Abstract
Sexualized drug use (SDU) is an umbrella term that is used to refer to sexual activities that are performed while under the influence of drugs. Such drugs are used with the intent of embellishing one’s sexual performance. However, this has culminated in Sexually Transmitted Infections (STIs) along with compromised sexual and reproductive health and rights (SRHR) outcomes. This article aims to describe the main types of drugs used to influence sexual activities, the underlying drivers of sexualized drug use and their implications on physiological, psychological, and sexual health. The global and local evidence has demonstrated the increasing burden of SDU among various populations, specifically women and marginalized, vulnerable groups. This phenomenon is rooted within diverse social and sexual contexts such as the need for community belonging, peer pressure, economic gain through sex work, augmenting sexual performance and proclaiming masculinity and femininity. This has led to elevated risks of unprotected intercourse, multiple sex partners and coercive sex. Countries like Indonesia and Vietnam have piloted harm reduction outreach programs which showed promise, therefore similar models after considering cultural contexts could be followed in Bangladesh.
Acknowledgements
We acknowledge the authors for their contributions to the paper. Additionally, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) acknowledges the Governments of Bangladesh and Canada for their core/unrestricted support.
Introduction
Drug use is a complex phenomenon that embodies a multitude of socio-cultural contexts and implications. This is particularly applicable for SDU, which is an umbrella term used to “refer to sexual activities whilst under the influence of a wide range of drugs and substances”.1 This term is not used interchangeably with chemsex, which is defined as the use of drugs to “initiate, enhance and prolong” sexual intercourse.2 While the latter highlights drug use as an intentional proponent to sexual activity, the former focuses on the circumstances where sexual activity incidentally occurs amid the use of drugs.1 Chemsex is a subset of SDU that includes the drugs like methamphetamine, gamma-hydroxybutyrate (GHB)/gamma-butyrolactone (GBL), ketamine, cocaine, and mephedrone; The broader SDU spans a wider range of substances, which includes amyl nitrates (poppers), cannabis, etc.2 (Ref-Table 1).
Figure 1: Drugs used in sexualized settings
SDU has become a burgeoning public health concern, particularly over the last decade. This is primarily attributed to its propensity to contribute to higher levels of unprotected sexual activity, which could potentially elevate transmission of HIV and other sexually transmitted infections (STIs) like chlamydia, syphilis, gonorrhea, etc.3 Amongst women, this raises the risks of compromised sexual and reproductive health and rights (SRHR) outcomes such as unintended pregnancies, reproductive tract infections, etc.3 In addition, the evidence revealed that SDU use among women is mostly a product of gender-based oppression, rather than a phenomenon where women choose to partake in drug use in order to increase their sexual performance.4 These circumstances underscore the need for scientific analysis and discourse about the underlying contexts and implications of SDU, which may or may not include chemsex. Therefore, this article aims to describe the underlying drivers of SDU, as well as their implications on physiological, psychological, and sexual health.
Types and Nature of Sexualized Drugs
Each drug carries a generic drug name, along with a set of street names (although this varies depending on the cultural context), based on the community in which it is situated. These drugs embody their own preparation and route of administration. Each drug has its duration of action- in terms of how long it takes to take effect, as well as its own set of desired effects. The key groups of sexualized drugs include the following:
Table 1: Generic and street names of drugs
| SL | Generic name of drug | Street names |
| 1 | Methamphetamine hydrochloride | Crystal meth, batu, blade, ice, yaba, baba, guti |
| 2 | Mephredone | Meow meow, m-CAT, Bounce, Bubbles, Mad cow |
| 3 | Gamma hydroxybutyric acid/gamma butyrolactone | GHB, G, GBL, salty water |
| 4 | MDMA | Ecstasy, Molly |
| 5 | Amyl nitrate | Poppers, jungle juice, liquid gold, rush |
| 6 | Ketamine | Special K, KitKat, Super K |
| 7 | Cocaine | Blow, Coca, Coke, Snow, flake |
| 8 | Cannabis | Marijuana, Dope, Pot, Mary jane, weed, gunja |
| 9 | Viagra | Blue diamond, Vitamin V, The blue pill |
Global and Regional Scenarios of Sexualized Drug Use
The prevalence and patterns of drug use in sexualized settings vary across different countries and geographical regions. According to estimates of the most recent world drug report by United Nations Office on Drugs and Crime (UNODC), 36 million people have used amphetamine-type stimulants, of which an overwhelming majority were practiced in sexualized settings.5 Notably, 45% of the users were women, yet their progression towards drug use disorders was found to be worse than their male counterparts and they were disproportionately affected by healthcare and treatment access barriers.5 The global manufacture, trafficking, and usage of methamphetamine remained skewed towards the East and Southeast Asian regions and North America, with both of these regions constituting almost 90% of the global methamphetamine seizures between 2017-2021.5 The same UNODC report indicated that the non-medical use of ketamine has recently emerged in East and Southeast Asia.5 Moreover, the use of new psychoactive substances has become a burgeoning trend worldwide, particularly in Central Asia and Eastern Europe, along with a few other regions.5
The existing literature base is predominantly focused on selected vulnerable, marginalized populations which include gender and sexually diverse people. For example, a systematic review revealed that 17.0-38.9% of these population groups partook in chemsex mainly with methamphetamine.2 Moreover, a scoping review based in Asia and the Pacific indicated that SDU ranged from 3.6-91.2% in this region.6 However, there is a dearth of epidemiological evidence about the situation of SDU in Bangladesh even though the qualitative evidence indicated the use of methamphetamine (locally known as Yaba) among gender and sexually diverse populations.7
Table 2: Types and nature of sexualized drugs
| Drug name | Pharmacological properties (Preparation, route of administration and duration action) | Desired effects |
| N-methyl-1-phenylpropan- 2-amine (Methamphetamine hydrochloride) | Clear chunky crystals Smoked through a pipe, snorted, or stirred with water and injected or anally inserted Duration: Half-life ranges from 2-4 hours | Powerful psychostimulant Intense sexual stimulation and lowered inhibitions |
| 4-methyl methcathinone (Mephedrone) | Swallowed as a tablet, snorted in powder form, injected (known as slamming), or taken rectally (known as booty bumping) Duration: 2-3 hours (orally or nasally), 30 min (intravenously) | Psychostimulants Increase libido and sexual performance |
| Gamma Hydroxybutyric acid/Gamma butyrolactone (GHB/GBL) | White crystal powder, salts (potassium or sodium), swallowed in small liquid doses or mixed with soft drink; less commonly injected Duration: Between 5-25 mins to kick in, lasts for 2-4 hours | Lowered inhibitions and increased sex drive Relaxant to make receptive anal sex easier and more pleasurable |
| 3,4-methylenedioxy methamphetamine (MDMA) | Commonly found as tablet or capsule but can also be powder or crystal MDMA tablet almost always orally (ingested), but powder could also be snorted, inhaled or injected. Duration: 4-6 hours | Cause deeply intense feelings of attachment Perceived feeling of enhanced sexual performance |
| Amyl nitrite (Poppers) | Volatile liquid, oily liquid usually inhaled Duration: Occurs after 15 seconds, lasts up to 3 mins | Sexual arousal Enhance sexual experiences and relaxing anal muscles |
| 2-(2-chlorophenyl)-2-(methylamino)-cyclohexanone (Ketamine) | Powder or liquid usually snorted, smoked or mixed in drinks Duration: 0.5-2 hours intramuscularly, 45-60 mins via insufflation, 1-6+ hours orally | Psychostimulant effect |
| Benzoylmethylecgonine (Cocaine) | White, crystalline powder, snorted or rubbed into the gums, injected or smoked Duration: 20 to 90 minutes | Increased sex drive |
| Delta-9-tetrahydrocannabinol (Cannabis) | Dried leaves, liquid, extracts Smoked, eaten or vaporized Duration: Within secs to few mins, maximum reached after 15-30 mins | Increased libido |
| Sildenafil citrate (Viagra) | Tablet, mouth spray, taken orally or sublingually Duration: up to 4 hours | Increases libido Improves sexual performance |
Contexts and Drivers of Drug Use
According to a global mixed methods systematic review conducted on vulnerable populations, including adolescents, youth, and marginalized populations, SDU was attributed to a variety of interpersonal and psychological contexts, which are not necessarily limited to increasing sexual performance.8 For example, the qualitative component of this systematic review revealed that drugs were often consumed when dealing with stressful events or emotional agony, or when succumbing to peer pressure or their personal need for a sense of community belonging.8 Specifically, participants from several studies cited that their drug use behaviors stemmed from the need for inclusion with their social circles and to fulfill their craving for social connectedness with their peers.8 This motive particularly resonated among adolescents and youth who were more prone to feelings of loneliness and marginalization, thus compelling them to self-medicate with methamphetamine and other similar drugs.8 Many individuals and communities cited that they were introduced into the SDU culture under duress of their partners.2,8 This uncovers the dimension of gender and intimate partner dynamics, where the subservient partner in the relationship feels compelled to appease their partner.
Yet some of the drivers of SDU were entirely sexual. For example, the literature alluded to the pervasiveness of SDU to augment their sexual performance.2,8 Thus, many sex workers opt for using drugs, namely various forms of methamphetamine, for increasing their sexual capacity and, consequently, garnering more income. This unravels the dimension of poverty and economic gain, where these populations often originate from circumstances of financial distress, and they perceive drug use as their solution to emerge out of poverty.8 The literature also uncovered various dimensions of masculinity and femininity in terms of SDU, a phenomenon that permeated both in heterosexual and homosexual partnerships. Such as, in the case of men or masculine partners, drugs often elevated their sexual performance, thus allowing them to showcase their masculinity, which was denoted by their ability to perform multiple rounds of sex, sometime even with multiple partners.9
Implications of Sexualized Drug Use
The literature revealed that SDU engendered physiological and psychological harms on various population groups, primarily attributed to its likelihood of increasing risky sexual behaviors. Specifically, due to the sexual disinhibition and hypersexuality incurred by drugs, studies reported that drugs increased the odds of violent or coercive sex, unprotected sex, multiple sex partners, etc.10 A study based in the UK pinpointed a correlation between sexualized drug use and group sex, thus increasing rates of unprotected sex.11 The phenomenon of unprotected sex was also corroborated by other studies.1 Several studies, both globally and regionally, revealed that SDU predisposed individuals towards violent and coercive sexual behaviors, to the extent of even committing rape. At the local level, a qualitative study by Khan et al. (2020) in Bangladesh indicated sexual coercion of participants to the extent of threats or blackmail.12
SDU is also linked to a diversity of global health repercussions which may not always necessarily be linked with sexual health. For instance, the global evidence, including a recent systematic review, established the association of SDU with health symptoms including depression, anxiety, and psychotic symptoms.13 A German survey about sexualized drug use revealed that mean scores for somatization, depression, and anxiety were significantly greater among those who participated in SDU.14 The limited body of evidence in Indonesia and Malaysia revealed the relationship between SDU and mental health issues.15 However, even though the qualitative evidence alluded to the elevated rates of unprotected intercourse among selected groups of marginalized, vulnerable populations in Bangladesh,12 there is scarce research concerning the other health implications of this phenomenon.
Interventions with Sexualized Drug Use
According to the latest harm reduction report, there are a total of 105 countries that have explicitly referenced harm reduction in their national policy documents, most of which are based in higher-income countries with more radical drug use laws.16 This suggests that more work needs to be done in terms of supporting harm reduction-focused policies as opposed to punitive legal policies. Specifically, many countries around the world, such as Bangladesh, Singapore, China, Malaysia, etc. have prohibited drug use to the extent of inflicting the death penalty.16 Nevertheless, some countries within the Asia and Pacific region with similar socio-legal contexts of drug use pursued evidence-based models that held promise in their respective locales. For instance, in Jakarta and Makassar/ Madagascar, Indonesia, an outreach program pioneered by Karisma Foundation instituted the distribution of safer smoking equipment to tackle the harms associated with stimulant drug use. This has documented notable success in terms of fostering community engagement and awareness.16
Similarly, two main metropoles in Vietnam- Ho Chi Minh City and Hanoi, have piloted outreach programs for combatting the risks of methamphetamine use by rendering various services such as mental health screening, harm reduction counseling, and referrals to psychological management and rehabilitative services.17 Surprisingly, Iran has a progressively reformed drug law relative to its conservative socio-religious context; they have piloted an approach where methamphetamine harm reduction services have been integrated within the existing opioid substitution therapy program.18 However, against the global backdrop, these interventions are few and far between, thus highlighting the need for a greater number of harm reduction-focused and people-centered interventions that challenge the punitive environment towards drug use.
Ways Forward for Bangladesh
In June 2022, UN rights experts called for the end of the “war on drugs” by postulating that, “Data and experience accumulated by UN experts have shown that the ‘war on drugs’ undermines health and social wellbeing while failing to eradicate the demand for illegal drugs and the illegal drug market.” 19 Thus, this statement alludes to the need for creating an enabling environment that does not necessarily promote drug use but strives to intervene in the public health aspects of drug use. This can be achieved by prioritizing the individuals’ physical, mental, and social health and well-being at the forefront of existing and future interventions, rather than viewing these populations as the public enemy. In order to fulfill these core principles, it is imperative to develop and implement an intervention that not only underpins the harm reduction aspect of sexualized drug use, but also addresses the other physical co-morbidities that could arise from drug use. A robust treatment and referral system needs to be in place for physical and mental health conditions, so that individuals’ needs are addressed in a holistic, people-centered manner.
Before mobilizing an intervention of this magnitude, it is crucial to conduct research that systematically measures and explores the burden, dynamics, contexts risk profiles and priority areas for sexualized drug use. Ideally, this needs to be conducted in the form of mixed methods research that ultimately segues into an intervention design workshop and a piloting of the intervention model. If such a model is piloted, it can be refined and scaled up over time, while concurrently creating an enabling environment alongside stakeholders from the policy planning structures.
Authors of this article
1. Dr. Sharful Islam Khan, MBBS, MHSS, PhD, Scientist and Head, Program for HIV and AIDS, Health Systems and Population Studies Division, icddr,b, Email: sharful@icddrb.org
2. Dr. Golam Sarwar, MBBS, MPH, PGD (SRHR), PhD candidate, Assistant Scientist and Program Manager, Program for HIV and AIDS, Health Systems and Population Studies Division, Email: golam.sarwar@icddrb.org
3. Dr. Samira Dishti Irfan, MPH, Assistant Scientist, Program for HIV and AIDS, Health Systems and Population Studies Division, Email: samira.dishti@icddrb.org
References
1. Hibbert, M.P., et al., A narrative systematic review of sexualised drug use and sexual health outcomes among LGBT people. International Journal of Drug Policy, 2021. 93: p. 103187.
2. Maxwell, S., M. Shahmanesh, and M. Gafos, Chemsex behaviours among men who have sex with men: a systematic review of the literature. International Journal of Drug Policy, 2019. 63: p. 74-89.
3. England, P.H., Sexually transmitted infections and chlamydia screening in England, 2016. Health Protection Report, 2017. 11(20): p. 1-20.
4. Mehmandoost, S., et al., Sexualized substance use among female sex workers in Iran: Findings from a nationwide survey. Substance use & misuse, 2023. 58(2): p. 298-305.
5. UNODC, World Drug Report 2023. 2023, United Nations Office of Drug and Crime: Geneva, Switzerland.
6. Kelly-Hanku, A., A qualitative scoping review of sexualised drug use (including Chemsex). 2021.
7. Khan, S.I., et al., Understanding the reasons for using methamphetamine by sexual minority people in Dhaka, Bangladesh. International Journal of Drug Policy, 2019. 73: p. 64-71.
8. Lafortune, D., et al., Psychological and interpersonal factors associated with sexualized drug use among men who have sex with men: A mixed-methods systematic review. Archives of Sexual Behavior, 2021. 50(2): p. 427-460.
9. Halkitis, P.N., K.A. Green, and L. Wilton, Masculinity, body image, and sexual behavior in HIV-seropositive gay men: a two-phase formative behavioral investigation using the internet. International Journal of Men’s Health, 2004. 3(1).
10. Hibbert, M.P., et al., Psychosocial and sexual characteristics associated with sexualised drug use and chemsex among men who have sex with men (MSM) in the UK. Sexually transmitted infections, 2019. 95(5): p. 342-350.
11. Wong, N.S., et al., Delineation of chemsex patterns of men who have sex with men in association with their sexual networks and linkage to HIV prevention. International Journal of Drug Policy, 2020. 75: p. 102591.
12. Khan, S.I., et al., The effects of methamphetamine use on the sexual lives of gender and sexually diverse people in Dhaka, Bangladesh: a qualitative study. Archives of sexual behavior, 2021. 50: p. 479-493.
13. Tomkins, A., R. George, and M. Kliner, Sexualised drug taking among men who have sex with men: a systematic review. Perspectives in public health, 2019. 139(1): p. 23-33.
14. Bohn, A., et al., Chemsex and mental health of men who have sex with men in Germany. Frontiers in psychiatry, 2020. 11: p. 542301.
15. Nevendorff, L., et al., Prevalence of sexualized drug use and risk of HIV among sexually active MSM in East and South Asian countries: systematic review and meta‐analysis. African Journal of Reproduction and Gynaecological Endoscopy, 2023. 26(1): p. e26054.
16. Harm Reduction International, Global State of Harm Reduction. 2022, Harm Reduction International.
17. Mainline, Harm reduction for key populations who use methamphetamine in Vietnam: An acceptability and feasibility evaluation report. 2021.
18. Radfar, S.R., S. Mohsenifar, and A. Noroozi, Integration of Methamphetamine Harm Reduction into Opioid Harm Reduction Services in Iran: Preliminary Results of a Pilot Study. Iran J Psychiatry Behav Sci, 2017. 11(2): p. e7730.
19. UN, Ending the war on drugs. 2022, United Nations