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The awareness of sexual experiences could be an effective factor in preventing high-risk sexual behavior pertaining to relapse during the recovery period of substances. This research explored the role of sexual behaviors among Iranian methamphetamine (MA) users in relapse process.
The study was conducted with a qualitative approach using content analysis method. 28 participants were selected through purposeful and theoretical sampling. Data were collected based on face-to-face, in-depth, semi-structured interviews based on open-ended questions. Interviews continued until the data saturation had occurred. All interviews were examined in four stages of codes, sub-categories, categories and themes according to the content analysis of explanations and descriptions of sexual behaviors.
Two main themes were emerged from the analysis of interviews, including extreme pleasure seeking (including the main categories of sexual tunnel vision and sexual totalitarianism) and comprehended threat (including the main categories of internal conflict and external disorganization) as well as 10 subcategories.
The results indicated that sexual behaviors played an important role in relapse process among Iranian MA users and needed to be considered and managed properly in the planning of prevention, treatment, and rehabilitation.
Abuse of amphetamine-type stimulant (ATS) is a major problem in this world.1-5 The most important type of ATS is methamphetamine (MA) which is widely used6 to the extent that its users (53.87 million people) stand in the second stage after Cannabis in the world.7 In Iran, the model of use is also transformed from opioids to synthetic substances that cause a serious warning in society. The notable growth of using stimulant substances particularly “Shishe,” which its main ingredient is MA and used as one of the common street substances in Iran, has turned to a serious threat that health and treatment systems in Iran encounters with.4,8-11 In addition to the fast increase of use, addiction to the substance as a chronic disorder, is reversible within time; the person, who stops using substance for a long time, may begin to use it again; therefore, recent researches noted that relapse would be an important challenge in addiction.12-15 Since relapse is not only very common after the complete treatment of substance abuse10,13,16 but also it is the most serious challenge among the treated substance addictors.14
Relapse is a return to the regular use of a substance after an abstinence period. The risk of relapse in the 1st month after the treatment reaches its climax.17 The failure in the management of the major MA withdrawal symptoms may lead to high rate of relapse in some 1st weeks of abstinence from the substance use.18 For this reason, prevention from relapse is much more important than treatment12 and it is a golden key to treat the addicted people.15 According to the recent researches, one of the effective factors in relapse is sexual behaviors and problems of the patients19-23 since sex is a strong relapse trigger in not only stimulants but also in all types of substances.24 Today, indeed, we are witnessing a great rise in MA use particularly among youths, as the part of the pattern of hypersexual behavior that is inseparably interwoven with substance dependence.25 MA popularity is partly due to its accessibility and inexpensiveness; and mostly is because of its disinhibiting effects on sexual relations, and creating the expectation of positive consequences caused by MA use on sexual relations.26,27 Therefore, MA is widely used for enhancing the sexual pleasure, accelerating the long time sexual activity and to increasing and delaying orgasm.28,29 Hence, in different phases of recovery from addiction, sexual tendencies of the patients, as well as their related problems, are analyzed and discussed in addition to the analysis of the patients’ motivations for abstinence, and recognition of relapse triggers.25 This study also applied qualitative interviews to explore the role of sexual behaviors in the relapse process in MA users to present the appropriate solutions for helping in prevention and improvement of caring and supportive actions after the treatment.
This study was a part of an extended qualitative research which was done by grounded theory as a doctoral dissertation to explain the relapse process in MA users. It explored the role of sexual behavior as an important and effective factor in relapse process in MA users.
The research setting includes five public substance abuse treatment centers and 9 private substance abuse treatment camps and clinics in Tehran and Karaj, Iran.
Data collected during September 2015 to September 2016 with the participation of 20 MA users, 2 family members of MA users, 6 therapists who were experienced in the treatment and rehabilitation of patients affected by ATS substance use disorders (2 physicians, 1 psychiatrist, 2 psychologists, and 1 social worker).
In this research, the purposeful and theoretical sampling according to snowball method had been continued till data saturation occurred. The researcher endeavored to choose various participants since this kind of sampling would facilitate the investigation of various phenomena and enable the researcher to recognize and understand the nature and the different aspects of the study.30
The main method of data collection in this research was the semi-structured, in-depth, face to face, individual interviews based on open-ended questions, probing questions, and causing depth questions. Each interview lasted for 50-90 minutes. Before each interview, the researcher explained the aim of the research and took an informed permission from the participant concerning taking part in the research, recording the interview and publishing the results.
As data collected, it was analyzed based on content analysis. Indeed, content analysis is beyond the derivation of objective content taken from context data; it rather reveals the themes and hidden archetypes within the research data.31 Hence, the researcher listen to the interviews twice and transcribed them word by word to get familiar with the data and to get a general understanding about them; Furthermore, the whole transcribed text of each interview had been read and reread by the researcher several times before data were coded. As a result, sub-categories, categories, and themes of the research were emerged from the constant comparison of the derivate codes and systematic categorizing.
The researcher’s interest in the subject of the study was an encouraging factor to make him to dedicate a lot of time to engage extensively with data and participants which resulted in the rise of credibility of the research data. Member check and peer check strategies were assessed the credibility of the research data. To verify the data and derivate concepts, member check was conducted by the participants and peer check was performed by other research team members. In addition, faculty members, who were associated with the subject of substance use disorders, were also consulted about research findings; the necessary revisions and edits were done consequently. The researcher attempted to provide a rise in dependability and conformability of the research data by field note, preserving the related documents of the research, writing detailed and full reports of limitation and different stages of the research. To achieve transferability of the research data, findings were shared with a few MA users not participating in the study, and they confirmed the importance of the findings and data coherence as well. Moreover, the researcher not only provided the most various sampling but also interviewed the family members of MA users and therapists to increase the credibility of the research data.
This research was approved by the Ethical Committee of University of Social Welfare and Rehabilitation Sciences. It was also considered to keep anonymity and confidentiality, and possibility of decline from the research at any stages and other ethical considerations.
The MA user participants were 12 males and 8 females aged 16-44 years (the majority of them aged between 20 and 30 years). 45% of them were under a high school diploma, 25% of them had high school diploma, and 30% had academic education. 10 of the participants were single, six of them were married and four of them were divorced. Besides, 50% of them had no job, 35% worked part-time, and 15% worked full-time. The duration of their MA use was between less than a year and 6 years (The majority of them had 3-4 years record of MA dependency). The frequency of their relapse was between 3 and 11 times. (The majority of them had 5 times record of relapse). Analysis of the collected data concerning the participated patients in the research introduced two pivotal themes of extreme pleasure seeking (including the main categories of sexual tunnel vision and sexual totalitarianism) and comprehended threat (including the main categories of internal conflict and external disorganization) as well as 10 subcategories (Table 1). Below, all main categories and subcategories are presented.
Sexual tunnel vision
One of the main categories of this research showed the patients’ extreme attention and concentration on their sexual life which was divided into the three following subcategories:
Sexual beliefs, memories, and fancies
Some internalized sexual beliefs in patients included the assumption that using MA stimulant was effective in delaying orgasm, extending the duration of sexual intercourse, heightening the sexual arousal, excitement, energy, and sexual pleasure, increasing the control over the sexual intercourse and improvement of sexual interest. They believed that to stop using MA stimulant might result in shortening the duration of sexual intercourse, unentertaining and unpleasurable sex, impotence, and the necessity of substitution of sexual pleasure for substance use.
A 21-year-old male user said: “Routine sex is not playful, I have to use first to get the reaction I’d like with all its kick. Only if she says I crack her (hurt) I drop her then (leave her).”
An addiction therapist said: “Most of the patients believe that they have experienced the highest level of sexual pleasure through a stimulant and they almost always seek to repeat the same pleasure. Therefore, they use a stimulant again and again in their sexual practices.”
In addition to the effect of beliefs in directing the patients’ sexual thought, feelings, and behaviors, they spent a long time reviewing their sexual memories and fancies; all these sexual temptations underlain relapse in such patients.
A 25-year-old male user said: “always I review my memories of sex, I’m always thinking of its joys, these cause that temptation like leprosy makes me itch, always I think next time with a full head (after using MA) go to put a sex.”
Attachment to the technological world of sex
Some patients spent a lot of time on surfing the pornography sites, taking part in pornographic channel in social network, collecting and watching pornographic photos and films, searching for a sexual partner on the net, pornographic conversations and chats to the extent that it seemed they were attached to the technological world of sex, and they were amused by it day and night. Technological world of sex made such patients tempted and excited, so they attempted to copy and perform exactly the same sexual scenes they had watched.
A 23-year-old male user said: “Always I’m following photos and films in sexual sites (on internet). I’m continually looking for a phone number in comments to call her and to put a sex with. I put my number too. I’m on these sites at least about 4 to 5 hours, and every time I’m wanking (masturbation).”
An addiction therapist said: “Physically arousal and exciting tensions, after watching pornographic films, form some new ideas about sex in the mind of patients that disturbs their behavioral and emotional balance, disrupts their judgment and seriously induce them to experience sex with substance.”
Sexual amusement of the real world: Besides the technological world of sex, some patients entertained themselves by sexual subjects such as watching other’s intercourse, making girlfriend, voyeurism, going to party, and special sex centers in the real world. This amusement acted as the facilitating factor for relapse process in these patients.
A 20-year-old female user said: “When the Roudehen’s (a town in Tehran) parties started we went to party every night, my reuse started with alcohol, then substance and this time my use
An addiction therapist said: “After leaving (substance abuse treatment center), making girlfriend and having relation with a partner is like a poison for the patients. Because with the least degree of dissatisfaction or upset they fell fall apart and seek to use substance again.”
It was one of the main categories of the research with two subcategories which expressed patients’ extreme attempt to obtain the maximum sexual ideals.
Endless sexual potency: The daydreaming of obtaining the maximum sexual potency to have a long intercourse, to increase the sexual desire, excitement, and pleasure, to heighten the energy were underlying the relapse in many patients; since according to their views, the only substance that could give them an endless sexual potency was MA.
A 22-year-old female user said: “When I use, my energy and dare become multiple, I can have sex in every way (vaginal, rectal, and oral) for hours without being tired.”
An addiction therapist said: “Obtaining the needed potency to increase the quality, time and duration of sex or to experience more excitement and pleasure are the patients’ major justification for relapse.”
Sexual marathon: As if some patients were participating in a sexual marathon contest, they inevitably extended the time of intercourse with their partner, had more sexual relations with different people in a party, or lengthened the duration of intercourse for long hours. These situations directed them to relapse through the induced sense of victory and honor in their sexual marathon.
A 26-year-old male user said: “My comrade said me ‘let’s go to a party’ he told me ‘just come, sit and watch the dances.’ I went and saw that all are naked, I became hot and horny in a way that I sat and used (substance) with them and I had sex with 7 of them till morning.”
An addiction therapist said: “More and more, and longer and longer intercourse, this is the desire and experience of many patients involved in group or causal sexual encounters. It leads even in multi-substance use in them.”
Sexual diversity: Many patients sought diversity in their sexual partner, in location of sex, in sexual behavior and position to the extent that some of them involved in high-risk sexual behaviors with negative consequences such as sex with homosexuals, sex with teenagers, sex in unsafe surroundings, and sex at workplace. Indeed, sexual diversity and high-risk sexual behaviors caused relapse in these patients.
A 25-year-old male user said: “How you love the different tastes of food, I love to taste different women, I hate a routine sex.”
An addiction therapist said: “Those (patients) who are seeking pleasure and are not abstinent are frequently involve in high-risk and unconventional sexual relations in which they infect with a mistake and then relapse sooner or later.”
As one of the main categories of this research, it dealt with burden of stresses, anxieties, and fears of patients with personal sexual problems. It had two following subcategories:
Sexual self-denial: Some cases such as having negative attitudes toward one’s body and gender, fear of weak sexual function and being neglected, doubt about one’s sexual appeal and potency, fear of being labeled or rejected which were founded in patients’ interviews, indicated sexual self-denial in them, and brought about agitation as well as justification for relapse.
A 25-year-old female user said: “My boyfriend told me that I was not how he’d like. Always I thought that I’m not attractive and he just tolerated me. He told me that our sex became usual for him and I was afraid that he left me, and I use again.”
An addiction therapist said: “Many patients make a catastrophe out of their fears and negative thoughts which are mostly unreal and not rationalized. Most of these thought are the result of ignorance, self-denial, and comparing themselves with others.”
Removal of sexual dysfunction: According to the patients’ views, relapse mostly happened to improve their situation or removal of mental pressure caused by sexual dysfunction including lack of sexual desire, arousal and orgasm, lack of sexual pleasure, premature ejaculation, and deficiencies of sex organs.
A 31-year-old male user said: “I adapt to use Viagra and stimulant with each other, or less I don’t have erection and I can’t sex for a long time.”
An addiction therapist said: “The long-term use or overuse of MA or even sexual dysfunction cause that sexual function in some patients, even after withdrawal, is not satisfying. Without addressing these problems, they seek to use substance again just to solve them.”
It was also one of the main categories of this research pertained to the patients’ stressful marital and social problems which, as they assumed, directed them willingly or unwillingly to involve with sexual relations and then relapse. This category included two subcategories as following:
Marital problems: Relapse induced in some patients as the result of sexual dissatisfaction of couples, abused by the spouse, imposed sexual assault, sexual and emotional deprivation by the spouse, the pressure of the extreme sexual demand of an addicted spouse, extra-marital relations, etc.
A 26-year-old female user said: “Whenever (my husband) uses, he just gets in sex phase, I had to use with him again because I was afraid that he went to other women. He told me that just in this way our sex is professional!”
A spouse of a patient said: “When they are in an emotional relationship, they‘ll finally involve with sexual relations too. They want to show off their sexual potency to their partner or to romanticize their sex; they go to use again lest they freeze up.”
Social problems: Based on patients’ ideas, involving with sexual relations to maintain their job, housing, income as well as getting in obligatory sexual relations, avoiding to be rejected, and loneliness in peer group were all caused by lack of proper support after leaving substance abuse treatment centers. They inevitably involved with such relations and albeit in substance relapse to avoid subsequent possible problems and damages.
A 27-year-old female user said: “My rent was lagged, every 2 or 3 days my house owner came and asked for the rent. I didn’t have any money to give him. I had to sleep with him to give me another deadline. After that, he came in frequently, one night he came with two of his friends, I was annoyed and that night I went to use.”
An addiction therapist said: “A patient prostitutes because she is jobless, penniless and is rejected by her family; because she doesn’t want to wander in ruin at night… after that she has to or is forced to use again to serve them better (better sexual services).”
The results of this study revealed that sexual behavior of MA users had an important role in the relapse process in such patients. As other researches had shown, one of the effective factors in relapse is sexual problems and behaviors.19-23 Indeed, excessive sexual ambition and sexual sensation seeking, besides tempting sexual beliefs and habits as well as expectation of positive effects of MA use on the process of sexual relation resulted in relapse in many patients. It seemed that the easy, at-hand and inexpensive access of the patients to pornography and sexual stimulant substance, fortified the sexual sensation seeking in these patients, which was associated with stimulant substance use.34
Consequently, as other studies had shown sensation seeking was one of the main directions to relapse.35 Furthermore, this research affirmed that sexual boldness and risk-taking in some patients, who performed high-risk sexual behaviors, particularly in sexual diversity and marathon, were in high level. Such high-risk sexual behaviors, indeed, caused the disturbance of their behavioral and emotional balance, damages to mental health and mostly to be surrounded by other risks such as sexual deviation, substance, and alcohol use36,37 which was leading to relapse finally. Other researches also demonstrated that the sense of sexual boldness, sexual adventure, and sexual marathon5,38 in MA users were intensified. Moreover, some patients attempted to access the high but unrealistic level of sexual standards such as the necessity of having the longest time of intercourse or recurring orgasm which indicated sexual perfectionism and it underlay the relapse in these patients. In this regard, other studies had also proved the positive relationship between perfectionism and stimulant abuse.39
This research indicated that acting uncontrolled sexual behavior in different time with more intensity, in more risky models, minimizing or abandon the important activities in life because of incapability in avoidance of obligatory sexual behaviors even with its negative consequences, obsession with pornography, experience negative feeling, being agitated and excitable in the time of the decrease of sexual activity, all revealed patients’ behavioral addiction to sex or pornography. Other researches also advocated that addictive sexual disorder were mostly coexisted with synthetic substance addiction which was one of the recurring and unrecognized reason of relapse in dependency to synthetic substances.40
A number of items such as doubtless about one’s sexual appeal and potency, negative attitudes toward one’s body, and so on indicated the patients’ denial to accept their sexual potency and status. This brought about lack of self-confidence, sex-negativity, self-inferiority, self-labeling, and self-distress in patients’ sexual relations and underlay relapse as well. As other studies clarified, some factors such as self-inferiority,41 the emotion of distress, absurdity, helplessness, and self-labeling42 were effective in relapse process.
This study presented that some patients who faced sexual dysfunction such as premature ejaculation or problems related to their sexual desire, arousal and orgasm cause them to become agitated, anxious, and dissatisfied in their sexual relations and finally leaded them to relapse. In this regard, other studies noted that sexual reluctance, impotency, and abstention from sexual intercourse contact were three main themes of relapse in patients’ with opioid disorders;20 Therefore, the simultaneous treatment of major sexual and mental disorders in such cases would help to prevent the agitation, anxiety and other symptoms underlying relapse.25
The desperation of some patients in confronting the stressful social and marital problems made them to feel being surrounded by the condition. Suffered from lack of self-efficacy, lack of adaptive skills, coping skills, communicative skills and lack of ability to solve the problem, they were able neither to adapt themselves nor to find a solution. Hence, they willingly or unwillingly involved with sexual relations and then substance relapse as the most accessible way for temporal oblivion of these problems and redemption of their ruminations and negative feelings. Furthermore, other studies approved that negative feelings, interpersonal conflicts,41,42 and low self-efficacy43 were effective factors in relapse process; moreover, patients’ incapability in coping with daily life’s pressures44 and forgetting life problems2 directed them to use MA.
The findings of this research demonstrated that patients’ sexual behavior had an important role in maintaining the relapse process in MA users. Because of that, it is necessary to consider the patients’ sexual needs, tendencies, and problems to decrease the time and intensity of relapse in MA users, especially in prevention, treatment and rehabilitation planning related to these patients. Hence, it is also important that therapists and nurses have positive and constructive cooperation, pay especial attention to MA users patients’ sexual needs, tendencies, and problems in the recovery process, and take the responsibility of their profession in this respect and in maintaining the results and effects of therapy in an admirable and extensive way.
Authors would like to thank the individuals, who participated in this research. Thanks are also due to the clinics that cooperated in the research. This study was supported by the University of Social Welfare and Rehabilitation Sciences, Tehran.
Conflicts of Interest
The Authors have no conflict of interest.