Anal sex has ascended to a position of cultural intrigue. Movies, shows, and the people who live and breathe on the internet, aren’t quite shying away from speaking of its erotic pleasure. It is daring. Sexy. While the shift reflects a healthy normalization of the different varieties of sex, safety may be lost in cultural translation. Women are at greater risk of side effects from anal sex, yet they receive scarce guidance or advice on how to navigate anal intercourse safely.

This lack of conversation in medical circles that still remains “may be failing a generation of young women, who are unaware of the risks,” warned doctors recently.

Their analysis, published in the BMJ on Thursday, drew on cases among heterosexual women in the U.K., who were presenting with injuries, pain, and bleeding as a result of anal sex. The curiosity about this particular sexual pleasure may not match the knowledge people currently hold.

The failure to have a medically informed conversation when women present with anorectal symptoms coasts on a lack of awareness and invariably causes physical and mental harm. It “exposes women to missed diagnoses, futile treatments, and further harm arising from a lack of medical advice,” wrote Tabitha Gana and Lesley Hunt at the Sheffield Teaching Hospitals NHS Foundation Trust and Northern General Hospital, Sheffield, United Kingdom.

Anal sex without safety precautions has been linked to fecal incontinence — an inability to control bowel movements that cause feces to leak unexpectedly — and anal sphincter injury on the pelvic floor. There is pain and bleeding that people may not be prepared to addresswithout prior information about these possibilities.

Moreover, women are at a higher risk of these injuries. The risk of incontinence, for instance, is different “than men because of their different anatomy and the effects of hormones, pregnancy, and childbirth on the pelvic floor,” the researchers wrote. What makes women more vulnerable to pain and fractures is that they “have less robust anal sphincters and lower anal canal pressures than men, and damage caused by anal penetration is, therefore, more consequential.”

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But these are risks rarely communicated, discussed, or addressed prudently. The reluctance among clinicians to address anal sex, let alone build a healthy discourse around it, may draw from a stigma around women’s sexuality in general. This aspect applies harshly to women in India who report being shamed and humiliated in gynecologists’ offices; the access to safety through information is hindered physically, economically, and ideologically. Moreover, doctors themselves may also struggle to effectively communicate “partly because they do not want to seem judgmental or homophobic,” Gana and Hunt added.

The aversion to anal sex and its link to women’s health is such that research about “anodyspareunia” — pain during anal penetration — has been sidelined and dismissed in the past.

“The study should have turned heads: It was the first research on anodyspareunia among women; it was conducted by a well-respected scientist (Dr. Aleksander Stulhofer from the University of Zagreb), and it was centered on young women and sex. That’s often the kind of research that attracts media attention (Young women sext! They get pregnant! They give oral sex! You get the picture …),” said sexual health researcher Debby Herbenick.

The taboo around anal sex presents a complex circuit of homophobia, purity, and misconceptions about addiction. “We have all been socialized that the ass is a ‘dirty’ place, meaning that many of us have some conditioned baggage to work through before exploring anal,” noted Sarah Tomchesson, a sex educator.

“No matter how excited someone is to explore anal or how sexually adventurous someone is, anal play requires sensitivity, open communication, and understanding that not everyone is going to be interested in it.”

But interest is no longer optional to engage in this conversation. More and more people are having anal sex: in the U.S., for instance, almost 40-45% of women and men in some age groups had reportedly tried anal sex as of 2009. PornHub data also shows that the search volume for anal sex on its website increased by a staggering 120% between 2009 and 2015. Older research dating back to 2010 found that anal sex was shown in 56% of porn videos.

Individual reasons for anal sex in straight relationships could be due to pleasure and curiosity, and even being influenced by pop culture. Think Fleabag and Sex and the City. Anal sex is shown to be daring and defiant, thus holding people’s fascination.

There is an element of coercion too that needs to be addressed. The surgeons note the “pain and bleeding women report after anal sex is indicative of trauma, and risks may be increased if anal sex is coerced.” As many as 25% of women surveyed say they felt pressured into having anal sex at least once. In 2017, a woman told MarieClaire: “I was drunk and said I didn’t want that [anal sex]. He kept doing it anyway even when I said stop.”

The conversation around the health risks for women then carries an imperative to address consent. “Anal sex is an area of sexual exploration where consent is even more essential for a number of reasons,” says Tomchesson. A “no” for vaginal sex could be interpreted as “yes” to anal. Or the pressure to be “fun” and “wild” could be construed as someone being open to trying anything. “No means no” falls inadequately in consent culture currently; its assertion in the context of anal culture then demands an education — sexual, social, and medical.

As the researchers noted: “With better information, women who want anal sex would be able to protect themselves more effectively from possible harm, and those who agree to anal sex reluctantly to meet society’s expectations or please partners, may feel better empowered to say no.”