organs other than the prostate gland may be involved." It was at this point that the category of "nonbacterial prostatitis" was replaced by the new category Type III: chronic pelvic pain syndrome (CPPS).26

Because prostatitis Types II and III are so similar in their chronic nature and the difficulty of treatment, they are often referred to collectively as CP/CPPS. To the frustration of doctors and patients alike, many men struggle with these conditions on an ongoing basis. This is an active area of research, and many studies are currently under way to fill in the many unknowns.

**NATIONAL INSTITUTES OF HEALTH CATEGORIES OF PROSTATITIS**

**Type I: acute bacterial prostatitis.** Bacterial infection of the prostate with sudden onset, fever and chills. Bacteria are detected, usually cured by antibiotics if full dose is taken.

**Type II: chronic bacterial prostatitis.** Ongoing or recurrent bacterial infection and inflammation of the prostate, often associated with frequent UTIs (urinary tract infections). Difficult to cure, even with antibiotics.

**Type III: chronic pelvic pain syndrome (CPPS).** There is pain, and sometimes inflammation, but no bacteria are found in cultures. Difficult to cure. Previously called chronic nonbacterial prostatitis or prostatodynia.

**Type IV: asymptomatic inflammatory prostatitis.** There are no symptoms, but bacteria or signs of inflammation are found in prostatic fluid during examination for other conditions.

**WHAT IS INFLAMMATION?**

Inflammation is a major symptom of Type I and II prostatitis, and it occurs in some cases of Type III. Even in cases of Type III where signs of inflammation are not found, it may still be present and undetected. Inflammation is the immune systems response to a perceived threat or injury: white blood cells are sent to the area to kill germs and do away with dead cells and irritants. In the case of prostatitis, inflammation is detected by looking at prostatic fluid or a urine sample through a microscope to check for a high number of white blood cells. Inflammation is not the same thing as infection: in an infection, microbes are present, while inflammation is the bodys protective response to microbes, injury, irritation, or other harmful stimuli.

Usually, inflammation stops when the threat has been dealt with and the damage healed. However, sometimes it becomes chronic, and the inflammatory process happens on an ongoing basis. This changes the tissue environment and may even cause damage. Inflammation has been established as playing a role in a number of cancers,27 and recent studies suggest that it may play a role in the development of prostate cancer and BPH.28

##  **What Causes Prostatitis?**

With Type I: acute prostatitis, the cause is clear—a bacterial infection, which clears up with antibiotics. Simple. With Types II and III (CP/CPPS), its not so simple. If Type II is caused by infection, why dont antibiotics always work? And if the infection is not really the cause of symptoms, what is? What causes the symptoms of CPPS, given that no microorganisms are detected in cultures? These questions are unresolved, though there are many theories. Here are some of them.

Blocked glands may trap prostatic fluid and prevent it from being flushed out with ejaculation, forming a cozy breeding ground for bacteria. It may be that a microorganism is undetectable, has evolved immunity to antimicrobials, or is protected by a biofilm within the prostate. (A biofilm is a protective casing created by microorganisms such as bacteria. Plaque on your teeth is an example of a biofilm. It has been suggested that antibiotics do not work in some chronic infections because they cannot get through the biofilm to the microorganisms inside.)

If symptoms are not related to infection, other factors have been suggested, including urinary backflow, prostate stones, or other irritants in the gland. Any of these could potentially cause inflammation in the absence of microorganisms. Yet another possibility is that inflammation may occur in the absence of bacteria as a result of an overactive immune system, in which the immune response continues even after any threat or damage is eliminated.

One recent and promising theory is that, in at least some cases, the cause is muscle tension. The authors of _A Headache in the Pelvis_ note that many men who have been diagnosed with CP/CPPS also have chronic tension in the muscles of the pelvis. The authors suggest that in some cases, CP/CPPS may arise as a result of this chronic tension. Some people tighten their pelvic muscles during anxiety—this is part of a natural instinct to protect the lower abdominal contents by tightening the muscles around them. The authors explain how, over time, this may lead to a vicious circle: anxiety causes tightening, which causes pain, which causes more anxiety, and so on.

The authors suggest that, over the course of many years of habitual tightening, the pelvic muscles may become shortened and chronically tense, which may interfere with the proper functioning of the nerves and blood vessels in the area. They suggest that this may be the original cause in many cases of CP/ CPPS, and may even increase a mans likelihood of contracting Type I: acute prostatitis. In support of their theory, they have achieved good results in treating men with CP/CPPS: through physical therapy (myofascial release and relaxation training) they have been able to significantly reduce or eliminate symptoms in many men. (See the Resources for more information.)

#  **PROSTATE HEALTH TIPS**

There are many things you can do to support prostate health. We discuss a few here.

##  **Keep the Urethra Healthy**

Urethral health is important to prostate health. Since the urethra runs through the middle of the prostate, it is possible for an infectious agent to travel up the urethra and enter the ducts and glands of the prostate, causing an infection (acute prostatitis). The chances of this happening are increased if a urinary tract infection (UTI) is left untreated. Symptoms of a UTI include burning and pain when you pee and having to go more often than usual. If you have these symptoms, see a doctor. If antibiotics are prescribed, be sure to take the full course. Do not stop early even if the symptoms clear up; there may still be a low-level infection present that could make a comeback.

Avoid touching your urethral opening if your hands are not clean. Risk factors for UTI include catheters and urethral sounds. If you have a catheter or sound inserted (for medical reasons or in the context of kinky play) be sure to drink lots of fluids afterward to flush out the urethra. Dont start and stop the flow of urine; this may cause reflux urine to wash back into the prostate, causing irritation.29

##  **Wear a Condom**

Being on the giving end of unprotected sex increases your risk of contracting a UTI because you are exposing the opening of the urethra to any bacteria that are present. This is particularly true for unprotected anal sex, since the rectum contains a very wide range of microorganisms. For this reason, having unprotected anal sex as the giver, with a partner of any gender, is considered a risk factor for prostatitis.30 Wearing a condom reduces this risk.

##  **Pee after Sex**

If you have sex without a condom, urinating afterward helps flush out the urethra. Drinking lots of water will help too.

##  **Eat for Prostate Health**

Studies increasingly indicate that diet and lifestyle have an impact on prostate health. Some studies suggest that particular nutrients may be linked to lower rates of prostate disease, and there are several prostate health cookbooks full of recipes that include these nutrients.

Not everyone feels that these diets are necessary. We  checked with Dr. Alan Shindel, assistant professor of urology at UC Davis, on the subject. He said, "Across the board, the diet that has been shown to be best for the health of every part of the body is whatever is smart for the heart. So a prudent diet (fruits, veggies, whole grains, light on the fats and fried foods) is best according to our knowledge."

That being said, most of the recipes in a prostate diet cookbook will be both heart-healthy and selected for nutrients that support prostate health, so if you feel inspired to try them, go right ahead!

##  **Herbal Supplements**

Many herbal supplements may also support prostate health. For a guide to herbal supplements, consult _Dr. Katzs Guide to Prostate Health: From Conventional to Holistic Therapies_.

#  **BENIGN PROSTATIC HYPERPLASIA (BPH)**

_Benign prostatic hyperplasia_ (BPH) is overgrowth of the prostate. It is sometimes called "benign prostatic hypertrophy," but this is a misnomer. Hypertrophy means that cells of the body are growing in size, but in BPH the growth happens as a result of cells increasing in number. The term _benign_ is used to differentiate this condition from cancerous growth. In the case of BPH, it is not cancer cells that are multiplying, so it is not life-threatening.

BPH usually occurs in the area of the prostate that immediately surrounds the urethra. This can make urination difficult if the growth of the prostate pinches off or blocks the  urethra. Symptoms of BPH include difficulty starting the flow of urine, weak flow, frequent urge to go (especially at night), and feeling like the bladder is not empty even after going. The bladder muscles are working against the resistance of the prostate, and over time this muscular strain may cause the bladder muscles to become weak. This can lead to incomplete emptying of the bladder and, as a result, an increased likelihood of bladder infection.

The cause of BPH is not known, but age is a factor: most of the men who have symptoms are over age 50,31 and your chances of developing the condition increase the older you get. The prostate undergoes growth at particular points in a mans life. In a boy the prostate is very small and underdeveloped. Then, at the start of puberty, there is a growth spurt. A second growth spurt comes in the mid-20s, and this growth continues (very slowly) throughout his life.32 This is why BPH is so common among older men, and why their prostate may feel less regular, larger than average, and have less clearly defined lobes. All men experience some prostate growth as they age, but not all men will have the kind of growth that leads to urine obstruction and BPH symptoms.

The most common treatment for BPH symptoms is alpha blockers or 5-alpha reductase inhibitors. If these dont work or the patient cannot tolerate them, the doctor may recommend surgical intervention: transurethral resection of the prostate (TURP). This involves inserting a device into the urethra and surgically removing a small portion of the prostate to relieve the pressure on the urethra. Retrograde ejaculation is typical after this procedure. This is likely due to damage to the  sphincter muscle that lies between the prostate and bladder, which pinches off the urethra during ejaculation to keep semen from entering the bladder. If this sphincter is damaged, semen may flow up into the bladder during ejaculation instead of out through the penis. The next time he urinates, itll simply get flushed out. His urine will be cloudy, but theres no known health risk from it. Reduced semen volume may also result from removal of some of the glandular tissue of the prostate during TURP, which means less prostatic fluid is being produced in the first place. Some men also report a difference in the sensation experienced at orgasm after TURP. Long-term impotence or incontinence occurs in a small percentage of cases.33

#  **PROSTATE CANCER**

According to the American Cancer Societys 2010 estimates, 1 out of 6 men in the United States will be diagnosed with prostate cancer at some point in their lives, and 1 out of 36 men will die of the disease.

##  **What Is Cancer, Anyway?**

The life cycle of a cell includes a process called _apoptosis_ —the programmed death of the cell. Apoptosis allows old cells to be broken down, recycled into the body, and replaced by healthy new cells. Cancer develops when changes in cellular DNA result in the cells failure to go through apoptosis and die when its time comes. Instead, cancer cells live abnormally long lives. Cell division continues, thereby creating more and more cancer cells. As the population of cancer cells increases,  they may form a detectable lump: a tumor. Eventually, the increasing number of cancer cells can interfere with the proper functioning of the affected body part. Worse yet, cancer cells sometimes travel to other sites: this is called metastasis. Once they settle in another part of the body, they continue to multiply in the new area.

##  **Symptoms of Prostate Cancer**

Prostate cancer would be much less troublesome if it were not for metastasis—the process by which cancer cells migrate to other parts of the body. Cancer cells within the prostate gland dont cause much trouble. The prostate is not a vital organ—you can survive just fine without it (though you might miss having it massaged). What causes life-threatening health problems is the spread of cancer cells to more vital parts of your body where they interfere with crucial life processes.

This is why prostate cancer is so markedly symptom-free. Most cases of prostate cancer are diagnosed in a total absence of symptoms. When symptoms do occur, they may include:

• Frequent or urgent need to urinate, difficulty in passing urine, interrupted or weakened flow of urine, dribbling afterward

• Pain during urination or ejaculation

• Blood in the urine or semen

• Pain or stiffness in the lower back, pelvis, hips, or thighs

• Partial erections or impotence

• Decreased quantity of semen during ejaculation

However, by the time these symptoms occur, the cancer is usually very advanced and may already have spread (metastasized) to other parts of the body where it poses a much more serious threat. This is why some doctors recommend screening for early detection. However, there is some controversy about the value of screening and aggressive treatment of prostate cancers. We discuss this a little later.

##  **Causes and Risk Factors**

Modern science has not yet discovered the cause of prostate cancer, though it is speculated that hormones play a role. In cases of very advanced prostate cancer, reducing the mans testosterone level slows the growth of the cancer. This has led many to believe that testosterone feeds prostate cancer growth and to caution against the use of chemical testosterone, which is sometimes prescribed to men with low testosterone levels.

However, this has recently come into question. Ernani Luis Rhoden MD and Abraham Morgentaler MD published a study in which they state, "Despite decades of research, there is no compelling evidence that testosterone has a causative role in prostate cancer." They point out that just because cutting off testosterone slows cancer growth does not necessarily mean that increasing testosterone will promote growth. Further, many men with low testosterone levels have prostate cancer, and since testosterone levels tend to decrease with age, "prostate cancer becomes more prevalent exactly at the time of a mans life when testosterone levels decline."34

Lately, also, a great deal of attention has been given to the fact that many cancers, including prostate cancer, grow in an environment of chronic inflammation such as occurs with prostatitis. Some studies suggest that inflammation may play a causative role in the development of cancer.

There are several risk factors for prostate cancer. Notably, older men are at a much higher risk, starting around age 50. From there, the risk increases with the years, and approximately two-thirds of cases are diagnosed in men over 65.35 If you have relatives with prostate cancer, you are at high risk for developing it. Furthermore, if your relatives were diagnosed at a relatively young age (before 50), you are at an increased risk of having it while young. Race is relevant as well: African American men living in the US are more at risk than any other racial group, and more likely to die from it. The reason for this is uncertain, but research is under way to answer this and other questions related to prostate cancer.

Other possible risk factors include nationality/geography (some countries have higher rates than others) and diet.

##  **Screening for Prostate Cancer**

As mentioned, prostate cancer is generally asymptomatic until the disease is very advanced, so it is usually diagnosed through routine screening. However, there is some controversy over the value of screening. (See the section "The Screening Controversy" that begins on page 291.) The American Cancer Society recommends that men discuss screening options with their doctor and make an informed decision about whether or not to pursue it. They recommend that this conversation take  place at age 50 for men with average risk, age 45 for men with high risk (African American men or men with a close relative who was diagnosed at an early age), and age 40 for men with multiple close relatives who were diagnosed at an early age.36

Two tests are commonly used to screen for prostate cancer. First is the digital rectal exam (DRE)—a finger exam. (Before computers, the word _digital_ referred to fingers.) The doctor inserts a gloved, lubricated finger into the rectum and manually checks the surface of the prostate for lumps which may be cancerous tumors.

Second is the PSA test. PSA stands for _prostate specific antigen_ , a protein that is released by the prostate. The test monitors the level of PSA in your bloodstream. Levels vary from person to person and over time, so when the doctor checks your PSA, he is less interested in the actual level of your PSA on a given day than in the rate of change over time. He is watching for sharp increases, which could indicate cancer.

Studies suggest that ejaculation37 and prostate massage38 may cause a temporary increase in your PSA level, which could raise a red flag on your test. For this reason, some doctors recommend that you abstain from all sexual activity for at least 48 hours before the test.

**PROSTATE CANCER SCREENING FOR TRANSGENDER WOMEN**

At present, most sex realignment surgery for transgender women leaves the prostate intact, placing it in the location where the G-spot would be in relation to the neovagina. This allows transgender women to keep a very erotically responsive tissue and adds to the pleasure they can experience with intercourse. It also means that they are still at risk for prostate cancer.

Some have speculated that transgender women who take feminizing hormones (antiandrogens) have a reduced risk of developing a fatal case of prostate cancer. This is believed to be the case because blocking a cisgender mans testosterone in cases of advanced prostate cancer has been shown to slow the growth of the cancer. The antiandrogens that are prescribed to these men are some of the same ones prescribed to transgender women to block testosterone and other androgens in order to feminize the body. So some have suggested that the antiandrogens would have the same effect in transgender women as they have in advanced cases of prostate cancer in cisgender men: to slow the development of any prostate cancer that may be present.

Its important to note that this has not been proven. Transgender health is a very young field of research and very little is known so far. Even if it is true that antiandrogens might slow the development of a prostate cancer, it doesnt halt it entirely, so there is still a risk there. Also, as Alan Shindel points out, "There are published studies indicating that cisgender males with low testosterone are still at risk for aggressive prostate cancers," so a low testosterone level is no guarantee.

Since there is still a risk, transgender women who are in the screening age range may choose to see a urologist for annual prostate screening. (Likewise, many doctors recommended that female-to-male transgender men see a gynecologist for cervical cancer screening.)

It may be scary for a transgender woman to go to a doctors  office where she may expect that all other patients will be men. However, unlike gynecologists, who do not see cisgender men, urologists see both men and women. A cisgender woman may visit a urologist for a urinary system issue such as incontinence, urinary stones, or cancers of the urinary system organs, so while there may be fewer women in the waiting room than men, its not unusual for a woman to see a urologist.

Still, transgender women may have concerns about whether the particular urologist will be open to seeing a transgender person and will treat them with the same respect as anyone else. If you are concerned about how you will be received, call the office, tell them your situation, and ask them frankly if they are comfortable seeing you. If they fumble over the phone, it saves you the hassle of going in.

There are more transgender-friendly doctors than ever before, so look for one in your area. Ask around among queer/trans-aware people or contact local LGBTQ organizations for a recommendation. Also, see the Resources for a link to a database of LGBTQ-FRIENDLY health professionals.

_**The Screening Controversy**_

Because prostate cancer rarely shows symptoms until it is too late to cure it, many doctors place a high emphasis on early screening and aggressive treatment of this disease. However, this has led to some controversy.

Relative to many other cancers, prostate cancer tends to grow slowly, and may exist in the prostate for years without decreasing quality of life. There have even been cases where men have died of an unrelated cause and were found, during autopsy, to have had a slow-growing tumor in the prostate.  In these cases, if the men had been diagnosed with cancer and had gone through all the stress, pain, financial burden, and decreased quality of life that comes with treatment, they would have done so unnecessarily, since the cancer never would have caused trouble during their lifetime.

This creates a dilemma for medical professionals: how vigorously should prostate cancer be screened, diagnosed, and treated given that in some cases the cancer may never cause any problems and the patient may die without ever knowing he had it? Or worse—given that in some cases the treatment for prostate cancer may actually cause more suffering than the cancer itself would have? (Incidentally, this is why urologists dont do prostate cancer screening for men with a life expectancy of less than 10 years.)

Recently, the U.S. Preventive Services Task Force actually recommended _against_ the use of the PSA test in screening. Its reasoning was that, first, studies suggest that early detection of prostate cancer may not actually extend the lives of patients. And second, since the test cant tell between life-threatening cancers and slow-growing cancers, it may do more harm than good, as mentioned above, by causing anxiety, pain, financial burden, and decreased quality of life to many men with manageable cancers.

Because screening has become controversial, many medical professionals recommend that men talk with their doctors about the possible benefits of screening and decide for themselves whether they will pursue it. To be clear, some men do die of prostate cancer, so screening may be of benefit to some men.

##  **Treatment**

If prostate cancer is found early, the patient may choose not to pursue any treatment right away. Since many cases of prostate cancer are very slow growing, the patient may enjoy years of uninterrupted quality of life and postpone more aggressive treatment until it is necessary. This is called watchful waiting, or active surveillance, where the patient collaborates with the doctor to monitor the development of the cancer over time. Typically, it involves regularly scheduled visits for blood tests and DRE exams, and perhaps repeated biopsies of the prostate. Some use the terms _watch ful waiting_ and _active surveillance_ interchangeably, while others consider them to be different, active surveillance referring to a more aggressive approach than watchful waiting.

When the patient decides to pursue treatment to eliminate the cancer, and if the cancer has not grown beyond the capsule of the prostate, the most common procedure is radical prostatectomy—the surgical removal of the gland. Another form of treatment is radiation therapy, either by way of external beam radiation or radioactive "seeds" that are implanted into the prostate. Numerous other forms of treatment are also being researched.

If the cancer has spread to lymph nodes, bone, or other organs, it cannot be cured, and the focus of treatment shifts to slowing its growth and minimizing symptoms.

#  **SEX AFTER PROSTATE CANCER TREATMENT**

##  **Erectile Function**

It used to be that surgical removal of the prostate meant complete loss of erectile function, leading to the common jest that the cure for prostate cancer is worse than the disease. The reason why removal of the prostate interferes with erectile function has to do with two bundles of nerves that flank the prostate on each side. These nerves play an important role in erection, and they run alongside the prostate on their way to the penis, so they are easily damaged during prostate removal.

Previously, doctors were not aware of the role that these nerves played in a mans ability to get hard, so they would take them out along with the prostate, resulting in a high rate of erectile dysfunction. Today many doctors practice a "nerve sparing" technique: whenever possible they leave one or both of these nerve bundles in place. Of course, this isnt always possible. If it appears that the cancer has moved beyond the prostate, the doctor may choose to remove some surrounding tissue in an effort to ensure that all cancer cells have been eliminated. This may mean taking out the nerve segments along with the affected tissue.

When one or both nerves are spared, erectile function can usually recover beginning at two to three months and increasing for up to two years following surgery. This means that erection rates post-surgery are much better than they used to be before nerve-sparing techniques were developed.

However, even among men who regain erectile function after surgery, it may not be what it once was. Along these  lines, whether or not an erection functions may vary by sex act. A super-hard erection is not required for vaginal sex, but it usually takes a pretty solid erection for anal penetration, since the anus tends to be tighter than the vaginal opening. Jerry Harris, a contributing author of _A Gay Mans Guide to Prostate Cancer_ , notes that in his experience many gay men are bottoms after prostate removal, even in some cases where they were tops beforehand. Point being: the question of whether or not your post-surgery erection functions depends in part on what you want to do with it.

Men who have consistent erections before the surgery have a better chance of regaining erectile function afterward. Its a prime example of "use it or lose it": you have a better chance of regaining and maintaining your erectile function after the procedure if you keep up an active (solo or partnered) sex life. Also, many doctors recommend taking an erection drug like Viagra, Levitra, or Cialis on a regular basis after surgery in the hope that regular increases in blood flow will assist the recovery of erectile function; however, a recent study suggested that better results may be achieved by taking these pills on demand, as they are needed.39

Radiation therapy can also decrease erectile function.40 In a reverse trend, with these procedures erectile function is initially unchanged, but may slowly decrease over time. At present, studies suggest that the procedure least damaging to erectile function is brachytherapy—radiation therapy that involves planting radioactive "seeds" or wires inside the prostate at the location of the tumor.41 However, even though brachytherapy may cause the least impairment, all  treatments for prostate cancer typically have a negative effect on sexual function.

##  **The Prostate after Cancer**

A lot of what is written about prostate cancer covers in detail the effects of treatment on erectile function, but very few articles mention the effect on receptive anal penetration or, for that matter, prostate pleasure. This is due to a lack of attention to these sexual practices by many medical professionals. Most information on sexual function after prostate cancer treatment focuses on heterosexual vaginal sex; there is little information on other types of couples or other types of sex.

At this time there are no studies on the effect that the various prostate cancer treatments have on prostate massage, though there are some reports from the experiences of individuals.

First, after surgical removal of the prostate, its just gone: you will no longer be able to massage it. You can still enjoy anal penetration for its own sake; the nerves of the anus and rectum will still be receptive as they were before. Plenty of men continue to enjoy anal play after having their prostate removed. Unfortunately, if your prostate is a big part of what you enjoy about anal penetration, youll probably experience a decrease in sensation.

It is unclear how radiation therapy affects prostate sensation. We have spoken with at least one man who still enjoyed prostate massage following external beam radiation therapy (radiation applied to the prostate in a beam from outside the body), though it is hard to say whether his pleasure was  simply coming from the anal penetration and not the prostate massage. Furthermore, radiation works by killing the cells of the prostate, so it is likely that any remaining sensation will be greatly decreased.

It should also be noted that your ability to receive anal penetration may be affected by some forms of treatment. In external beam radiation therapy, mentioned above, some radiation may contact the rectum, causing irritation in the form of diarrhea, rectal bleeding, and discomfort and putting receptive anal penetration on hold. Usually the symptoms pass after treatment is completed. Occasionally the irritation persists, which may mean a permanent halt to anal sex. (This is rare.) If you choose the other form of radiation, brachytherapy (seed implanting), irritation of the rectum is less likely, though your doctor may recommend that you refrain from receiving anal sex for a period after implantation while the seeds are radioactive (about 6 weeks).42

##  **Other Effects**

Most men have dry orgasms after prostate cancer treatment: they dont ejaculate any fluid. A study on orgasm after radical prostatectomy indicated that for some men the lack of ejaculation diminishes their experience of pleasure at orgasm.43 Also, those who eroticize semen may miss having it as a part of the experience. Generally, dry orgasm also means infertility.

Also of note, the length of the penis may decrease slightly after prostate removal. Some men also have issues with urinary continence (holding their urine) after prostate treatment. Stress incontinence is common after radical  prostatectomy, and some men report an emission of urine with ejaculation.44 Some men also experience urge incontinence after radiation therapy. Incontinence issues may improve over time, or they may be persistent. This can be very challenging—many people find loss of bladder control highly embarrassing. However, some men have eroticized this by getting into water sports!