The relationship between drug abuse and sexual performance among women on methadone: Heightening the risk of sexual intimate violence and HIV
Introduction
Research on the effects of drugs on women's sexual expectations, desire, and performance and on heightening risks of intimate partner abuse and HIV is limited. To date, most research on drug use and sexual performance has focused on men. However, there is consensus across studies that shows that the effects of any illicit drug use on sexual performance for both genders depend on the type of drugs, amount consumed, length of time used, and environmental factors as well as individual expectations (Smith, 1982).
Studies on the pharmacological effects of most illicit drugs on sexual performance suggest that heavy drug use has a negative impact on sexual performance by decreasing physical arousal, reducing the ability for orgasm, and contributing to diminished libido Cushman, 1972, De Leon & Wexler, 1973, Mintz et al., 1974, Reiss & Leik, 1989. For example, cocaine, which is a central nervous system stimulant with anesthetic properties (Buffum, Moser, & Smith, 1988), increases levels of dopamine, serotonin, and noreprinephrine and is often linked to sexual desire and activity Cohen et al., 1994, Hudgins et al., 1995. Increased dopamine levels are associated with feelings of pleasure and have been found to trigger sexual excitement in animals and increase their sexual behavior (Leavitt, 1995). Cocaine has been reported to induce spontaneous erection and ejaculation and multiple orgasms in some users (Buffum, 1982). However, these heightened sexual effects may turn to sexual dysfunction with long-term use. The impact of cocaine on dopamine may eventually inhibit sexual arousal as repeated stimulation generates dopamine deficiency Cocores et al., 1988, Gold & N.S., 1997, which may create such adverse conditions as difficulty in maintaining an erection and delayed ejaculation in men. Moreover, impotency and other problems may persist after cocaine use has stopped (Gold, 1997).
Among women, chronic cocaine use can also contribute to difficulty in achieving orgasm Gold, 1997, Henderson et al., 1995, Inciardi et al., 1993, Kim et al., 1992, Weatherby et al., 1992 and diminished sexual desire Inciardi, 1994, McCoy et al., 1995, Ratner, 1993. These findings challenge the popular belief that crack/cocaine is an aphrodisiac, which may stem from the widespread practice of sex-for-crack prostitution. For most crack-addicted women, however, crack for sex is not about sex, it is merely their most expeditious means of procuring the drug (Sterk, 1999).
Other studies have shown that the relationship of opiates (e.g., heroin, morphine, methadone, and codeine) to sexual functioning is a complex interaction of pharmacological, physical, psychological, and sociocultural factors. Opiates are central nervous system depressants that relieve pain and cause sedation (Pinger, Payne, Hahn, & Hahn, 1998). They act on a variety of neurotransmitters in the brain, including endorphins, morphine-like substances produced naturally in the body (Pinger et al., 1998). Opiates are thought to redirect blood away from the genitals, which may contribute to sexual dysfunction (Gay, Sheppard, Inaba, & Newmeyer, 1973). Due to its ability to delay orgasm and its relaxing and analgesic effects, heroin is sometimes used by addicts to self-medicate for such sexual dysfunctions as premature ejaculation in men or pain during intercourse for women (Smith et al., 1982). Heroin may also suppress testosterone production (Buffum et al., 1988) and may lead to decreased sexual desire. In a small dose, heroin may prompt arousal and enhance sexual performance Jaffe et al., 1997, Mirin et al., 1980, but large dosages and chronic use diminish the sex drive, contribute to impotence, and interfere with ejaculation and orgasm in men. Decreased libido and problems with erection, ejaculation, and orgasm have been found in methadone users (Buffum et al., 1988).
Despite the negative pharmacological effects of chronic cocaine or opiate use, widespread myths about the perceived positive effects of these drugs on sexual performance continue to heighten sexual expectations and stimulate sexual risk taking in the context of drug use. It is commonly believed that, if one's mental state is improved through drug use, then sexual desire and performance will also improve, as inhibitions and resistance are reduced (Lindesmith, 1980). This myth can be explained by social symbolic expectations of how drugs affect sexual performance (Lindesmith, 1980). Specifically, drug-involved persons communicate to others in their social networks how certain drugs affect them; this information, then affects how these other drug users experience the same drugs.
Research on women's perceptions of the effects of drug abuse on their libido and sexual performance remains scarce. It is necessary to explore women's expectations and interpretations on how drugs affect their own and their partner's sexual performance, as well as how drugs affect discrepancies between women and their partners with respect to sexual arousal and functioning, and how these discrepancies may lead to sexual coercion and unprotected sex. Moreover, neither substance abuse nor HIV researchers have paid adequate attention to how drug use differentially affects sexual expectancies and performance among drug-involved women and their partners and how these sexual discrepancies may heighten risk of intimate partner violence and HIV transmission.
A growing body of research has documented a relationship between substance abuse and intimate partner violence. Studies have found that men who abuse drugs and alcohol are at increased risk for inflicting sexual violence against women Abbot et al., 1995, Byles, 1978, El-Bassel et al., 2001, Fagan & Wexler, 1987, Hotaling & Sugarman, 1986, Leonard et al., 1985, Miller, 1990, Miller et al., 1993, O'Leary, 1999. Women's abuse of drugs and alcohol has also been associated with experiences of physical and sexual intimate violence Amaro et al., 1990, Berenson et al., 1991, El-Bassel et al., 2000, Gilbert et al., 2000, Kantor & Straus, 1989, Kilpatrick et al., 1997, Paone et al., 1992 particularly when their partners are also involved in a substance abusing lifestyle El-Bassel et al., 2000, Gilbert et al., 2000.
This paper is designed to qualitatively explore this link through women's own accounts and experiences. Through in-depth interviews with 38 women on methadone, this paper examines individually stated subjective experiences on the effects of illicit drugs on their sexual expectancies and habits, mainly changes in libido, performance, and pleasure, as well as on sexual intimate violence and HIV risk. Several questions were examined: (1) How does drug use affect women's sexual performance? (2) How does drug use affect their partners' sexual performance and the sexual dynamics in their relationship? (3) How does drug use affect these women and their partners differently? (4) How are sexual discrepancies, with respect to the level of sexual arousal and functioning between women and their partners, heightened by drug use, linked with sexual and physical violence and risk of HIV?
This in-depth narrative study addresses these issues and discusses the implications of the women's subjective experiences for designing interventions to reduce HIV transmission and intimate partner violence among drug-involved women.
Section snippets
Participants
Data were drawn from a study on the relationship between HIV risk behavior, drug abuse, and intimate partner violence among women recruited from methadone maintenance treatment programs (MMTPs). The study had two phases: a qualitative phase, consisting of focus groups and in-depth interviews, and a longitudinal quantitative phase. Women were recruited from three MMTPs in New York City. Between May and December 1997, 20-min structured screening interviews were conducted with 251 women to
Several women described their impressions that use of crack/cocaine and heroin increased their sexual pleasure
For some women, this was the case because illicit substances made them feel “relaxed,” “numb,” or “sexier.” The following woman, who used both heroin and cocaine on a daily basis, said that she would never have sex with her partner of 8 years without being high because she would not enjoy it. As she explained,
- Participant:
When I was sober I didn't dare have sex with him. I had to be high to be able … to make love to him.
Drugs gave her the power to make love, as she further explained:
- Interviewer:
Conclusion and discussion
The findings of the study provided women's narrative accounts of how drug abuse affects their sexual desire and performance and that of their steady sexual partners. Several themes emerged.
Implications for intervention
The way in which drug abuse affects women's sexual performance and triggers partner violence among drug-involved couples has not been sufficiently addressed in either drug or domestic violence treatment programs. These topics are rarely incorporated in the assessment and treatment of drug-involved women. Limited resources exist in drug treatment programs to screen for intimate physical and sexual violence as well as to conduct a more comprehensive assessment of how drug use influences client
Acknowledgements
This study was supported by grant no. R01DA11027 awarded to Dr. El-Bassel.
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