Sexuality Reduction Syndrome in Opiate Addicts by Dr. Yuriy Zharkov

Introduction

The harmful effects of drug abuse manifest themselves not only in psychological traumas and reductions in moral, ethical, and social adaptation, but they also influence the vital sphere of sexuality. The main phenomena associated with the reduction of sexuality accompanying opiate abuse are that the addict deviates from the normal modes of sexual reaction in intimate relationships, and that he or she develops patterns of sexual deviance during the formation of a physical dependence on the narcotic. Groups of narcotic users show altered sexological and behavioral characteristics.
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When a man is severely intoxicated, his sexual reactions become slower, and the process of sexual intercourse is lengthened, leading as far as to the development of anejaculatory syndrome. Women experience a reduction in the ability to experience orgasm. Addicts are generally indifferent to such matters. An intoxicated person often does not attempt to achieve orgasm, as its experience interrupts or reduces the effect of the drug, which can lead to a renewed craving for opium or heroin. It is important to note, however, that a man's desire for the narcotic is sometimes reduced after the experience of orgasm. The general quality of an addict's sexual reactions is dependent on the amount of drugs he or she uses: the higher the dose, the longer coitus is prolonged, the harder it is to ejaculate, and the weaker the experience of orgasm is.
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Frequent opiate use quickly leads to the formation of a physical dependence, and when this happens, sexual desire is always reduced. The extent of libido reduction varies, depending on the intensity of drug use, and on the specific features of a patient's sexuality. Sometimes sexual desire disappears altogether, whereas in other cases the reduction is less strongly pronounced. Correspondingly, the intensity of the addict's sexual life can vary from total abstinence, to a more normal rate, regulated by a person's need to fulfill marital or social roles.
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From the investigation of the sexological characteristics of drug-users, it has been established that groups of users show a high rate of HIV and other sexually-transmitted diseases, prostitution, and sexual assault.

The goal of the present investigation was to describe the phenomenon of reduced sexuality accompanying opiate addiction, and to distinguish the most common symptoms of this syndrome - to formulate a clear picture of this sexual pathology which will enhance the clinical knowledge. The phenomenological spectrum of sexual reduction will by examined in connection with Anokhin's theory of functional systems (1).

Diagram 1

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The main idea of this theory is that a person's mental activity and behavior can be divided into discrete elements which have a classical organization and are systemically inter-related (6). The behavior of drug addicts exhibits two systems: one is directed towards the satisfaction of sexual desire, the other towards the pathological craving for narcotics. The general approach of this investigation will be to take these two systems as being fundamentally similar. They both appear in typical patterns of behavior which are genetically determined and in patterns which are conditioned by personal experience. As Anokhin's theory states, these are the 'wired-in' and 'dynamic' forms of mental programming. The proposed approach links these basic categories to independent structural elements in the functional system being studied. As postulated by Anokhin, when a 'positive' (though in the case of pathological systems, not always 'good') result is achieved, it becomes the primary factor in the system's further development, and future behavior stems from the foundation of self-regulatory mechanisms. When comparing forms of behavior, we use the principle that the systems are hierarchically ordered, and that they compete between themselves for the desired result. In the systems investigated here, the desired result is pleasure.

Materials and Methods of Investigation

Under active medical supervision, 81 patients were found, having been diagnosed as heroin addicts, and having used the drug intravenously for between 1 and 3 years. All of the patients were subjected to psycho-pathological and to clinical testing. The level of patients' rehabilitative potential was determined.

In the patients' histories were recorded: age, marital status, presence or absence of sexual partners, and other biographic and demographic information. During the gathering of anamnesis, the intensity of patients' sexual life, and the rate of drug use were recorded. For convenient comparison of data, a blank form was used, which is typical in the practice of socio-pathology. Intravenous use of heroin was usually preceded by a period of nasal use, and by the use of marijuana, ecstasy, and other psycho-active substances. 11 patients (14%) were considered to have a high potential for rehabilitation, and 70 (86%) a moderate potential. The program of rehabilitation was started after the easing of withdrawal symptoms at a hospital or out-patient clinic. A medical regime was prescribed, usually consisting of drugs that block opiate receptors for 3-6 months, neuroleptics, and anti-depressants and tranquilizers for periods of 3-8 weeks (according to medical necessity). The patients' parents and loved ones were also included in the rehabilitation process. The frequency of group and individual consultations varied from 2-3 per week, to 1 per month. Consultation usually continued for between 3 and 14 months, although sometimes further consultation with the patient became impossible after the initial 2 month course of intensive group sessions. The average length of observation was 6 months.
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The group under investigation consisted mainly of young people. There were 47 men (58% of the total), between 17 and 27 years of age (average age: 20.5), and 34 women (47%), between the ages of 18 and 24 (average age (20.9). The distribution of patients in age groups is shown in diagram 2:

Diagram 2

14 of the patients were full-time students (17% of the total); 21 patients were taking time off from school (26%); 16 patients (20%) worked or combined work with schooling; and 30 patients (37%) neither worked nor attended school. 46 patients (57%) lived with parents or relatives, 35 (43%) lived apart from them. The patients' family structures were as follows at the time of the investigation: 29 patients (36%) had a full family with both parents; 4 patients (5%) had no parents; and 48 patients (59%) had divorced parents, subdivided into the following categories: raised only by mother - 19 cases (23% of the total sample); raised only by father - 3 cases (4%); mother remarried - 20 cases (25%); and father remarried - 6 cases (7%).

Results of the Investigation

The investigation was carried out in the department of out-patient care and rehabilitation at NN center of Narcology of the Russian Ministry of Health. Most of the drug addicts studied were un-married (63%), including 25 women (73% of women in the sample), and 37 men (79% of the men). 5 of the women (15%) and 7 of the men (also 15%) were divorced; 4 of the women (12%), and 3 of the men (6%) were married.
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28 of the patients (34%) had not had a sexual partner in the 3 months before the start of the investigation - this number included 7 women (20% of the women) and 21 men (41% of men). 12 women (35%) and 9 men (19%) had had casual sexual relationships, and 11 women (32%) and 14 men (30%) lived with partners outside of wedlock. 4 women (12%) and 3 men (6%) lived with their spouses.

6 of the married couples had 1 child each. 4 of the women had children out of wedlock. Of the patients' children, 6 were boys and 4 were girls. The reproductive rate (ratio of children to total sample size) of the group was 12%.
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12 of the patients were infected with HIV (15%). Antibodies for Hepatitis C were found in 68 patients (84%), and antibodies for Hepatitis B and C were found in 5 (6%).

Significant differences were found in the way the representatives of different genders had first been exposed to narcotics. Boys usually began using heroin with a group of adolescents, into which later entered an addict already in an advanced stage of drug-dependence. This pattern was reported in 32 cases (68% of males in the survey.) Girls, on the other hand, usually received their first dose of heroin directly from an addict, with whom they were engaged in a platonic, or a sexual relationship. This was reported in 27 cases (79% of females).
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For men, in every case without exception, a fall was observed in the rate of sexual activity with a corresponding rise in the use of heroin. During periods of heavy drug use, they usually separated from their partners, especially if their partners were not also using drugs.

No such clear pattern was observed in the case of women. When drug use was moderate, women often engaged in infrequent, casual relationships; with heavier drug use, however, sexual activity did not always stop. This was because many women reported engaging in prostitution (14 patients, or 41% of women in the sample).
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Disruption of the menstrual cycle to the point of amenorrhea was observed in the periods where heroin use was most intense. After the cessation of drug use, menstruation began again over the course of 2-4 months.
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17 men (36%) reported having had a serious sexual relationship which preceded the use of heroin. A couple was formed, sometimes even living together within a 'trial-marriage' framework. The rhythm of sexual life was regular and intense (almost daily sexual activity with frequent excesses). With the onset of drug addiction, the couples usually separated, and the man's sexual life tended to become more promiscuous, with sexual gratification being achieved mainly through oral-genital contact. These men would often engage in sexual relations with women following joint injections of heroin. The experience of orgasm was either reduced or completely absent, so coitus did not end in ejaculation. Sometimes patients imitated orgasm. The rate of ejaculation fell, and with heavier drug use (2 or more injections a day), and higher doses, sexual life ceased altogether.
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14 men (30%) did not report having had a regular partnership before the use of heroin. Their sexual life was promiscuous during the periods of cannabinoid use which often preceded the use of heroin. With the formation of a physical dependence on heroin, sexuality was reduced: sexual desire fell, and platonic feelings disappeared completely. The addicts demonstrated erotic behavior in the presence of other drug users, but after the injection of the drug, they did not usually engage in sexual intercourse.

9 men (19%) reported only minimal sexual experience (isolated sexual acts with casual partners) and 7 (15%) reported no sexual experience at all. These patients reported alternating periods of masturbation (1-4 times a month) when they abstained from the drug, and the complete absence of ejaculation during periods of drug-use.
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Attention must be drawn to the disparities between the patients' subjective experiences of the sexual act under the influence of drugs, and the objectively observed facts which provide evidence of the de-actualization of sexuality (separation from partners, reduced sexual activity, promiscuity, long periods of abstinence, and the disruption of the menstrual cycle). Addicts tended to give high subjective evaluations to the sexual experiences they had during periods of intoxication, and they were generally indifferent to the negative characteristics of their intimate lives.
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In the investigation there were 25 un-married couples in which both partners used heroin. Out of the 7 married couples, there was only one case in which both the husband and the wife were users. In 3 cases, only the wife used heroin, and in 3 others, only the husband. The behavior of men and women who jointly used drugs was distinguished by the absence of the close emotional attachment which is seen in 'normal loving relationships'. A relationship where both partners use drugs does not fit the category of a 'normal loving relationship' because the rate of sexual activity is usually very low, and there are no reproductive intentions.
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If we take into account that the age of the onset of heroin use is usually the same period where a young person's sexuality emerges (puberty, post-puberty, and transitional periods), then the sexological disruption in the structure of drug addiction can be seen as the result of a characteristic process: competition between the dominant motivation of libido with the motivation towards heroin use. The characteristic feature of this process is that drug use is formulated into the same pattern as sexual and erotic behavior, and eventually, sexuality is totally supplanted. This competitive relationship is shown in diagram 3 : Competition Between Sexuality and Addiction.

Diagram 3

 

Formation of dependent behavior in heroin addicts - through the competition of drug use with sexuality: 1) triggering stimulus, 2) central integration, (3-7) intermediary results, 8) acceptor, and 9) final result.
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The motive for the use of heroin is of the same category as the motive for fulfilling sexual desire (1): these are the 'triggering stimuli,' in accordance with the theory of functional systems. The experience of platonic, erotic, and sexual feelings during intoxication leads to the under-valuation of sexual behavior as a source of pleasure, because the drug reduces the pleasurable effects of sexual acts and orgasm. As a result, normative views of sexual behavior are simplified, while the compulsion to use drugs is strengthened. The subject adopts these attitudes as a result of 'central integration,' the essence of which consists in the patient's contact with a group of 'narcoticized' adolescents (the mechanism of central integration in this case is discussion). The patient then moves towards more intense drug use, either forming a relationship with another user, or separating from a non-using partner, and then beginning heavy drug-use (5). The use of heroin, in this system, is the intermediary result which appears along with the 'triggering stimulus.' This situation agrees with the theory of functional systems, where actions' results direct the further development of the system. The final result of this activity is that the drug user does not reproduce and is eliminated from the population (9).
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The competition between sexuality and the pathological system also manifests itself in the disruption of the mechanism of negative reverse linking and anticipation - the 'acceptor.' Consequently, many patients find themselves alone during the period of their illness - platonic, sexual, and erotic links with others are simply annulled.
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Note that this process leads to the formation of a characteristic sexological disorder, which can be classified as sexual reduction syndrome accompanying opiate addiction.

The structure of this disorder includes the following symptoms:

1) a fall in sexuality and a rise in promiscuous behavior
2) engaging in sexual activity after the injection of heroin, ie. After the biological motivation (libido) has been over-ridden by the pathological need for drugs
3) a high subjective evaluation of sexual relationships occurring during periods of intoxication; indifference towards the negative aspects of intimate life

In the structure of the sexual reduction syndrome, we always see a set of three symptoms. The first is a de-actualization of libido, the second, a subordination of sexual desire to the need for drugs, and the third is a failure of self-criticism (table 1).

Table 1

Symptoms	Characteristics
1. Reduced libido	Fall in the rate of sexual life, indifference to oneself as a representative of one's gender, over-emphasized/vulgarized eroticism.
2. Subordination of libido to the pathological need for drugs	Drugs have primary importance, relationships secondary
3. Failure of self-criticism	Indifferent attitude towards negative changes in intimate life

Thus, heroin addiction demonstrates the failure of both the recreational and procreative functions of sexuality. In normal people, the libido organizes behavior, leading to the development of individual personal characteristics. In the case of drug addicts, however, behavior is organized by the need for drugs, and the patient develops negative personality traits. The diagnosis of this disorder will help to differentiate patients according to the level of their addiction, and to choose the correct psycho-therapeutic tactics for treatment and rehabilitation.
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Literature

1. Anokhin, P.K. Notes about the physiology of functional systems. - M: Meditsina, 1975.
2. Vasjilchenko G. C. (ed.). General sexopathology. - M: Meditsina, 1997, pg. 486.
3. Dudko T. N., Puzenko V.A., Kotelnikova L. A. A Differentiated System of Rehabilitation in Narcology: Methodological Recommendations. - Moscow, 2001, pg. 38.
4. Ivanets N.N. (ed.). Lectures on Narcology. - M. 'Knowledge', 2000, pg. 448.
5. Koporov C. G. // Narcological Questions; 1994 No. 2, pp 27-33.
6. Sudakov K. V. A General Theory of Functional Systems. - M: Meditsina, 1984, pg. 224.
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Synopsis
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81 heroin addicts were studied - 47 men (average age 20.5), and 34 women (average age 20.9). The patients had been intravenous users for 1-3 years. All the patients were found to have characteristic changes in sexual behavior, which can be characterized as a sexual reduction syndrome. The syndrome comprises a set of three symptoms: a fall in sexual desire and in the rate of sexual activity, a subordination of sexual desire the pathological need for drugs (injection first, then coitus), and an inadequate evaluation by the patient of the negative aspects of his or her sexual life (the failure of self-criticism). The study suggests viewing the changes in sexuality during the formation of a dependence on heroin as resulting from competition between two functional systems for the results of activity: the pathological system, for the use of drugs, and sexuality, for the realization of libido. The definition of this syndrome will assist doctors providing therapy and consultation to addicts during the process of rehabilitation.
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