Sexuality and Substance Abuse NAADAC 2009

1. Sexuality and Substance AbuseNAADAC 2009 David Fawcett, PhD, LCSW davidfawcett@earthlink.net www.fortlauderdalecounseling.com

2. Topics • Introduction • Substance Abuse and Sex • Biological factors • Psychosocial factors • Best Practices

3. Drinking and Sex • Men aged 18 to 30 • 17% had sex after one or two drinks • 35% had sex after five to eight drinks • 45 % had sex after consuming eight or more drinks • Women aged 18 to 30 • 14% had sex after one or two drinks • 39% had sex while consuming five to eight drinks • 57% percent had sex when consuming eight or more drinks Kaiser Family Foundation

4. Drugs, violence, and disease • Alcohol use, by the victim, the perpetrator or both, is implicated in up to 75% of date rapes of college students • 66% of sex offenders in state prison were under the influence of drugs or alcohol at the time of their crime • Adults who use alcohol and drugs: • more sexual partners, more casual sex partners and higher rates of sexually transmitted diseases and HIV/AIDS National Center on Addiction and Substance Abuse at Columbia University

5. Drugs and sexual dysfunction • Heavy or chronic use of alcohol and other drugs, such as cocaine or heroin, impairs sexual desire and performance • Few substance abuse or violence prevention and treatment programs or pregnancy prevention programs emphasize the connection between substance use and sex National Center on Addiction and Substance Abuse at Columbia University

6. Perceptions of risk • Nine out of ten (88%) 15 to 24-year-olds say: people their age drink or use drugs before having sex at least “sometimes” — including 50 percent who say this happens “a lot.” • Girls and young women are more likely than boys and young men to report peers’ unprotected sex under the influence (79% vs.65%, respectively). Kaiser Family Foundation

7. Sexuality and Substance Abuse Biology

8. Recreational Drugs and Sex • Alcohol • Amphetamines • Cocaine, Methamphetamine • Other “Club Drugs” • Ecstasy, GHB, Rohypnol • Marijuana • Less… • Opiates, Benzodiazepines

9. Two Neural Pleasure Systems • Exciting “appetitive” pleasure • Largely dopamine related • Raises tension level • Satisfying “consummatory” pleasure • Largely endorphin related • Calming, fulfilling

10. Addiction and the brain • Neurotransmitters • Excitory or inhibitory • 5HT (Serotonin) • appetite, sleep, memory and learning, temperature regulation, mood, behavior, cardiovascular function, muscle contraction, endocrine regulation, and mood • Dopamine • ventral tegmental area which is a region involved in producing pleasure and reward

11. Addiction and the brain • GABA • Chief inhibitory neurotransmitter • Hippocampus – memory • Norepinephrine • Dual roles • Stress hormone: regulates attention and responding hormones • Neurotransmitter: fight or flight response

12. FOOD SEX 200 200 NAc shell 150 150 DA Concentration (% Baseline) 100 100 15 % of Basal DA Output 10 Empty Copulation Frequency 50 Box Feeding 5 0 0 Scr Scr Scr Scr 0 60 120 180 Bas Female 1 Present Female 2 Present Mounts Time (min) Sample Number 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 Intromissions Ejaculations Source: Di Chiara et al. Source: Fiorino and Phillips Natural Rewards Elevate Dopamine Levels

13. Effects of Drugs on Dopamine Levels COCAINE AMPHETAMINE Accumbens 1100 Accumbens 400 1000 900 DA 800 DA 300 DOPAC 700 DOPAC % of Basal Release HVA HVA 600 % of Basal Release 500 200 400 300 100 200 100 0 0 0 1 2 3 4 5 hr Time After Amphetamine Time After Cocaine NICOTINE 250 200 Accumbens Caudate 150 % of Basal Release 100 0 1 2 3 hr 0 1 2 3 4 5 hr 0 Time After Nicotine Source: Di Chiara and Imperato

14. Alcohol • Increases 5HT and dopamine; inhibits GABA • Acute effects: • disinhibiting, social confidence, risky behavior,reduced sexual response, reduction in sexual arousal, difficulty getting erections or orgasms • Chronic effects: • erectile disorders and sexual dysfunction in men; loss of desire in men and women; difficulty experiencing orgasm for men and women

15. Alcohol and women • Consumed some alcohol (still under the legal limit (0.08% to 0.10%): • decreased vaginal blood measures • took longer to reach orgasm • decreased intensity of orgasm • Same women subjectively reported sexual arousal and orgasmic pleasure increased at higher levels of alcohol consumption • Expectancy effect

16. Alcohol and men • Difficulty getting and maintaining erections • Difficulty ejaculating/delayed ejaculation • Reduced sexual desire • Increased sexual aggression • Infertility

17. Alcohol and sex • Hypogonadism • Decrease in testosterone both in alcoholic men and in non alcoholic men who drink enough to become intoxicated. • One study of over 17,000 alcoholic men after several years of no alcohol: • 50% returned to normal erectile functioning • the other 50% were either partially or completely unable to get an erection, even when sexual desire returned.

18. Meth and sex “Remember when we only had black & white tv? Then came color tv-- it’s the same with methamphetamine and sex”

19. Methamphetamine • Compare and Contrast with Cocaine

20. Meth and sex

21. Mesolimbic Pathway Reward Emotions Frontal Lobe Higher level thinking Logic Judgment Decision Making Affected Brain Regions

22. Meth and the Brain • Dopamine levels in the brain

23. Meth and the Brain

24. Sensitization • Less needed to create intense craving • “I am an addict and it relieves the craving mostly. I do not enjoy the sex on it that much anymore. When I have it I flush the last bits down the toilet with self disgust.” • Extends into peripheral cues (including sexual) • Δ Fos B (Eric Nestler, UT)

25. Fusion of Meth and Sex • Neurons that “fire together wire together” • Focused attention • Reinforced through fantasy • New cognitive maps increase at expense of old ones (“vanilla” sex replaced by darker sex) • Increased desire vs ED (“crystal dick”)

26. Fusion of Meth and Sex Sex without Meth “I’m a sexual cripple.” “I can't think of a way that sober sex could ever hope to be as passionate, as driven and hungry as speed sex. And please don't give me that ‘Oh it's so much more intense with someone you truly, deeply care for... crap. Gimme a break, huh? Save it for the greeting card companies.”

27. Why is meth a sexual problem? • Meth (among HIV positive men) was associated with: • High rates of anal sex • Low rates of condom use • Multiple sex partners • Sexual marathons • Anonymous sex Semple, Patterson and Grant (2002)

28. Meth + STIs MSMs who use meth vs. non users: • 2-3X more likely to have HIV • 6x more likely to have syphilis • 2X more likely to have gonorrhea (Studies in New York and San Francisco)

29. Meth and HIV • Long term MACS (Multicenter AIDS Cohort Study) • MSM using meth had 46% greater risk of becoming infected with HIV • MSM using poppers (93%) and meth had 3x risk • Plankey MW, Ostrow et.al. The relationship between methamphetamine and popper use with HIV seroconversion in the Multicenter AIDS Cohort Study. J.Acquir Immune Defic Syndr. (published online ahead of print (March 29, 2007)

30. Drug interactions: HIV meds • Drug Interactions • ritonavir (Norvir) and CYP2D6* • Inhibits metabolism of amphetamines • Speeds up metabolism of some opiates • Interacts with benzodiazepines • Drug Resistance • Adherence (planned and unplanned) • Metabolism *Halkitis, Parsons, and Stirrat (2001)

31. Straight Men, Meth and Sex • Sexually active w/ casual or anonymous female partner • Multiple female partners • Anal sex with female partner • Sex with IDU • Received drugs or money for sex • Forced into sex Methamphetamine use and HIV risk behaviors among heterosexual men; MMWR, 55(10) 3/17/2006,

32. Sexuality and Substance Abuse Psychosocial Factors

35. Sex and Drugs: Just say no? • Complex relationship • Perceived advantages • Perceived disadvantages

36. Desire • “I was a sex maniac on the drug…” • “I never wanted the sex to end…ever” • “I was uninhibited, horny, insatiable.” • “No one in their right mind would have sex the way I did on drugs.”

37. Desire • Sexual Risk • Not using condoms • Orgasm doesn’t relieve desire • Health complications • Sexual violence

38. Disinhibits • Breaking Taboos • Alleviates social/sexual inhibitions • “It's sleazy! [Meth] is so dangerously addictive and leads to such reckless sexual behavior, more so than other drugs.”

39. Disinhibits • Judgment • Would you say “hi” in public? • Careless in choice of partner • “It pushed my personal boundaries and changed preferences of the type of sex (rough, more adventurous, etc.)”

40. Self Image • Overcome negative feelings • Reinforce and intensify concepts of sexual selves • Gives permission to re-inhabit body

41. Self Image • “I feel hot!” • “I’m invincible!” • “I’m visible” • “At 50 I don’t exist socially in the gay community anymore. Having a ‘connection’ has made me ‘cool’ albeit temporarily. But it’s better than being invisible when I want to get laid.”

42. Self Image • Drug-dependent self image • Disrupts relationship with self • The price of crossing lines • Rational, moral, ethical, dependable • Wreckage of addiction

43. Intimacy • “I have never been so connected to another person – it was so intense.” • “It gave me permission to really touch.”

44. Intimacy • Disrupts Love/Lust Balance • Increased narcissism • Increased partner objectification • Decreased empathy • “He became selfish on the drug…sex with him was one way…his way.”

45. Love/Lust Balance LUST LOVE LUST LOVE

46. Group Identity • Social Leveler • Clubkids • Tribe • Slammers

47. Group Identity • Polarization • “It has created a polarized community of PNPers versus those who are sober and safe.” • “chem-friendly”; “PNP”; “d/d free – ub2” • Stigma • “I think some of the community sees it as yet one more tragedy to make us look bad.”

49. Impact of the computer

50. Best Practices