Bottoming in anal sex can be immensely pleasurable — until it isn’t. If you do develop irritation, pain, or bleeding, or find that you are no longer experiencing pleasure, you should talk to a doctor. Unfortunately, not all primary care physicians are well versed in anal health. They may perform a physical exam and prescribe a topical cream, but sometimes that’s not enough. If you do have a recurrence of the symptoms you may be sent to a proctologist, only to discover that these specialists too often lack sensitivity to LGBTQ issues, ask for only limited sexual history, and perform a superficial physical examination.

After this inadequate evaluation, the proctologist may follow your primary physician’s lead and offer what I call an “I don’t know but use this cream” diagnosis. This cycle can go around and around, with second and third opinions offering you as little long-term relief as the last doctor. By this time, you’re likely to have become frustrated and depressed, fearing you may have to throw in the towel and (heaven forbid) live the rest of your life as a top.

I’ve seen this narrative play out over and over, and seen many gay and bisexual men and women (cis and trans) who feared they might never again enjoy receiving anal sex. The root cause is often a condition known as anal fissures — even if your proctologist can’t pinpoint it. And there is new hope for resolving these issues long term.

An anal fissure is a small tear in the tissue that lines the anus, which can cause pain, sphincter spasms, and bleeding. If you have recurring symptoms like these but your doctor says she didn’t find anal fissures during her exam, you might have what we call a phantom fissure; and it’s no delusion.

What is a phantom fissure?

It’s no different than the usual anal tear or fissure, except that it’s generated only from the pressures encountered during anal intercourse, which can cause ripping of the surrounding tissues or muscle. Because it only appears under dialation, during a traditional exam, it may appear that the fissure has healed or needs simple topical treatment.

So, what should you do? Most importantly: don’t give up. LGBTQ-friendly (and educated) specialists are determined to solve these problems and do so in a way that is not alienating or shaming. At my practice, we are destigmatizing and removing the taboos around anal intercourse, bringing the science into penetrative sex, and providing vital information to a community lacking appropriate resources. The best treatment can only be determined by analyzing one’s detailed sexual history and current dilemma to arrive at the diagnosis of pathologies — in this instance, a phantom fissure.

What are my options then?

Your first option is to attempt medical management of the problem. If anal fissures are caught early on while still in the initial stages, you could use at-home dilators or alter your sexual techniques. Not only will you become a more educated bottom, you’ll find preparation and specific techniques can increase pleasure while decreasing pain and risk of injury. Unfortunately, since so many of those suffering from anal fissures have been misdiagnosed or delayed seeking expert medical opinion due to fear of judgment, they have developed chronic issues that mean simple medical management isn’t enough.

That’s when you might consider surgical interventions. Sometimes, the best course of action — even if nothing is found during the initial examination — is to bring the patient to the operating room. One diagnostic technique simulates anal intercourse. Under sedation and local anesthesia, full relaxation of the anal region can occur and allow for inspection and evaluation of friction points as relating to both the skin and underlying muscle. (This is generally done via the insertion of progressive diameter dilators.)

For example, one may be able to fully relax the deep muscles for entry, but the skin is too taut, causing localized tearing. Or vice versa: the skin relaxes fully, but the muscles won’t dilate to accommodate. An experienced physician can spot this during surgical evaluation, but they need to know what to look for. They need to have the knowledge behind the sexual science not only to understand how to make the diagnosis, but also to be inclined to offer appropriate and proven treatments.

Once the diagnosis is made, there are corrective procedures to alleviate these issues. The overall goal is to remove any chronic scarring of the skin, which will initiate healthy tissue growth and new scar formation to build strong connections that can withstand pressures in that area. Sometimes just dilating and stretching with local lasering or cautery of the cuts and skin will allow you to get to the next level of anal engagement.

Botox can also offer benefits. Using botulinum for both the surrounding skin and muscles allows for temporary relaxation, which gives you time to heal, strengthening the surrounding skin, and allowing full dilation of the underlying muscles, until finally you can reach your bottoming goals.

Post-surgical treatment relies on a collaborative approach between clients and physiciansathe client will be advised to use at-home bi-weekly butt plugs and then return to the office for local cautery treatments to encourage healthy and tough scarring. Right before one is fully healed, we suggest a regimen to encourage strong and distensible scars, which will allow you to get to the desired diameter for receiving. Remember: the skin, muscle, and, of course, Botox, all play a key role here. There is plenty for us to do to get one back in the game. It’s not rocket science. It’s looking at this in a different light, with a different approach — science and healthcare.

Recovery from these surgical interventions

can last a couple of months and occurs in stages. Admittedly there is some significant pain during the first few days, and then some localized pain during defecation that resolves within two weeks. Four to six weeks after the surgery you’ll initiate at-home dilation with butt plugs, which last for the subsequent three to four weeks. You can certainly incorporate this dilation into your sex play, but one is unlikely to be able to receive an average penis girth until two or three months post-surgery.

Most people do not need follow-up Botox shots, though depending on your size-queen ambitions, it may be necessary. The goal is to set oneself up to fully heal and be completely dilated by the time the Botox wears off, which is around three to five months. Then you can safely engage in consistent, daily bottoming with a partner or favorite toy — and continue doing so pretty indefinitely.

Plenty can be done — not only to heal one’s phantom fissures, but also to educate physicians and patients on the resources available for this condition. Don’t accept failures in the health system that limit your narrative. We need a collaborative approach to demand high-level specialized care for those in the LGBTQ community. I won’t say bottoming is easy for everyone. It can be hard work, but as we all know, it’s totally worth it in the end (pun intended).