1. ASAM 2009 Workshop Cocaine and Methamphetamine Addiction Presenters Mark S. Gold, M.D. Richard A. Rawson, Ph.D. Joan E. Zweben, Ph.D. Arnold M. Washton, Ph.D.

2. Stimulant-Induced Hypersexuality Arnold M. Washton, Ph.D. www.recoveryoptions.us awashton@gmail.com New York, NY and Princeton, NJ

3. Stimulants and Sex Many COC and MA users report potent aphrodisiac effects Increased sex drive (libido) Decreased sexual inhibitions Various types of sexual acting-out behaviors

4. Sex and Drug Binges Marathon masturbation to pornography Internet sex Sexual encounters with anonymous partners Sex with multiple partners Unsafe sex

5. Stimulant & Sex Homosexual behavior in otherwise heterosexual men “SheMales” or “Half & Half” escorts Cocaine stimulates homosexual fantasies and behaviors Post-cocaine crash may involve repulsion, self-loathing, suicidal ideation and actual suicide attempts

6. Sexual Effects of Stimulants Some users report no sexual effects Some report decreased sexuality Reasons for these individual differences is unknown

7. Stimulants and Sex Stimulants + Sex = “Super High” 2 extraordinarily potent reinforcers More addicting than drug use alone

8. Stimulants and Sex Drugs + sex become inseparable It is the entire drug-induced sexual experience that becomes addicting Sex and drug binges lasting 2-3 days

9. “For me, cocaine and sex are one and the same. Every time I feel sexually aroused, my brain immediately thinks ‘cocaine’. Last time I tried to give up cocaine I thought I could do it without giving up the escorts and wild sex scenes. But, I was wrong. Every time I got turned on sexually, all I could think of was cocaine. Sex without cocaine just seemed so boring. I guess I’ll have to learn how to enjoy sex without the hookers and the drugs. It won’t be easy, but unless I can break this connection once and for all, I don’t see how I can stay clean and sober for very long. I don’t want remain stuck in this vicious cycle of cocaine and sex any longer. I feel like a dog chasing its tail.”

10. Stimulants and Sex Behavior becomes stereotyped and ritualistic Impaired sexual performance in chronic users further escalates intensity of acting-out behaviors When sexual performance is totally eliminated by chronic cocaine use, sex becomes a purely mental/visual experience devoid of any physical contact Many stimulant users take Viagra and other sexual performance-enhancing drugs to counteract the drug-induced sexual dysfunction

11. Factors Influencing the Sexual Effects of Stimulants Gender COC vs. MA Dose, chronicity, route of administration Prior sexual addiction

12. Stimulants and Sex MA more likely to stimulate hypersexuality in both men and women More intense, extreme, and longer-lasting sexual behaviors with MA MA less likely than COC to cause sexual dysfunction thereby increasing likelihood of MA users engaging repeatedly in high-risk sex IV use of MA associated with highest rates of drug- induced hypersexuality

13. Issues of Heightened Concern About Methamphetamine Use A recent study* of gay and bisexual MA users in LA found that during the 12 months prior to entering treatment –63% reported having anal sex without a condom –56% reported having sex with someone who had HIV _____________________________________________ * Frosch et al. Journal of Substance Abuse Treatment, Vol 13, pp. 483-486, 1996.

14. Issues of Heightened Concern About Methamphetamine Use Less tolerance develops to MA’s ability to increase libido and stimulate hypersexual behavior More anal unprotected sex in gay and bisexual men more unprotected sex Greater number of sex partners in females and in gay men MA users Higher rates of HIV positivity in MA users Higher rates of IV use and sharing of injection apparatus in MA users

15. Pre-Treatment MA and Sexual Risk (Rawson UCLA) 76% of clients had sex while high or feeling the effects of MA within the past 30 days 82% of clients report that MA and sexual activities “always” or “often” go together

16. 52-Week Follow up MA and Sexual Risk (Rawson, UCLA) 33% of clients had sex while high or feeling the effects of crystal within the past 30 days Sexual behavior changes accrued in the following areas: –Number of Sex Partners –Sexual Activities –Condom Use –Disclosure of HIV Status

17. Obstacles to Successful Treatment “Super High” reduces motivation for change Drug-sex linkage can be difficult to break “Reciprocal Relapse” Substance use and sex remain instantly gratifying, but consequences are often delayed Failure to routinely identify and address these issues in treatment

18. Treatment Considerations If clinician does not specifically assess for drug-related sexual behaviors and develop an open dialogue with patients regarding this issue, then –Patients will not bring it up –They will assume that it is irrelevant to treatment –Relapse will be inevitable

19. Sex-Drugs Questionnaire 28 items In: Washton, AM, Zweben JE Cocaine and Methamphetamine Addiction WW Norton, 2009

20. Treatment Considerations Reciprocal relapse pattern Sex-drug linkage greatly increases strength of addiction Sex becomes synonymous with drugs, and drugs become synonymous with sex Sexual compulsivity not only continues but often intensifies in the face of drug-induced sexual dysfunction The disinhibiting effects of alcohol increase the likelihood of acting on sexual impulses generated by stimulant drugs

21. Treatment Considerations A sexual “cooling off” period is usually required to break the cycle Even “regular” non-drug sex can trigger overwhelming urges and cravings that lead to resumption of use Address unrealistic hopes of continuing sexual acting-out behaviors without drugs or vice versa

22. Treatment Considerations For those totally unwilling to accept temporary abstinence from sex as a starting point, an alternative is switching from more harmful to less harmful behaviors (e.g., from HIV-risky sex to masturbation)

23. Treatment Considerations Patients with stimulant-related hypersexuality generally do best in groups with others who share this problem

24. Sex-Drugs Survey Survey Sample 321 Outpatients New York City & Los Angeles Primary Substance Dependence 25-Item Questionnaire

25. Survey Sample N = 321 MA (N=52) 34 Male 18 Female Cocaine (N = 56) 38 Male 18 Female Opiates (N =138) 94 Male 44 Female Alcohol (N = 75) 41 Male 34 Female

26. Rawson RA, Washton AM, Domier, CP, Reiber, C. Drugs and sexual effects: Role of drug type and gender. Journal of Substance Abuse Treatment, 22, 103-108. 2002.

27. Q1: My sexual thoughts, feelings, and behaviors are often associated with use of these substances:

28. Q2: My sex drive is increased by use of these substances:

29. Q3: My sexual drive is decreased by use of these substances:

30. Q4: My sexual performance is improved by use of these substances:

31. Q5: My sexual performance is impaired by use of these substances

32. Q6: My sexual pleasure is enhanced by use of these substances:

33. Q7: My sexual pleasure is reduced by use of these substances:

34. Q8: My use of these substances has made me feel obsessed with sex and/or made my sex drive abnormally high.

35. Q9: Use of these substances has reduced my interest in sex and/or made my sex drive abnormally low.

36. Q10: I am more likely to have sex when using these substances:

37. Q11: I am more likely to have sex with an unknown partner or someone other than my primary mate when I am using these substances:

38. Q12: I am more likely to have “risky” sex under the influence of these substances (e.g., not use condoms, be less careful about who I chose as a sex partner, etc.)

39. Q13: I have been involved in sex acts that are unusual for me when under the influence of these substances:

40. Q14: My use of these substances is so strongly associated with sex that I believe it will be difficult for me to separate use of these substances from sex

41. Q15: I am concerned that sex will not be as interesting or pleasurable- maybe even boring- without these substances

42. Q16: Sexual fantasies or desires have triggered my use of these substances:

43. Q17: My sexual fantasies/desires make it more difficult for me to stop using these substances:

44. Q18: My sexual behavior under the influences of these substances has caused me to question my sexual orientation

45. Q19: My sexual behavior under the influence of these substances has caused me to feel sexually perverted or abnormal

46. Q20: My sexual behavior under the influence of these substances has resulted in feelings of depression

47. Q21: My sexual behavior under the influence of these substances has resulted in feelings of shame/guilt

48. Q22: My sexual behavior under the influence of these substances has caused me to think about harming/killing myself

49. Q23: My sexual behavior under the influence of these substances has caused me to plan to harm/kill myself

50. Q24: My sexual behavior under the influence of these substances has caused me to attempt to harm/kill myself

51. Q25: I believe that I need treatment for my sexual behavior as it is linked to the following substances:

52. Conclusions & Implications Linkage between sex and substance use is strongly influenced by gender and by the specific substance being used Strongest linkage occurs with stimulants Weakest linkage occurs with opioids Overall, men show stronger drug-sex linkages than women Men and women respond most similarly to one another with MA

53. Conclusions & Implications Stimulants increase sex drive, fantasies, feelings, behaviors, and high-risk behaviors MA users report much stronger linkages with sex than do cocaine users Chronic use of cocaine as compared to MA causes more sexual dysfunction For women, the alcohol-sex connection is more powerful than for all other substances

54. Conclusions & Implications Treatment of stimulant addiction must address drug-related sexual behaviors Clinicians must routinely assess all clients for substance-related sexual behaviors