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Abstract

The aim of this study was to evaluate the potential relationship between self-reported sexual dysfunction, sexual behavior, and severity of addiction of drug users. A cross-sectional design study was conducted at an inpatient addiction treatment unit in Sao Paulo, Brazil, with a sample of 508 male drug users. Sociodemographic data, sexual behavior, and severity of dependence were evaluated.The prevalence of sexual dysfunction was 37.2% and premature ejaculation was 63.8%. Men with sexual dysfunction presented from moderate to severe level of alcohol, tobacco, and other drugs of dependence. The findings from this study are particularly relevant identifying those sociodemographic factors, severity of drug use, and sexual behavior are related to men who experience sexual dysfunction. Health promotion and motivational interventions on sexual health targeted to male drug users can contribute in reducing these at-risk behaviors. More interdisciplinary research is desirable in future in considering men’s sexual health.

Keywords

sexual dysfunction sexual behavior men substance abuse treatment

Introduction

Sexual behavior related to drug use is a growing area of scientific focus due to it being a risk factor in the transmission of HIV and other sexually transmitted infections (STI; Booth, Kwiatkowski, & Chitwood, 2000; Calsyn et al., 2009). Male sexual dysfunction is defined as the disorders related to one or more stages of the human sexual response cycle (desire, arousal/erection, ejaculation/orgasm, and resolution) with inability to perform the sex act satisfactorily for himself or the partner or both (Carvalho, Vieira, & Nobre, 2011; Chang, Klein, & Gorzalka, 2013). Sexual dysfunction is a very common and prevalent chronic problem among people who use drugs worldwide (Chen et al., 2012; Dişsiz & Oskay, 2011). Alcohol, nicotine, and other illicit drugs such as cannabis, heroin, and crack/cocaine are reported to have hazardous effects on male sexual function leading to low self-esteem, depressive symptoms, and poor health and can trigger a drug relapse (Bang-Ping, 2009; Cioe, Anderson, & Stein, 2013; Mialon, Berchtold, Michauld, Gmel, & Suris, 2012; Okulate, Olayinka, & Dogunro, 2003).

Studies have been conducted mainly with opioid users or on the effects of the medications used for the maintenance treatment of heroin addicts (methadone and buprenorphine) on their sexual responses (Babakhanian, Mehrjerdi, & Shenaiy, 2012; Cioe et al., 2013). Three studies reported that the prevalence rates of erectile dysfunction (ED) are between 21% and 52% in opioid-dependent males (mean age ranging from 28 to 49 years; Babakhanian et al., 2012; Cioe et al., 2013; Hallinan et al., 2008). Prevalence of current premature ejaculation in opioid dependents has been reported to be almost three times greater than that reported in the general population (Chekuri, Gerber, Brodie, & Krishnadas, 2012). These sexual dysfunctions are due to the effect that opioids have on the hypothalamic-pituitary-gonadal axis and interfere with the production of sex hormones. This contributes to ED as the exogenous opioids bind to mu receptors in the hypothalamus, decreasing the release of gonadotropin releasing hormone (GnRH). In addition, opioids increase the release of prolactin from the pituitary and modify the production of dehydroepiandrosterone in the adrenal glands, both affecting the production and release of testosterone. This leads to a decrease in the release of luteinizing and follicle-stimulating hormone from the pituitary, and a drop in gonadal steroid production (testosterone and estradiol; Cicero, Schainker, & Meyer, 1979).

Nicotine, which is widely consumed, has its share of negative effects on male sexual health. Meta-analyses and clinical observations have revealed that both chronic and acute nicotine use can significantly affect men’s sexual health with repercussions on physiological sexual arousal attenuation (Harte & Meston, 2008; Tengs & Osgood,2001). Additionally, nicotine is an important risk factor for the development of ED. There is evidence to suggest that about 40% of ED in men were current smokers compared with 28% of men in the general population (Tengs & Osgood, 2001). Smokers were 1.5 times more likely to have ED than nonsmokers (Dorey, 2001). Cigarette smoking–induced ED is associated with impaired blood flow to the penis or acute vasospasm of the penile arteries. Long-term nicotine smoking produces deleterious effects on the vascular endothelium and peripheral nerves and causes ultrastructural damage to the body tissue, all considered to play a role in smoking-induced chronic ED. Clinical and basic science studies provide strong indirect evidence that cigarette smoking may affect penile erection by the endothelium-dependent smooth muscle relaxation injury or by more specifically affecting increased nitric oxide production via reactive oxygen species generation (Tostes et al., 2008). In order to reduce sexual dysfunction in men, it is valuable to offer them smoking cessation treatment, which includes nicotine replacement therapy and continued support and smoking prevention (Harte & Meston, 2008). It was reported that long-term and high amount of alcohol consumption cause sexual dysfunction in men since it is believed that alcohol can cause neurogenic damages (Pandey, Sapkota, Tambi, & Shyangwa, 2012). Previous reports have indicated that the prevalence of sexual dysfunction in alcohol-dependent populations to be about 8%, and persisting in 50% even after long abstinence from alcohol (Lemere & Smith, 1973). Arackal and Benegal (2007); Krupnov, Shustov, Novikov, and Kiselev (2011); and Zaazaa, Bella, and Shamloul (2013) reported that sexual dysfunction to be in the range of 40% to 95% with alcohol-dependent patients. The common sexual dysfunctions reported included ED, followed by premature ejaculation, retarded ejaculation, and decreased sexual desire among men (Arackal & Benegal, 2007; Krupnov et al., 2011; Zaazaa et al., 2013).

A study evaluating the relationship between marijuana with issues related to sexual function indicated that those who use marijuana had an increase in the number of sexual partners, difficulty in reaching orgasm (in males), and EDs (Shamloul& Bella, 2011). Other studies have pointed out the relationship of marijuana with altered hypothalamic-pituitary gonadal axis and development of infertility (Saso, 2002). An Italian study revealed that men who are chronic marijuana users may have early endothelial damage to arteries and are predisposed to ED (Aversa et al., 2008). Cocaine has been associated with both increased and inhibition of sexual desire. Male cocaine users report a strong association between sexual arousal and drug use. Male users of cocaine have ED when under the influence of cocaine. Initially, the use of cocaine can enhance the sexual functioning (libido) of men, but prolonged use can reduce desire and sexual performance, and increase the difficulty in achieving orgasm (Zaazaa et al., 2013). The association between substance use and sexual risk behavior is well documented in the literature, and several studies have reported a strong relationship between those two variables (Bertoni et al., 2009; Choi et al., 2005; Drumright et al., 2006).

The risks in the use of psychoactive substance are related to the increased likelihood of sexual intercourse (anal, oral, vaginal) and unprotected sexual (without condom) involvement with several sexual partners. Thus, having several sexual partners increased the risk of STIs, HIV/AIDS, and unwanted pregnancies (Bastos, Cunha, & Bertoni, 2008; Bertoni et al., 2009). The Joint United Nations Programme on HIV and AIDS (UNAIDS) indicates that the rate of newly infected by the virus in Brazil rose 11% between 2005 and 2013, contrary to the global trend figures, which revealed a decline (overall decrease of 27.5%; UNAIDS, 2014). The rates in Brazil indicated that a new epidemic has high infection rates. This increase is also being associated with “crack epidemic” experienced by the country over the past 24 years. There is paucity in the literature on the assessment of sexual dysfunction and other sexual behaviors in crack users.

Brazil is currently considered to be the largest global market for crack cocaine in the world. Approximately 1.8 million people reported using crack cocaine during their life, and one million people have used crack in the past year (INPAD, 2012). There is still a considerable lack of national studies evaluating sexual dysfunction and correlates of sexuality in crack users in Brazil (Rodrigues et al., 2012). Many clinicians avoid asking difficult questions about their patients’ sexuality. The routine of taking a sexual history is absent in many clinical settings, and as a result, sexual dysfunction is often neglected and unexplored in addicted patients (Ribeiro et al., 2014). The identification of the magnitude of these disorders and the management of issues related to sexual health in this population may have a significant impact on the promotion of sexual and reproductive health. Despite the relationship between substance misuse and sexual dysfunction there is limited literature available. There is a lack of descriptive studies focusing on sexual dysfunction in male drug users in Brazil. This study aims to evaluate the possible relationship between self-reported sexual dysfunction, sexual behaviors, and severity of addiction with drug users attending an inpatient treatment unit.

Method

This study is a cross-sectional design and was conducted at an inpatient addiction treatment unit in Sao Paulo, Brazil. The sample comprised consecutive admissions of 508 male users of alcohol, tobacco, and cocaine (smoked and sniffed). The inclusion criteria were aged 18 years or older, confirmed clinical dependence diagnosis according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) diagnosis criteria (American Psychiatric Association, 2000). In this service, the therapeutic program provides for a mean duration of 45 days hospitalization for each patient.

Questionnaires

Sociodemographic Data

The sociodemographic data included age, educational level, race, marital status, monthly income, employment status, and religious affiliation.

Characteristics Related to the Treatment of the Substance-Related Disorder

The characteristics included duration of substance abuse and the number of previous treatments excluding the present one.

Sexual Behaviors Information

Information obtained included self-reported sexual dysfunction/difficulty (variable dependent), type of sexual dysfunction, frequency of condom use, number of sexual partners in the last year, history of sex with sex workers, sexual orientation, homosexual experience in exchange for drugs, history of STIs, and age at the time of first intercourse.

Drug Abuse Screening Test (DAST) 20

The DAST consisted of 20 questions related to drug use within the last year. The questions pertained specifically to abuse, dependence, withdrawal (signs and symptoms), social impairment, family relations, legal implications, medical problems, and previous treatment. Problem severity was classified on a scale from 0 to 20 and was scored as follows: 0 = no problem; from 1 to 5 = mild; 6 to 10 = moderate; 11 to 15 = substantial; and 16 to 20 = severe. The severity scale has been used in several studies, and measures of reliability and validity have been reported to be satisfactory in all the versions for utilization as a clinical and/or research tool.

The Short Alcohol Dependence Data (SADD)

The SADD consisted of 15 questions related to severity of alcohol dependence. The severity was classified on a scale from 0 to 20 and was scored as follows: mild (0-9), moderate (10-19), and severe alcohol dependence (≥20). The Brazilian version of the SADD and the original English version are highly correlated, and the coefficient of internal consistency is 0.79 (Rosa-Oliveira et al., 2011).

The Fagerström Test for Nicotine Dependence (FTND)

This test consisted of a screening instrument extensively used and translated in many countries, including Brazil, for the assessment of physical nicotine dependence. The instrument consists of six items that are easily understood and rapidly applied. The scores obtained on the test permit the classification of nicotine dependence into five levels: very low (0 to 2 points), low (3 to 4 points), moderate (5 points), high (6 to 7 points), and very high (8 to 10 points). The reliability index is excellent (0.87), and Cronbach’s alpha coefficient ranged from 0.55 to 0.74, indicating that the FTND has moderate internal consistency. The FTND exhibited satisfactory sensitivity (0.75) and specificity (0.80; Meneses-Gaya, Zuardi, Loureiro, & Crippa, 2009).

Data Analyses

A descriptive data analysis was initially performed. Both the categorical variables (the absolute and relative frequencies) and the numerical variables (the frequency measurements of the mean, minimum, maximum, and standard deviation) are presented. Statistical analyses include chi-square test or Fisher’s exact test for small samples and Student’s t test for independent samples. For all the statistical tests, a significance level of 5% was considered. The statistical analyses were performed using the Statistical Package for Social Science (SPSS version 20).

Ethical Approval

This study was approved by the Federal University of Sao Paulo (UNIFESP) Ethics Committee (Protocol Number 1193/09), and all the subjects signed an informed consent form. Data collection was conducted by four members of the staff who were previously trained to apply the questionnaire used in this study.

Results

Sociodemographic Data

The sample was composed of 508 (100%) men, adults (mean 34.3 ± 10.7 years) ranging in age from 18 to 75 years, unmarried, with low level of education and income, non-Caucasian, Catholic religion, informal employment; data are presented in Table 1. Many of sociodemographic variables that were identified were found to be associated significantly with sexual dysfunctions with substance-related disorder (Table 1). One hundred and eighty-nine (37.2%) participants reported sexual dysfunction. The differences were statistically significant between sexual dysfunction and marital status (p < .001), education (p < .001), ethnicity/skin color (p ≤ .010), religion (p < .001), and salary range (p ≤ .001). Note that sexual dysfunction was predominant in married men, with secondary education or incomplete, skin color—not White, Catholic religion, with low income. In comparing the mean age, there were no statistically significant differences between participants with (34.4 ± 10.7) and without (34.2 ± 10.7) sexual problems (p < .005).

Table 1.

Sociodemographic Data of Participants.

			Sexual difficulty
	Total		Yes		No
	N	%	n	%	n	%	p Value
Total	508	100	189	100	319	100
Marital status
Single	292	57.5	90	47.6	202	63.3	<.001
Married/stable union	116	22.8	57	30.2	59	18.5
Widowed/divorced/separated	100	19.7	42	22.2	58	18.2
Educational level
Illiterate	62	12.2	4	2.1	58	18.2	<.001
Elementary school	180	35.4	80	42.3	100	31.3
Secondary school	189	37.2	81	42.9	108	33.9
Higher education/graduate education	77	15.2	24	12.7	53	16.6
Ethnicity/skin color/race
White	282	55.5	118	62.4	164	51.4	.010^a
Non-White	226	44.5	71	37.6	155	48.6	.010^a
Religion
Catholic	270	53.1	84	44.4	186	58.3	<.001
Evangelical	108	21.3	49	25.9	59	18.5
Spiritist/Umbanda/Candomblé/Other	67	13.2	25	13.2	42	13.2
Atheist/without religion	63	12.4	31	16.4	32	10,0
Occupational status
Retired	12	2.4	7	3.7	5	1.6	.061
Registered employee	149	29.3	63	33.3	86	27
Nonregistered employee/liberal profession	294	57.9	107	56.6	187	58.6
Fully unemployed	50	9.8	11	5.8	39	12.2
Homemaker	3	0.6	1	0.5	2	0.6
Salary range
≤1 MW	170	33.5	36	19	134	42	<.001
2 to 3 MW	185	36.4	90	47.6	95	29.8
4 to 5 MW	87	17.1	39	20.6	48	15
6 to 7 MW	23	4.5	5	2.6	18	5.6
≥7 MW	43	8.	19	10.1	24	7.5

Note. MW = minimum wage = R$ 724 reais or US$280.18. Descriptive level of the chi-squared test (test statistics; degrees of freedom). N = 508.

Descriptive level of the Fisher’s exact test (p value ≤ .005).

Addiction and Sexual Dysfunction

The average time period of previous treatments reported by the participants was 2.6 (SD = 3.2) [2.3-2.9]. Tobacco use time in this sample was 17 years (SD + 11.2) [15.9-18.1], and the time of use of other psychoactive substances was 15.4 years (SD = 10.2) [CI 95%14.5-16.3]. Years of tobacco and other substances did not differ significantly between groups (p ≥ .005). The main drug of choice for almost half of the sample was the use of crack. The users are categorized as having a substantial and severe level of dependence (DAST). Users of amphetamine and injectable drugs were not identified in the sample. In addition, 201 of the subjects (39.6%) were nonsmokers, while among smokers, 170 (33.5%) had very low, low, and moderate levels of dependence on nicotine. Data are presented in Table 2. Of the 189 (37.2%) men with sexual dysfunction, 129 (68.3%) had substantial/severe level of drug dependence (DAST), 83 (43.9%) were nonsmokers, 61 (32.3%) were smokers with high and very high level of dependence of nicotine (FTND), and 74 (39.2%) had severe dependence of alcohol (SAAD), with statistically significant associations (p ≤ .005), when compared with men without sexual dysfunction. Three hundred and nineteen men (62.8%) without sexual dysfunction focused on low, very low levels in the FTDN, and nonusers of alcohol (SAAD).

Table 2.

Data of Drug of Choice and Severity Level of Dependence Among Participants.

			Sexual difficulty
	Total		Yes		No
	N	%	n	%	n	%	p Value
Total	508	100	189	100	319	100
DOC
Crack	249	49	80	42.3	169	53	.201
Alcohol	126	24.8	55	29.1	71	22.3
Cocaine snorted	90	17.7	39	20.6	51	16
Marijuana	27	5.3	12	6.3	15	4.7
Polydrug	15	3.0	3	1.6	12	3.8
Oral opiates	1	0.2	—	—	1	0.2
DAST
No problem/low/moderate level	135	26.6	26	13.8	109	34.2	.000
Substantial/severe level	290	57.1	129	68.3	161	50.5
Does not use drugs	83	16.3	34	18	49	15.4
FTND
Nonsmoker	201	39.6	83	43.9	118	37	.002
Very low/low/moderate	170	33.5	45	23.8	125	39.2
High/very high	137	27	61	32.3	76	23.8
SAAD
Does not use alcohol	203	40	50	26.5	153	48	.000
Mild dependence	55	10.8	18	9.5	37	11.6
Moderate dependence	107	21.1	47	24.9	60	18.8
Severe dependence	143	28.1	74	39.2	69	21.6

Note. DOC = drug of choice; DAST = Drug Abuse Screening test; FTND = Fagerström Test for Nicotine Dependence; SAAD = Short Alcohol Dependence Data. Descriptive level of the chi-squared test (p value ≥ .005).N = 508.

Sexual Dysfunction and Sexual Behaviors

Data of sexual behaviors and sexual dysfunction in the sample are presented in Table 3. Behaviors such as having active sexual life (p = .000), homosexual experience (p = .029), homosexual experience by exchanging drugs (p = .020), use of medication for sexual dysfunction (p = .000), history of STI (p = .000), HIV test (p = .000), sex with sex workers (p = .003), medical help for sexual difficulties (p = .000), sexual function (p = .000), type of sexual difficulty (p = .019), and condom use (p = .003) were associated positively to sexual dysfunction in this sample. There was no significant difference in sexual orientation in men with and without sexual dysfunction. Regarding the type of sexual difficulty, premature ejaculation was predominant in men with sexual dysfunction. In this sample, it was observed that in those patients who reported sexual difficulty, the prevalence by age group was as follows: 18 to 26 years (23.5%), 27 to 42 years (55.9%), 43 to 58 years (18.2%), 59 years or more (2.4%; p = .389).

Table 3.

Sexual Behavior and Dysfunction Among Participants.

			Sexual difficulty
	Total		Yes		No
	N	%	n	%	n	%
	508	100	189	100	319	100	p Value
Sexual activity in the past 12 months
Yes	367	72.2	160	84.7	207	64.9	<.001^a
No	141	27.8	29	15.3	112	35.1	<.001^a
Sexual orientation
Heterosexual	485	95.5	181	95.8	304	95.3	.054
Homosexual	16	3.1	3	1.6	13	4.1
Bisexual	7	1.4	5	2,6	2	0.6
Homosexual experience
Never	409	80.5	143	75.7	266	83.4	.029^a
At least once	27	5.3	16	8.5	11	3.4
More than once	72	14.2	30	15.9	42	13.2
Homosexual experience in exchange for drugs
Yes	62	12.2	31	16.4	31	9.7	.020^a
No	158	83.6	288	90.3	446	87.8	.020^a
Medication for sexual dysfunction
Yes	82	16.1	46	24.3	36	11.3	<.001^a
No	426	83.9	143	75.7	283	88.7	<.001^a
History of STIs
Yes	125	24.6	64	33.9	61	19.1	<.001^a
No	383	75.4	125	66.	258	80.9	<.001^a
HIV testing
Yes	339	66.7	153	81	186	58.3	<.001^a
No	169	33.3	36	19	133	41.7	<.001^a
Sex with sex workers
Yes	300	59.1	127	67.2	173	54.2	.003^a
No	208	40.9	62	32.8	146	45.8	.003^a
Seeking medical counseling’s for sexual difficulty
Yes	29	5.7	20	10.6	9	2.8	<.001^a
No	479	94.3	169	89.4	310	97.2	<.001^a
Self-evaluation of sexual performance	423		187		236
Excellent	96	22.7	25	13.4	71	30.1	<.001
Good	232	54.8	96	51.3	136	57.6
Regular	76	27.3	51	10.6	25	18
Bad	19	4.5	15	8	4	1,7
Type of sexual dysfunction	208	100	185	88.9	23	11
Premature ejaculation	127	61.1	118	63.8	9	39.1	.019
Delayed ejaculation	31	14.9	25	13.5	6	26.1
Decreased or difficulty erection	27	13	25	13,5	2	8,7
Decreased or inhibition of sexual desire	13	6.3	11	5.9	2	8.7
Pain during penetration	7	3.4	4	2.2	3	13
No orgasm	3	1.4	2	1.1	1	4.3
Condon use
Always use	227	44.7	69	36.5	158	49.5	.003^a
Never use or sometime use	281	55.3	120	63.5	161	50,5
Number of sexual partners
Up to two partner last year	331	65.2	114	60.3	217	68	.048
Three or more partners last year	177	34.8	75	39.7	102	32	.048

Note. STI = sexually transmitted infection. Descriptive level of the chi-squared test. N = 508.

Descriptive level of Fisher’s exact test.

In terms of average age of first sexual intercourse, men with sexual dysfunction had sexual initiation later (15 ± 3.6 years), t = 2.798, p ≤ .005, compared with those without (14.2 ± 2.7 years). The duration (years) of tobacco use and other psychoactive substances did not differ significantly between groups (p ≥ .005).

Discussion

The present study reveals the prevalence range of sexual dysfunction to be 37.2% in patients with substance-related disorders. As expected, the findings showed that there are high rates of sexual dysfunction in male drug users, as compared with a Brazilian study population (Abdo, 2004). This is similar what has been reported in the literature on opiates (21% to 52%; Babakhanian et al., 2012; Cioe et al., 2013; Hallinan et al., 2008), alcohol dependence (40% to 95%; Arackal & Benegal, 2007; Krupnov et al., 2011; Zaazaa et al., 2013), cocaine (62% to 66%; Zaazaa et al., 2013), tobacco (27%; Foresta et al., 2004), and marijuana (around 80%; La Pera et al., 2008). The prevalence varies according to the method of research (data collection strategies), the different conceptual definitions used, and the types of sexual dysfunction. Evaluation of sexual dysfunction is an important clinical concern in health care (Rizvi, Yeung, & Kennedy, 2011). There are many barriers in preventing health care professionals in the taking a sexual history (Palha & Esteves, 2008; Ribeiro et al., 2014).

Male sexual health is currently recognized as a crucial aspect of overall health and well-being (Choi et al., 2014; Mialon et al., 2012). Male sexual dysfunction is a considerable health problem that needs to be further evaluated. It is a very common and prevalent chronic problem among people who use drugs worldwide (Chen et al., 2012; Dişsiz & Oskay, 2011). Illicit drugs have harmful effects on male sexual function leading to low self-steam, depression symptoms, and poor health life quality and can be a trigger to drug relapse perceived as beneficial for sexual response (Bang-Ping, 2009; Cioe et al., 2013; Mialon et al., 2012; Okulate et al., 2003).

Earlier studies have reported on the possible associations between sociodemographic variables and male sexual dysfunction (Christensen et al., 2011). In the present study, variables such as marital status (single), educational level (secondary school), ethnicity (White), religious affiliation (Catholic), and income (2-3 minimum wage (MW),1 MW= R$724 reais or US$280) were associated with sexual dysfunction in males with substance-related disorders. Sexual dysfunction is influenced by biological and psychosocial factors, and psychosocial factors can be both contributing factor and reactions to substance misuse (Bang-Ping, 2009). Findings from the literature on marital status and sexual dysfunction indicated that single men frequently reported more sexual problems (premature ejaculation and reduced sexual desire) when compared with those who were in a stable relationship with ED (Symonds, Roblin, Hart, & Althof, 2003). Sexual dysfunction of drug abusers reported cannot be all attributed to direct drug effect. Our findings do not confirm these prior observations regarding age, as there was no association between age and the presence of sexual dysfunction in the present sample. However, there is evidence to suggest that age is a predictive factor for sexual dysfunction; especially ED tends to be more prevalent in older individuals (Mialon et al., 2012). Sexual dysfunction is associated with various sociodemographic characteristics, including age and educational attainment (Lauman, Paik, & Rosen, 1999).

Severity of Addiction and Sexual Dysfunction

Crack was the most common illicit drug (DOC) used in our sample. Crack use was reported to be increasing since the last decade in Brazil (INPAD, 2012). Increasing as well as inhibition of sexual desire was reported to be common problems in male cocaine addicts (Zaazaa et al., 2013). Chronic use may contribute to impaired sexual performance and increase the difficulty to achieve orgasm.

Further studies should investigate whether the dose effect and the rapid development of tolerance might be the reasons why frequent users had a higher risk of sexual dysfunction than those with a dosing frequency less than once per day (Bang-Ping, 2009). It is still worthconsidering that trend in cocaine users to be heavy drinkers of alcohol. A study with men who use both cocaine and alcohol revealed that 62% reported low sexual desire (Cocores, Miller, Pottash, & Gold, 1988).

Another finding that is in accordance with the current scientific evidence is the association between severity of drugs (DAST), nicotine (FTND), and alcohol (SAAD) and sexual dysfunction in the sample.

Nicotine dependence is considered to be one of the biggest risk factors for sexual dysfunction, besides nicotine’s impact on the cardiovascular system (Santamaria, Sapetti, Glyna, & López, 2011). The risk of developing ED is 1.6 times higher in smokers, reaching 2.3-fold in chronic smokers (Chew, Bremner, Stuckey, Earle, & Jamrozik, 2009). There is evidence to suggest that nicotine can negatively affect the level of sex hormones, testosterone and estrogen, in male smokers (Halmenschlager, Rossetto, Lara, & Rhoden, 2009). The findings of a study with 2,288 males indicated that 43.3% were smokers and had some sexual dysfunction, and among all risk factors examined, the highest incidence was tobacco (Oksuz & Malhan, 2005). Tobacco tends to have more negative impact on young smokers than in older (Santamaria et al., 2011).

Alcohol was the second drug of choice in our study, with higher levels of severity in users who reported sexual dysfunction. Alcohol is the most commonly used recreational drug. It has been linked to sexual behavior (Pandey et al., 2012) for centuries, because it generates disinhibition and therefore can enhance sexual desire. However, studies had established the potential damaging effects chronic alcohol consumption has on male sexual function. These effects are consequences of harm in the cardiovascular and neurologic systems (Pandey et al., 2012; Zaazaa et al., 2013). Evidences from epidemiologic studies are not sufficient to make definitive conclusion regarding the role of alcohol use on sexual function (Zaazaa et al., 2013).

Sexual Behavior and Dysfunction

Overall, 40.9% men with substance-related disorder self-reported some type of sexual dysfunction. Eighty four percent of men had active sexual life in the last 12 months, 24.3% used medication for sexual dysfunction, 10.6% sought medical help for sexual dysfunction, and 63.8% complained of premature ejaculation, the type of sexual dysfunction with the highest prevalence. This should be regarded as a clinically relevant problems. A Brazilian study indicated that the main complaints of male sexual problems were ED (46.2%) and premature ejaculation (15.8%), with variations according to age (Abdo, 2004).

Users of drugs exhibit high levels of risky sexual behaviors. Crack cocaine smoke has been linked with the sexual transmission of HIV, an increase in the numbers of sex partners, trading sex for drugs or money, and unprotected sex (Booth et al., 2000). Of the sexual behaviors identified in the sample, 33.9% self-reported STI, 81% HIV test, 67.2% sex with professional, 16.4% sexual experience in exchange for drugs, 60.3% had two sexual partners, and 63.5% did not use condom or used it occasionally; 75.7% had never had a homosexual experience. Although only 1.6% of the sample identified themselves as homosexual, 24.3% reported having had homosexual experience at least once in their lifetime. Drug use is one factor that has been explored as a potential factor in high rates of HIV incidence. There is a growing body of evidences that suggest that the rates of illicit drugs use are higher among men who have sex with men compared with the general population and heterosexual counterparts (Vosburgh, Mansergh, Sullivan, & Purcell, 2012). Most of the studies defined sexual risk behavior as sex without a condom (Vosburgh et al., 2012) resulting in the transmission of HIV and other STIs. Studies have reported both an increase in sexual activity and increase in numbers of sex partners (Booth et al., 2000). Addicts may engage in sexual risk behaviors such as exchanging sex for drugs or money, vaginal and anal intercourse without condoms, or sex with multiple partners. In addition, engaging in sexual behavior among drugs or alcohol users, especially stimulants users, has been associated with increased potential involvement in sexual risk behaviors (Booth et al., 2000).

This study has several limitations. Sexual dysfunction was evaluated by self-report, without use of standardized tools, and this study was undertaken in a specialized unit of inpatient treatment. This is a strategy widely used to collect data on searches of the area, with advantages and limitations (Kline, Sulsky, & River-Moriyama, 2000). Self-report measures are highly cost-efficient, usable with a variety of populations and experimental settings, and, perhaps most important, are well-suited to evaluate the range of behaviors, experiences, and emotions of interest to both sex researchers and clinicians (Taylor, Rosen, & Leiblum, 1994). Another limitation is that the DAST has not yet been validated in Brazil or other Portuguese language communities (Yudko, Lozhkina, & Fouts, 2007). As the information that was recorded referred to the issues that occurred “last year,” it may be possible that there may have been some bias of memory and hence the importance of this point as another possible limitation of this study. Psychiatric comorbidities, detoxification periods, use of medication, and other clinical conditions that might cause sexual dysfunction symptoms were not controlled. Hence, they might be potential confounding variables.

Conclusion

The findings of this study have indicated that sociodemographic factors, severity of drug use, and sexual behavior had an influence on the sexual dysfunction of males attending an addiction rehabilitation treatment center. The main type of sexual dysfunction is premature ejaculation, which is consistent with the prevalent rates in young adults. This is a highly vulnerable sample with high risks for HIV infection and other STIs. Educational and motivational interventions on sexual health targeted at male drug users can contribute in reducing these risk factors.

More of interdisciplinary research is needed in the future among these male populations. Psychiatric comorbidities, detoxification periods, and use of medication are topics that deserve more attention in future research.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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Sexual Dysfunction and Sexual Behaviors in a Sample of Brazilian Male Substance Misusers

Abstract

Keywords

Introduction

Method

Questionnaires

Sociodemographic Data

Characteristics Related to the Treatment of the Substance-Related Disorder

Sexual Behaviors Information

Drug Abuse Screening Test (DAST) 20

The Short Alcohol Dependence Data (SADD)

The Fagerström Test for Nicotine Dependence (FTND)

Data Analyses

Ethical Approval

Results

Sociodemographic Data

Addiction and Sexual Dysfunction

Sexual Dysfunction and Sexual Behaviors

Discussion

Severity of Addiction and Sexual Dysfunction

Sexual Behavior and Dysfunction

Conclusion

Footnotes

Declaration of Conflicting Interests

Funding

References