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��ࡱ�>��	������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������	��09Xbjbj$$	4�F|F|9P�������_____����ssss|�dsG%~S��������$�$�$�$�$�$�$$�'�g*D�$_���$__���%���_�_��$��$��::#,�#������z��sl�s.f#
�$%0G%p#.�*.��*�#�*_�#��$�$�G%���������������������������������������������������������������������*	%:	Sexual Activities in Methamphetamine Users; A Qualitative Study on a Sample of Iranian Meth-Users in Tehran

Masoomeh Maarefvand*, Azarakhsh Mokri**, Ahmad Danesh***, Hamed Ekhtiari****
* Department of Social Work, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
** Iranian National Center for Addiction Studies (INCAS), Tehran, Iran
***Regional Knowledge Hub, and WHO Collaborating�Centre�for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
**** Iranian Institute for Cognitive Sciences Studies (ICSS), Iranian National Center for Addiction Studies (INCAS), Translational Neuroscience Program, Tehran, Iran. (Corresponding Author)

Abstract
Introduction: It is known that psychostimulants including methamphetamine have great impact on sexual behaviors. Since the level of methamphetamine use has recently surged in Iranian population, there are concerns that this may drive up sexual risky behaviors among the users. The result could shift the dominant mode of HIV transmission from drug injection to sexual contact in the country. The current study, which is the first one in Iran, was conducted to restate the threat to the decision makers in the country.
Materials and Methods: A reaffirm qualitative study was conducted through three Focus Group Discussions (FGDs) among 50 (30 males and 20 females) abstinent methamphetamine users in Tehran. Data analysis was done by thematic framework analysis method. Member-checks and review and discussion of the final set of themes was used to ensure the trustworthiness.
Results: The results highlighted the effect of methamphetamine use on sexual drive, desire, and performance. Methamphetamine users reported intense sexual desire and arousal, in addition to increased sexual pleasure. Methamphetamine users expressed decreased sexual inhibition, risky behaviors, homosexual tendencies, and compulsivity in their sexual activities. Quite the opposite, data showed long term methamphetamine abuse was associated with sexual dysfunction including problems in erection and ejaculation as well as diminished desire and interest and higher levels of compulsivity in sexual behavior. 
Conclusion: The findings reiterate concerns about the effect of methamphetamine on sexual behaviors. The methamphetamine driven bizarre sexual behaviors can cause a combination of disinhibited sexual activities that under normal conditions would have regarded inappropriate and taboo by individuals and their cultural context. Further studies are needed to explore the prevalence, quantitative features and typology of these behaviors among methamphetamine users in Iran. 

Key words: Methamphetamine, Risky Behavior, Sexual Activity, Iran.


Introduction: 
According to the 2013 World Drug Report, seizures and consumption level of Amphetamine-type stimulants are increasing. Middle East and North Africa (MENA) region is among those that is being reported to have high amount of amphetamine seizures. This could underscore the possibility of high prevalence of psychostimulant users in this region (1).
Methamphetamine is a synthetic psychostimulant with sympathomimetic and cytotoxic effects. Because of these effects, addicted individuals may experience wide range of physical and mental disorders. Abnormal sexual behaviors are among those experiences that need special attention, specifically from the public health perspective. It is widely recognized that Amphetamine-type stimulants, including methamphetamine, can promote high-risk sexual behaviors such as unprotected sexual contacts and multiple sex partners (2-4). This could be supported by looking into the effect of abstinence from methamphetamine on the level of engagement in high-risk sexual behaviors (5-6). The basis for this association could be reasoned by pharmacological, instrumental, trait � based, and situational explanations (7). The unsafe sexual practices and the multiple sex partners can put methamphetamine users at increased risk for HIV infection and other Sexual Transmitted Infections (8). This is exceedingly important in countries that the prevalence rate of methamphetamine users is high or is in rise.
Despite of awareness about the association between methamphetamine use and high-risk sexual behaviors, few studies in the MENA region have examined the impact of methamphetamine use on sexual activities. This is highly important, when it is needed to keep decision makers sensitized on the matter.  
In order to examine the effect of meth use on sexual activities, we have conducted several focus group discussions in samples of meth users referring to two harm reduction facilities in Tehran. The notion for conducting this study was concerns about increasing use of methamphetamine in Iranian youth population, which may fuel HIV transmission by high-risk  sexual contacts. This is could happen in an era that less than twenty percent of young people aged 15 � 24 ( 15.5% for male and 17.5% for female) having correct knowledge about HIV prevention (9).
Materials and Methods: 
Using a purposive sampling, 50 abstinent methamphetamine users (30 males and 20 females) referring to two NGOs in Tehran for treatment (Rebirth Society Organization in Verdij and Chitgar Residential Centers  and Congress 60 in its main office) joined the study to share their personal experiences. Three rounds of focus group discussions (FGDs) were conducted (two in males and one in females) to explore the matter. Verbal consents were obtained from the participants before each FGD. 
Probing questions focused on the impact of meth use on sexual drive and desire, performance, disinhibition, risk taking, and compulsivity. Because of probable discussions about taboo subjects (sexual behaviors), research team avoided tape recording during the FGDs. Detailed notes were taken  and driven comments from the notes were written on a piece of paper to put on a wall for further discussion. During the FGDs and tea-breaks, clients could review the responses/comments on the wall and add any related comment(s). After each session, reflections of participants were written down as quotations immediately. Two authors reviewed the quotes and discussed about themes. Sampling was stopped when the saturation confirmed by research team. In order to achieve an overall understanding, all notes were read several times. Initial analysis of the notes resulted in some themes and categories that originated from the FGDs and intent of the study. We made repeated comparisons and modifications to achieve similarities in categories. To ensure trustworthiness of the findings, member-checks method was used to confirm credibility of the responses. Furthermore, the set of themes is reviewed and discussed by two authors several times in order to finalize it.  

Results: 
As it was planned, three FGDs were conducted among abstinent meth users. Table 1 shows demographic characteristics of the participants.

Table 1: Demographic characteristics of the participants disintegrated by recruitment site
NGOs (Centers)Rebirth Society Residential CentersCongress 60Verdij ChitgarNumber of clients122018GenderMaleFemaleMaleMean age (SE)31.1 (1.8)29.1 (1.0)31.3 (1.4)Marital status Married5512Single435Divorced271Separated110Widow/Widower010Temporary marriageN/A3N/AYears of education (SE)12.4 (0.9)10.3 (0.8)12.7 (0.7)
During the interview, participants were questioned about their drug use and sexual behaviors in the past. Table 2 shows collected information relevant to these questions broken down by recruitment site.  
Table 2: Drug abuse and sexual history of the participants disintegrated by recruitment site 
NGOs (Centers)Rebirth Society Residential CentersCongress 60Verdij ChitgarPast history of opium use61118Past history of heroin/crack use2167Mean age of meth use (SE)23.4 (1.4)24.6 (1.2)27.2 (1.5)Mean duration of meth dependence in years (SE)3.7 (0.6)4.5 (0.8)2.9 (0.7)Mean days of meth use in the last month (SE)23.8 (3)21.3 (2.9)25.5 (2.2)Ever had sex101517Ever had sex with non-spouse61012Mean number of sexual intercourse in the last month (SE)*7 (2.1)9.7 (3.5)8.7 (3.3)Number of participants did not used condom in the last month**037*Total number of sexual acts in recent month ranges between 0 to 20 acts for Verdij group and 0 to 60 for Chitgar
**Among those who had sex in the last 30 days

Using the main questions and follow up probing questions, responses were collected and relevant themes were explored. The themes could be supported by quotations from the responders. 

Impact on sexual desire and pleasure:
A cluster of replies was focused on meth�s impact on the desire stage of sexual act. Participants unanimously expressed that in early and mid stages of meth use, it increases sexual desire and prompts users to have sex. Meth use extremely enhances sexual pleasure and, as the result, intercourse becomes rewarding.    
Male, 23 years old, Single
"Everybody looks beautiful and arousing"
Male, 27 years old, Married
�You feel that you want to have sex with many people�
Male, 31 years old, Married
 �Meth increases your fantasy about sex ... If you have fantasized about something and then perform it, it becomes even more pleasurable�.
Impact on sexual performance
Most participants emphasized the impact of meth use on their sexual performance. Although the answers were less unanimous, it was repeatedly stated that meth has different impact on performance depending on the stages of abuse. Beneficial effects appear in the early stages, but at later stages the effect is usually negative and associated with impotence, decreased hardness of the penis, impaired or spontaneous ejaculation, and loss of pleasure in climax. 
Male, 30 years old, Married
�At beginning you get a boost in your performance�
Male, 27 years old, Married
�You are able to have sex after ejaculation and get to orgasm again without delay or a gap�  
Female, 25 years old, Single
�You have great desire for sex but you can�t do it�
Impact on sexual assertiveness and lack of inhibition
Meth was claimed to increase sexual assertiveness and the power to negotiate and demand sex from partners and other people. Participates stated that it enabled them to persuade or even deceive people to comply with their sexual demands. It would give them a sense of prowess and self-esteem. They would set aside concerns and hesitation and make clear straight forward demands, whereas, in abstinent mode they would be shameful to make such recommendations. Sexual innuendo with strangers and colleagues and family members were facilitated. 
Male, 32 years old, Divoeced
�I could set aside laws and regulations for sex�
Male, 31 years old, Married
�I would do anything to get sex and could go any far� 
Male, 28 years old, Single
�You get heightened self-esteem when it comes to women ... You are able to �con� women into sex�.
Engaging in unusual practices and reckless and taboo acts
One major feature that constantly emerged in the discussion groups was meth capability to encourage people to perform unusual and usually high-risk acts along with lack of shame or remorse. Some claimed that all unusual acts must have been fantasized before and you should have an inherent, though concealed predilection toward them. For example, �you must have latent homosexual feeling in order to perform them under meth. Meth only releases your fantasy world�. Others stated that de novo fantasies and acts totally alien to the individual might appear.
Male, 27 years old, Married
�You find great interest in group sex and orgies ... and you might perform sex with same sex people� 
Female, 24 years old, Single 
�You like to perform sex in unusual and inappropriate locations and never ask your partner to use condom".
Sex becomes compulsive
An important feature that emerged from the content of the focus group discussions was the compulsive nature of sexuality. It was stated that after meth use and during sexual pleasure seeking through meth, sexual urges become more and more irresistible and compulsive. Clients feel on the edge and forced to perform sex otherwise tension is built up and individuals feel irritable, frustrated and depressed. After succumbing to the urges, they feel guilty and ashamed. Meanwhile sexual issues become a cornerstone of their lives. Many stated that after long-term meth use, nothing except sex makes sense and the final point to meth abuse is pure sexual preoccupation. They have trouble concentrating on anything other than sex and it centers the world of the addict. 
Male, 26 years old, Married 
�Despite fatigue and physical discomfort I insisted on continuing to have sex�, 
Female, 23 years old, Single 
�Sex was not for pleasure but for giving me comfort and relaxation ... I needed to perform sex in order to return to normal life�
Male, 41 years old, Married 
�If I failed to have sex I became angry and very frustrated� 
The above-mentioned issues clearly show that sex becomes compulsive and pursued not purely for sake of its pleasure but compulsively to decrease tension and alleviate negative mood.

Sexual pleasure as a reason for meth use
Another topic, which was closely related to the study objectives and covered during the FGDs, was the sexual pleasure as a reason for meth use. A few clients indicated that their first use or motivation for use was sexual issues.
Male, 34 years old, Married
�... I forced my spouse to use meth to make her more aroused and sexually disinhibited�
Male, 26 years old, Married
�If I used meth, even if my partner did not use meth, she became more disinhibited and gradually more promiscuous"
Male, 23 years old, Single
�Before taking meth I must be in the sexual �phase� and fantasize about it otherwise I wouldn�t feel much of its impact ... you must anticipate sexual effects in order to experience them�.
 
Discussion: 
The findings of this study showed the effect of methamphetamine use on high-risk sexual behaviors. A wide range of effects from heightened sexual desire and pleasure to increase in the number of sexual acts were expressed by the participants due to methamphetamine use. Our results showed that methamphetamine could promote peculiar sexual behaviors such as lack of inhibition in sexual act and engagement in unusual sexual practices. According to the responders, uncontrolled sexual acts could become more compulsive in the long term. Such a combination can lead to practices, which under normal conditions would have regarded inappropriate and taboo by individuals. 
Users often reported having numerous sexual partners and less likely to use protection/condom in their sexual acts, a finding that is consistent with previous studies (3, 10). In addition, the respondents expressed that long term methamphetamine use is associated with sexual dysfunction including problems in erection and ejaculation as well as diminished desire and interest in sex. Findings of the study, which were similar to the findings of previous studies, raised concerns about the effect of methamphetamine on sexual behavior norms of the users. This may put the users at higher risk for HIV and other Sexual Transmitted Infections. The process could become more complicated, when cultural norms of the society hinder the users from seeking counseling and medical cares. It is more distressing, when it is reported that less than 20 percent of young generation in the country both correctly identify ways of preventing the sexual transmission of HIV and reject the major misconceptions about HIV transmission (9).
An important issue is that meth must work in accordance with a socio-cultural belief system to affect sexuality. Meanwhile, people in the context and not using meth, as abstinent partners of meth users, feel sexual effects as well. It seems a part of the effects is rooted in the belief system and context and is contagious as well.
Future studies should focus more on measuring the effect of methamphetamine use on high risk sexual behaviors and finding solutions/interventions for treating the affected cases. More specifically, the works should be focused on the methods of measurement and ways of intervention. Defining the prevalence of methamphetamine use and existence of such high risk behaviors among methamphetamine users are other areas of studies that needed to be explored.     
We acknowledge that the study has its limitations, which are come in qualitative studies. These data are coming from a sample of methamphetamine users referring to three treatment centers in Tehran, which may not necessarily be representatives of meth users in the country. As the collected information on sexual behaviors is self reported, the findings may underestimate the actual sexual risk behaviors in the respondents. This is mostly due to the stigma that is attached to these behaviors.
Conclusion: It seems that the association between methamphetamine use and high risk sexual behaviors is tight. Moreover, it is said that a small percentage of young generation has correct knowledge about ways of preventing sexual infections. Therefore, the methamphetamine driven bizarre sexual behaviors in combination with lack of correct knowledge about ways of preventing sexual infections is a real threat for further expansion of HIV epidemic in the country.  Further studies are needed to explore the situation and look for solutions to mitigate the threat in the country. 

Acknowledgements
We would like to thank two NGOs; Rebirth Society and Congress 60 and their direct managers Mr. Abbas Deilamizadeh and Mr. Hossein Dezhakam for helping us to run FGDs. We would also like to thank the FGD participants that helped us kindly during the study. Authors declare no conflict of interests.








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