1. Sex under the Influence is Common for Substance Abuse Treatment Patients Donald Calsyn, Ph.D. 1,2, Mary Hatch-Maillette, Ph.D. 1, Suzanne Doyle, Ph.D. 1, Sarah Cousins, M.A. 3 & George Woody, M.D. 4 1 Alcohol & Drug Abuse Institute and 2 Department of Psychiatry & Behavioral Sciences, University of Washington, Seattle, WA 3 Matrix Institute, Rancho Cucamonga. CA 4 Research Treatment Institute, Department of Veterans Affairs Health Care System &University of Pennsylvania, Philadelphia, PA

2. Abstract Objectives: In the context of substance abuse treatment, sex under the influence of drugs or alcohol is a risk behavior of interest for HIV/STI transmission. However, normative data concerning sex under the influence is lacking. Methods: All men in NIDA CTN protocol 0018, a gender specific HIV prevention intervention, were administered a structured self report questionnaire at baseline using ACASI methodology focusing on sexual risk behavior in the prior 90 days. This report focuses on the 238 methadone maintenance (MM) and 247 outpatient psychosocial (OPS) patients who self report engaging only in heterosexual sexual behavior in the prior 90 days. Results: The majority of MM (81.9%) and OPS (67.6%) patients reported engaging in sex under the influence in the prior 90 days. OPS patients in long term monogamous relationships (53.3%) were less likely to report sex under the influence than OPS patients with casual partners (75.8%,  2=13.3, p<.001). Both MM and OPS patients reporting being with a casual partner at their most recent sexual event were more likely to be under the influence (68.2%, 60.5%) than MM (46.8%) and OPS (26%) patients with a regular partner during their most recent sexual event (MM  2= 8.8, p<.01; OPS  2=26.8, p<.001). OPS patients under the influence compared to those not under the influence at last sexual event were more likely to engage in anal sex (20.2% vs. 10.3%,  2=4.6, p<.05) and insertive oral sex (81.1% vs. 68.4%, %,  2=4.7, p<.05). Men under the influence for their most recent sexual event associated more sexual enhancements than sexual impairments for that event. However, satisfaction with the most recent sexual event was rated higher on a 0 (not at all pleasurable) to 10 (extremely pleasurable) scale (m=8.03, sd=2.35) for by those not under the influence for that event than those under the influence (m=6.99, sd=2.59, t=4.44, p<.001). Conclusion: Sex under the influence is the common for MM and OPS patients and is associated with riskier sexual behaviors. A challenge for treatment providers is combating the lure of sexual enhancements associated with being under the influence.

3. Background HIV/STI prevention programs with substances abusers routinely included messages to not engage in sex under the influence of drugs and alcohol. However, there is a lack of data concerning how common sex under the influence is for individuals in substance abuse treatment and if sex under the influence is related to risky sexual behavior for these individuals. Previous studies have used both “situational association” and “event analysis” approaches. Situational association studies are those in which a temporal link is made between the drug use and sexual behavior. Although a temporal link is made, no causal connections can be inferred. We know little of the context of the behavior. Event analysis assesses a "critical incident(s)" in detail. For example, a participant is asked to describe the most recent sexual encounter. Probes are used to identify contextual variables of interest. The event analysis technique allows for a greater understanding of the connection between drug use and sexual behavior. Besides the HIV/STI risk concerns, combining sex and drugs is a relapse prevention concern for the substance abuser from whom sex under the influence is common. Sex under the influence is a secondary outcome variable in NIDA Clinical Trials Network Protocol 0018, “HIV/STD safer sex skills groups for men in methadone maintenance or drug free outpatient treatment programs.” Both “situational association” and “event analysis” approaches were used to measure sex under the influence in CTN0018.

4. Methods Subjects. Men enrolled in one of 14 substance abuse treatment programs across the US (see Figure 1) were recruited to take part in an HIV/STI prevention project specifically tailored for men (NIDA Clinical Trials Network Protocol 0018). Inclusion criteria included age of 18 or more, engagement in unprotected vaginal or anal intercourse in the prior 6 months, willingness to attend HIV/STI prevention groups and complete assessments at baseline and at 2 wk., 3 mo., 6 mo. post intervention. Exclusion criteria included having a primary partner planning to get pregnant or a Mini Mental Status Exam < 25. This report focuses on the 238 methadone maintenance and 247 psychosocial program outpatients who reported engaging exclusively in heterosexual sexual behavior during the 3 months prior to the baseline assessment. Demographics for the sample are provided in Table 1.

5. Figure 1: Treatment Sites Seattle San Francisco Hartford Philadelphia (x2) Staten Is. Greensboro Norwalk Rancho Cucamonga Santa Fe Richmond Toledo Huntington Raleigh Red=Psychosocial Outpatient Black=Methadone Maintenance

6. Table 1: Sample Demographics

7. Methods, cont. Procedures. The study schema is presented in Figure 2. This report focuses on data regarding sexual behavior from the baseline assessment, especially related to engaging in sexual behavior under the influence of drugs or alcohol. The Sexual Behavior Inventory (SBI), an extensive structured interview concerning sexual behavior, was administered to eligible subjects via audio computer assisted interview (ACASI) methodology. The SBI covers the following topics: Number and type of sexual partners Frequency and type of sexual behaviors Use of condoms Communication about sexual matters Sex under the influence of drugs and alcohol Detailed description of most recent sexual event Data Analysis. Descriptive statistics were calculated for frequency of combining sex and drugs in the prior 90 days and at the last sexual event. For dichotomous variables, groups were compared by cross tabulation utilizing the  2 statistic. For continuous variables groups were compared utilizing a t-test.

8. Figure 2: Study Schema Advertise Study Availability  Consent to Screen for Inclusion/Exclusion & Screening Assessment  Obtain Informed Consent from Eligible Participants  Conduct Baseline Assessment Conduct Baseline Assessment → Place in Waiting Cohort  Randomly Assign Cohort to Intervention   Standard HIV Education Gender Specific Intervention (one session) (five sessions)   Conduct Post Intervention Assessment  Conduct Three Month Follow Up Assessment  Conduct Six Month Follow Up Assessment

9. Results 1.The majority of MM (81.9%) and OPS (67.6%) patients reported engaging in sex under the influence in the prior 90 days (see Figure 3) and more MM than OPS reported this (  2=13.13, p<.001). Similarly, during their most recent sexual encounter, more MM patients (52.7%) than OPS patients (36.6%) reported sex under the influence (  2=12.76, p<.001).

10. Figure 3: Sex under the influence of drugs: baseline assessment *** ***p<.001 ***

11. Results, cont. 2.Fewer OPS patients who reported only having a single “low risk“ partner in the past 90 days reported engaging in sex under the influence in the past 90 days (53.3%) than OPS patients with a high risk partner (75.8%,  2=13.29, p<.001; see Figure 4). For Methadone patients there was no difference between patients on engaging in sex under the influence as a function of partner risk status. 3.Both MM and OPS patients reporting being with a casual partner at their most recent sexual event were more likely to be under the influence (68.2%, 60.5%) than MM (46.8%) and OPS (26%) patients with a regular partner during their most recent sexual event (MM  2= 8.8, p<.01; OPS  2=26.8, p<.001; See Figure 4).

12. Figure 4: Sex under the influence of drugs as a function of partner status Prior 90 Days Last Sexual Event *** ** ** p<.01 *** p<.001

13. Results, cont. 4. Presented in Figure 5 are the sexual behaviors engaged in during the last sexual event by MM and OPS patients as a function of being under the influence. For OPS patients both anal intercourse (  2=4.6, p<.05) and fellatio (  2=4.7, p<.05) occurred more frequently when under the influence.

14. Figure 5: Sexual acts for most recent sexual event and being under the influence * * *p<.05

15. Results, cont. 5. Presented in Figure 6 are various sexual enhancements and impairments reported by subjects for the most recent sexual event for those under the influence during the most recent sexual event.

16. Figure 6: Sexual Enhancements and Impairments Reported for the Most Recent Sexual Event UI Sexual Impairments Ejaculation Desire  Potency /  Lubrication DelayedOrgasm Sensation  Social Inhibition Sexual Inhibition Desire  Potency / LubricationOrgasmicDysfunction Sensation

17. Results, cont. 6. Despite the report of more sexual enhancements than impairments, satisfaction with the most recent sexual event was rated higher (See Figure 7) on a 0 (not at all pleasurable) to 10 (extremely pleasurable) scale by those not under the influence for that event (m=8.03, sd=2.35) than those under the influence (m=6.99, sd=2.59, t=4.44, p<.001). Even when those subjects who report no sex under the influence in the past 90 days are removed from the analysis sexual satisfaction is rated higher by those not under the influence at the most recent sexual event (m=7.96, sd=2.58) than men under the influence (m=7.02, sd=2.39, t=3.45, p<.001) for that event. 7. Men under the influence during the most recent sexual event were not less likely to use condoms with a high risk partner (19.3%) than men not under the influence for the event (30.0%). Even when men who did not engage in sex under the influence for the past 90 days are excluded from the analysis the null result remains.

18. Figure 7: Sexual satisfaction for last sexual event *** ***p<.001 *** Extremely pleasurable Not at all pleasurable

19. Conclusions  Engaging in sex under the influence of drugs or alcohol is common for men in substance abuse treatment.  Sex under the influence is associated with having higher risk partners and engaging in higher risk behaviors, but not less condom use.  Men associated more sexual enhancements than sexual impairments with being under the influence.  However, sexual satisfaction was rated higher when not under the influence. Acknowledgements  Supported by NIDA (1 U10DA13714-01, Dennis Donovan, PI).  The authors wish to thank the CTN 0018/0019 lead node teams, the 23 RRTC and site PIs, the 15 site coordinators, the 21 research assistants, the 15 therapy supervisors, and the 29 therapists who worked on this project.