1. Background
In the recent decade, the explosion of using the amphetamine type stimulants, especially methamphetamine, has become a major problem in Iran (1). According to studies, non- intravenous use of amphetamines is associated with an increased risk of HIV (2). There are an association between prolonged sexual performance and the use of crystal methamphetamine (3). Numerous researches in western countries show that methamphetamine use is associated with sexual high-risk behaviors, especially in men who have sex with men (MSM) (4). From the perspective of HIV prevention, a sexual marathon, particularly if it involves prolonged anal sex, is considered high risk (5). In a study of motivations associated with methamphetamine use reported that 80% of the participants engaged in marathon sex while high on methamphetamine (6). Because of these attributes, public health officials are concerned that users may be putting themselves at increased risk of acquiring or transmitting HIV infection (7). Researches show that people who use methamphetamine may increase their sexual risk (7).
2. Objectives
Most of these studies have been done on HIV-positive MSM. There are few studies on heterosexual males, who are HIV-negative methamphetamine users (8), and current available knowledge about them is based on generalization of findings about similar substances such as cocaine. In addition, there are numerous socio-cultural determinants of sexual behavior. Till now, no study has been performed in Iran to investigate the methamphetamine-related sexual high-risk behaviors. The purpose of this research was to investigate the high-risk sexual behaviors in methamphetamine user males who sought treatment at addiction treatment centers in Tehran, Iran.
3. Patients and Methods
3.1. Participants and Plan
The participants were selected based on opportunistic sampling and a peer referral process. The participants were 35 people that 25 of them were methamphetamine user males, 5 of their sexual partners, and 5 physicians who were experienced in addiction treatment or research. The methamphetamine users were selected from three residential and outpatient addiction treatment centers. The researchers tried to select them from different socioeconomic classes. The participant physicians included a number of psychiatrists of universities, an addiction researcher, and experienced physicians. Finally, five groups of methamphetamine users, a group of their partners and 5 physicians participated in this study. The current study was performed in Tehran in 2013.
3.2. Procedure
Semi-structured in-depth interviews with the participant physicians, and focus group discussions with groups of methamphetamine users, were used as data gathering tools. The main focus of the questions was “Can you explain your sexual experiences related to methamphetamine dependency?” The interviews were performed in relaxed environments and lasted between 50 and 120 minutes. Data were collected through open-ended questions. The interviews were recorded and transcribed subsequently. The research team analyzed the transcribed text. The analysis was performed by qualitative content analysis approach developed by Graneheim and Lundman (9). The transcribed text was read and reread in order to find the main idea of each dialogue in interviews. Then units of meaning (the words, sentences or paragraphs relating to the same central concept) were considered and a number of sub-categories were developed. Finally, four categories were created. The categories were internally homogenous and externally heterogeneous. During the interview process, member checking was done. In addition, two addiction researchers performed the peer review of the analysis of transcripts, and developing subcategories, and final categorization.
3.3. Ethical Considerations
Prior to the study, the participants were told about the general nature of the study. The participants took part in the study voluntarily. They were assured of anonymity and confidentiality. It was mentioned that they were free to decline the participation at any time. An informed consent was obtained from each participant. The institutional review board of “University of Social Welfare and Rehabilitation, Tehran, Iran” approved the study.
4. Results
The methamphetamine user participants were 25 males aged 25 to 45 years (the majority of them aged between 25 and 35 years). The educational level of 40% of them was under a high school diploma, 20% of them had high school diploma, and 40% had academic education. 12 of them were unmarried, and 10 were married and 3 of them were divorced. The duration of their methamphetamine use was between less than a year and eight years (The majority of them had 2 - 5 years history of methamphetamine dependency). About 80% of them had a history of opioid dependency as well. Almost half of them reported illicit drugs' use in the previous month. In the majority of cases, this substance was methamphetamine and in other cases, the most frequently used substances were alcohol and sedative – hypnotics, respectively.
Three themes emerged from the data analysis: 1) “different attitude towards sexual behaviors” including ‘daring to do high-risk behaviors’, ‘paraphilia’, and ‘preference to have sexual relationship with drug user partners’, ‘attitude towards condom use’ and ‘methamphetamine-related desire for sexual promiscuity and various sexual behaviors;. 2) “compulsive sexual behavior” including ‘sexual compulsion and high risk sexual behavior’ and ‘sexual relationships in any places’ and 3) “health - related issues in sexual relationships, ‘inability to use condoms.’
4.1. Different Attitudes Towards Sexual Behavior
4.1.1. Daring to Do High-Risk Behaviors
Most of the methamphetamine user participants, especially those who had experienced periods of abstinence, believed that methamphetamine users tend to engage in high- risk behaviors more, during the period of its use. Also, the participant physicians believed that all high-risk behaviors (sexual and nonsexual) increase in methamphetamine users.
A 31- year- old user male: “In fact, we got a kick out of doing high risk behaviors, as the blast was actually, the fact of being dangerous.”
A 28 -year - old user male: “What were you worried about, catching AIDS or something like that? No way.”
4.1.2. Paraphilia
Changes in the sexual preference and the form of sexual behaviors were mentioned in more than half of user participants. Most of them believed that they had experienced an increase in their tendency towards voyeuristic behaviors. Only one of the user participants mentioned that he had experienced a tendency to have a same sex relationship during the period of his methamphetamine dependency. None of the user participants mentioned incestuous relationships and only three of them mentioned that they had experienced some desires for incestuous relationships.
A 20 -year - old user male: “Having sex with an old woman? I just couldn’t imagine ever doing that. It felt like there was an angle in front of me!”
A 28 -year - old user male: “I became a gay, the moment I started using meth.”
4.1.3. Preference to Have Sexual Relationships With Drug User Partners
The majority of users preferred sexual relationships with user partners because it had been more enjoyable. One of the reasons why the methamphetamine user males preferred the user females was that these women behaved seductively, and even in some cases they provide an opportunity for these men to have relationships with other women.
A 30- year - old user male: “A girl who uses stuff; it is what this story all about, give you a feeling that no other girls would.”
4.1.4. Attitude Towards Condom Use
Most of the methamphetamine users did not use a condom when they had a high-risk sexual relationship; they felt a sexual relationship with using a condom couldn’t be delightful.
A 28 - year - old user male: “You couldn't like it with a condom. Do you know what it’s like? It’s like having rice with kitchen gloves.”
4.1.5. Methamphetamine - Related Desire for Sexual Promiscuity and Various Sexual Behaviors
Most of the users believed this substance could cause various sexual behaviors and desire for sexual promiscuity. These people frequently change their partners, and they tend to have a group sex. They experienced different sexual positions, sexual promiscuity, tendency for a group sexual activity, preoccupation with sex, and voyeuristic attitudes.
A 30- year - old user male: “You would have to try different positions that you couldn’t deal with them as you are now.”
A 35 -year - old user male: “Who dares? A man likes all sorts of it and even the group type.”
4.2. Compulsive Sexual Behaviors
4.2.1. Sexual Compulsion and High-Risk Sexual Behavior
The majority of methamphetamine users said that they had become sexually compulsive; they fail to resist sexual impulses of engaging in a sex. Even if they encountered difficulty to engage in a sex, they insisted on it, and they would experience anxiety, restlessness, or irritability if they lost the chance to engage in.
A 29 -year - old e user male: “If a girl was so hot, I would say it is a shame if I don’t catch AIDS from her.”
4.2.2. Sexual Relationships in Any Places
The majority of methamphetamine users stated they had sexual relationships in inappropriate places such as cars, streets and on the roof of houses while they were high on methamphetamine.
A 29 -year - old user male: “I was with a girl in a ruin, who had run away from home and was homeless. I wanted to take her home, but I felt my mom would snitch on me, so I stayed with her in the ruin; I was terrified.”
4.3. Health - Related Issues in Sexual Relationship
4.3.1. Inability to Use Condom
The methamphetamine users mentioned they had been unable to use condom because of the methamphetamine-related erectile dysfunction.
A 33 - year - old user male: “You couldn’t use condom even you were out to use it. Most of the times, I struggled to use a condom, it wouldn’t stick.”
5. Discussion
The purpose of this qualitative study was to explore the sexual high-risk behaviors of methamphetamine user males. The study showed that methamphetamine use could increase sexual high-risk behaviors. These results are consistent with the results of studies which have done in other countries (8, 10, 11). In Iran, an opioid substitution treatment program could control the intravenous use of illicit heroin and HIV transmission. However, HIV transmission through sexual high-risk behaviors in methamphetamine users and their partners remained the main challenge (12). Amphetamines, not only through their intravenous use, but also through increasing sexual high-risk behaviors, increase the risk of HIV transmission (2). The results of this study showed methamphetamine could cause sexually high- risk behaviors in heterosexuals and this is consistent with other few studies (10). Sexual relationships with the unknown HIV status partners and anal intercourse could increase the risk of HIV transmission significantly (10). In addition, in HIV-positive people, there is higher association between methamphetamine use and sexual high-risk behaviors that could increase the risk of HIV transmission (13). Some of the participants described their sexual behaviors' essence was compulsive and some of them use the term “sexual addiction” to describe their behaviors. Other researchers reported sexual compulsion as well (14). It seems sexual addiction is not simply a subcultural behavior pattern, and it would be a biological effect of methamphetamine use (15). In this study both physicians and methamphetamine users believed that with a few months of abstinence, the methamphetamine-related sexual behaviors would change to normal, the intensity of sexual desire would decrease, and the sexual profile would improve. The negative effects of methamphetamine on decision-making (16), and control of sexual behavior (17), may be other reasons for changes in sexual behavior. Therefore, the methamphetamine users are unable to inhibit the behaviors that are not socially and morally desirable. In the present study, the methamphetamine users often were self-medicated with sildenafil. According to studies, taking medications like sildenafil is more common in methamphetamine users who report engaging in sexual marathon (5). The people who take the combination of methamphetamine and Viagra have more sexual partners (18), engage in sexual high- risk behaviors (19), and this combination is strongly associated with a much higher prevalence rate of HIV (20). In addition, according to some studies methamphetamine could affect the sexual orientation. There is an association between methamphetamine use and attraction to the same sex relationships in men (5). In the present study, most of the users denied any changes in their sexual orientation. However, it could be due to the small sample size, and the social stigma of homosexuality in Iran. There are few studies on sexual marathon (a prolonged sexual activity that last hours in a session) in methamphetamine users. The main mechanisms contributing to this phenomenon include increased sexual drive and behavioral disinhibition (2). In Semple et al. study, more than 80% of MSM users reported engaging in marathon sex while they were high on methamphetamine and users who took sildenafil were six times more likely to have participated in marathon sex (5). Condom use is one of the most common harm reduction strategies and its use is highly dependent on the attitudes of people towards it (21). Illicit drug use is associated with an increase in high-risk behaviors and impaired judgment. Therefore, methamphetamine users have a lower tendency to use condom (13). Another important point is that methamphetamine users may experience impotence, in spite of preserved or even increased sexual desire. Their inability to use condom as a result of impaired erection, could result in a risky sexual behavior. The results of the present study demonstrate methamphetamine-related sexual promiscuity. This is consistent with other studies such as the study of Liu et al. that showed having multiple sexual partners is more common in heterosexual methamphetamine users (22). Also, the sex workers who use methamphetamine have more partners and have more relationships with methamphetamine users (23). In the present study, methamphetamine users tended to have group sex and sexual activity in open spaces. These changes are late consequences of methamphetamine use and would alleviate during abstinence. According to the qualitative study performed by Reback et al. the number of sexual relationships with unknown partners decreased during the abstinence phase and the persons demonstrated stronger commitment to their partner (24). Because of the type (qualitative) and limitations of this study, we cannot determine exactly the pattern of sexual high-risk behaviors among the participants; so, we suggest future quantitative studies about this issue.
