SEXUALITY OF HEROIN ADDICTS:
ASPECTS OF STUDIES
Research Center on Addictions
Originally published in:
European Jornal of Medical Sexology:
2. General Methodology
3. Methods and Materials
4. Results and Discussion
A total of 81 heroin addicts were examined.
These were 47 males (58% of the total number of patients),
aged on average 20.5 (17 – 27) years, and 34 female
patients (42%), aged on average 20.9 (18 – 24) years.
The patients had 1 to 3-year-long experience of heroin
Using sexologic categories differing in social, personality,
and biological sexuality levels, and also using the
theory of functional systems, helped reveal damaged
sexuality in our patients. Not only higher functions,
but also biological functions were affected in our patients:
men had decreased libido, while women demonstrated upset
menstrual cycle. A specific phenomenon is described:
the rhythm of sexual activity in men decreases with
increasing intensity of heroin use. The reproductive
level in this social group is 12%; prostitution, 41%.
It is suggested that formation of heroin dependence
be considered as competition of two functional systems
for the result of action: pathological system competes
for heroin use, while sexuality competes for realization
It is recommended that the program for rehabilitation
of drug addicts includes sexological consultation, special
course in sexologic education, and training. The program
may be accomplished in three stages, namely, the diagnostic
stage (lasting for 1 – 2 weeks), the active training
stage (2 – 3 months), and the stage of patient withdrawal
from the program with control of treatment result (to
physician’s discretion). The program should be conducted
by a pair of specialists in psychotherapy, comprising
a general physician and a psychologist.
Working out new psychotherapy programs to fight heroin
addiction is a pressing problem because of the tendency
to recurrence of the disease: once an individual addicts
to heroin, he or she often resorts to the drug again on
completion of specific treatment at a clinic or a rehabilitation
center. Heroin addiction incidence in Russia increases
at an amazingly rapid pace and specialists dare define
the situation as close to epidemic. Hence the importance
of working out new approaches to rehabilitation of heroin
Addicted individuals are a special group of community,
characterized by high diversity as regards their social
origin, walk of life, income, and other characteristics.
What is common of them is behavior oriented at drug abuse.
This behavior is a peculiar stereotype characterized by
specific episodes of cyclic addiction, which come in sequence
one after another. Brief description of the stereotype
agrees with the concept of the triggering mechanism of
pathological addiction (Friedman L. at al., 1998).
An addict develops the irresistible desire to use heroin
and starts seeking for the drug; this may be a time-taking
period. If heroin is unavailable, the addict usually develops
the state of affect, which is followed by symptoms of
the abstinence syndrome. As soon as the drug is scrounged,
a short ritual of preparing the dose follows, which finally
ends with injection of the drug. This is accompanied by
a marked emotional stress. Shortly after the injection
(or virtually during the intravenous injection) the addicted
individual develops the condition which, as a matter of
fact, is the purpose of dependent behavior: the drug produces
a psychosomatic action and the patient falls into ecstasy
attended by a pronounced vegetative reaction. This state
lasts from few minutes to dozens of minutes, after which
the addict feels euphoria for a few hours. This period
is characterized by decreased criteria for subjective
estimation of own behavior and reality (defective judgement)
. As soon as the effect of the drug lessens, the patient
develops a transient state of rest or quiescence: the
ability of critical estimations normalizes and the desire
to use heroin fades out. This period lasts from several
minutes or hours to several days and even weeks, and depends
on daily dose and history of heroin addiction. For months
and years, intensive periods of using heroin alternate
with more or less long periods of withdrawal. During this
period, the patients abstain from heroin because they
take the course of therapy and rehabilitation, or they
may use other drugs or smoke marijuana. Or else, they
begin abusing alcohol.
Observation of patients during periods of using heroin
and remission, shows that in several months after an individual
beings using heroin, he or she develops specific changes
in personality and behavior. Patients stop attending school
or office, and begin conducting asocial or antisocial
way of life. They become aggressive, develop emotional
rigidity, and break ties with close friend and the family.
It is important to note that when an addicted person abstains
from heroin for 6 - 8 months and over, his or her individuality
partly restores. The patient resumes studies, finds a
job, begins associating with healthy people, gets married,
etc. In order to encourage addicted individuals to treatment
and rehabilitation, it was proposed to work out psychotherapy
programs, in which the concepts of functional systems
regulating behaviour of an individual, are given due consideration
(Sudakov K., 1984). Three functional systems are differentiated,
which control behavior of addicts during psychotherapy
(Zharkov Y., Glushko A., 2000). It was shown that during
rehabilitation of patients, it is helpful to offer them
sexological counselling. This improves remission quality
(Zharkov Y.,2000; Zharkov Y.2001).
It is known that sexual behavior changes in heroin addicts.
For some reasons, these changes have not been widely discussed
in special literature, and phenomenology is therefore
the subject of interest. We shall consider behavior of
heroin addicts during their sexual intercourse after using
the drug, specific features of sexuality in habitual users
of heroin, and some sexological characteristics of the
social group of drug addicts.
Sexual reactions of male heroin addicts change in the
state of acute intoxication. The intercourse becomes abnormally
long and failure to ejaculate becomes not unusual. Female
addicts develop anorgasmy. The patients remain indifferent
to these changes, probably because motivation to coitus
is other than sexual. It is important to note that heroin
addicts often refuse orgasm because the highest sexual
excitement disrupts the psychosomatic effect of the drug
and the necessity of taking another dose thus arises.
Interestingly, addiction to heroin lessens in some male
subjects after experiencing an orgasm. It has been found
that quality of sexual reactions depends on the dose:
duration of coitus increases, ejaculation becomes attainable
with greater difficulty, and the orgasmic excitement weakens
with increasing doses (Koporov C., 1994).
Both men and women rapidly develop physical dependence,
which is always followed by a decrease in libido. The
extent to which libido decreases depends on intensity
of drug use and constitutional characteristics of individual
sexuality. Some addicts demonstrate total reduction of
sexuality, while in others the reduction is not so pronounced.
Accordingly, sexual behavior of male patients varies from
full sexual abstinence to a limited frequency of sexual
intercourse, which only allows him to maintain the status
of a husband; in some families frequency of sexual intercourse
depends on female initiative. The character of sexual
relations in married couples changes. Petting begins dominating
over vaginal intercourse.
As regards sexologic characteristics of the social groups
of heroin addicts, it is characterized by the growing
incidence of prostitution and sexual violence, AIDS and
other diseases transmitted by genital contacts.
The objective of this study is to verify phenomenology
of sexuality in heroin addicts and to formulate basic
concepts, which might underlie the psychotherapy program
including sexologic consultation.
A systemic approach differs from other approaches to
the scrutiny of sexuality in that it allows to establish
relationships between sexologic categories. These, in
turn, reveal a functional system, which, being an objectively
existing system, produces the result of activity observed
by the researcher. This approach proved effective in the
study of factors maintaining c. As a result, a biosocial
functional system controlling reproduction of human population
was revealed (Zharkov Y., 1988). It has been already said
that heroin addiction in Russia is estimated as an epidemic
outburst. In other words, this is a biosocial process,
and, in order to establish biosocial relations between
sexological categories, it is quite adequate to use a
systemic approach to the study of human sexuality. Here
are some of these categories, which will be used in the
analysis of findings obtained during examination of our
patients: free love, marriage, prostitution (social categories),
platonic, erotic, sexual categories (personality categories),
rhythm of sexual activity, sex ratio (biological categories).
The listed categories fall within the framework of systemic
relations, and in order to fill them with concrete data,
some special methods of examination were used.
All our patients were given medical examination, their
addiction status was estimated, rehabilitation potential
determined (Dudko T., et al., 2001), and sexologic characteristics
established. Case histories included patient age, marital
status, availability of sexual partner, and some other
parameters. Sexologic anamnesis included information on
the rhythm of sexual intercourse and addiction severity.
For sake of convenience of comparative studies, a special
sexology form (Vassiltchenko G., 1977) was completed.
In the course of treatment and rehabilitation, the patients
were examined by doctors during consultation and during
their attendance of psychotherapeutic courses.
A group of 81 patients with the diagnosis of heroin addiction
was given dynamic medical observation. The patients practiced
intravenous injections from one to three years. The period
of intravenous injections was usually preceded by a period
of intranasal use of heroin, and also by use of ecstasy,
marijuana, and the like. The rehabilitation potential
was high or medium in these patients. The rehabilitation
program commenced after abatement of the withdrawal syndrome
at hospitals or in outpatient conditions. Medicines were
prescribed, which included blockers of opiate receptors
(for 3 – 6 months), antidepressants and tranquilizers
(3 – 8 week courses), depending on indications. Parents
or close friends (relatives) were involved in the rehabilitation
program as well. Frequency of consultations and groups
studies varied from two or three times a week to once
a month. Consultations and group psychotherapy continued
from 3 to 14 months. In some cases, after a two-month
course of intense studies and consultations, contacts
with patients were interrupted for 3 – 4 months.
Subjects of the study were young heroin addicts, of which
47 were male patients (58%) aged on average 20.5 (17 -
27) years and 34 females, average age 20.9 (18 – 24) years.
Sex ratio, 138. Distribution of patients in age groups
is shown in Fig. 1.
Fig. 1. Distribution of
patients in age groups
Fourteen patients (17%) were students, 21 (26%) were
on a long leave for pregnancy or other legal indications,
16 (20%) were employees (some of them were also students),
and 30 (37%) patients neither worked nor studied anywhere.
As to the family status, 46 (57%) lived with their parents
or in families of their relatives and 35 patients (43%)
lived alone. At the time of observation, 29 (36%) addicts
lived in full families, 4 (5%) had no parents, parents
of 48 patients (59%) were divorced; of the latter patients,
19 (23% of the total number of patients) lived with their
mothers, 3 (4%) patients had only father, 20 (25%) patients
lived with their mothers who married second time, and
6 patients (7%) lived with their fathers and step mothers.
Most patients (n = 62; 76%) were single: these were 25
females, i.e., 73% (34 = 100%) and 37 male patients, i.e.
79% (47 = 100%). Divorced were 5 females, i.e., 15% (34
= 100%) and 7 male patients, i.e., also 15% (47 = 100%);
4 (12%) females and 3 (6%) male patients were married
by common law.
Twenty-eight addicted individuals (34% of the total number
of patients) had no sexual partner within three months
preceding their attendance to the doctor. Of this number,
7 were females, i.e., 20% (34 = 100%) and 21 were male
patients, i.e., 45% (47 = 100%). Twelve (35%) females
and 9 (19%) males had occasional intercourse with pickup
partners. Eleven (32%) females and 14 (30%) males had
permanent partners; 4 (12%) females had their husbands
as a permanent sexual partner and 3 male patients (6%)
had their wives as permanent partners. Six married couples
had one child each, and 4 women had illegitimate children.
The children were 6 boys and 4 girls. The reproduction
level in the studied group was 12% (the number of children
expressed in percent of the total number of patients).
Twelve (15%) patients were AIDS-infected; hepatitis C
virus was found in 68 (84%) patients, and 5 (6%) patients
had the virus of both hepatitis B and C.
Involvement into heroin addiction differed as regards
sex: young males began using heroin in a group of adolescents,
one of which had a long history of addiction. These were
32 cases which made 68% (47 = 100%). Girls were given
the first dose of heroin by addicts to whom they felt
platonic affection, or with whom they had erotic and sexual
relations. These were 27 girls, i.e. 79% (34 = 100%).
As regards the rhythm of sexual activity and its relation
to intensity of heroin use in male patients, we observed
the following phenomenon (Fig. 2): sexual activity decreased
with increasing intensity of heroin use. If the woman
did not use drugs, sexual partnership usually broke during
Fig.2. Decreasing rhythm
of sexual activity is related to increasing intensity
of heroin use. Patient A.V.P., aged 25. (Publication on
patient’s consent. The patient used intranasal heroin
from the age of 16 till 21; changed from nasal to intravenous
administration from the age of 21.5 till 25).
We failed to reveal said dependence in women while comparing
their sexual rhythms and intensity of heroin use. When
women used heroin in small amounts, they had numerous
casual sexual relations; nor did they change the rhythm
of their sexual behavior when the dose increased, because
the women exercised prostitution. Fourteen female patients
(41%, 34 = 100%) confessed to prostitution. Disorders
in the menstrual function (amenorrhea included) developed
during the periods of the most intensive heroin use. On
suspension of drug injections, normal menstrual function
restored within two to four months.
Sexual experience of 17 male patients, i.e., 36% (47 =
100%), included a period of important (subjectively) relations
before they started using heroin. As a rule, partnership
formed during this period. Sometimes this partnership
was a sort of “test” marriage, including cohabitation.
Sexual life was regular and intensive (daily intercourse,
excesses). Partnership normally broke with development
of addiction to the drug. Sexual life of male patients
became promiscuous; orgasm was mostly achieved through
fellatio. Men had sexual intercourse after injecting drugs
together with women. Orgasmic excitement weakened or became
unattainable at all because coitus often ended in the
absence of ejaculation. Sometimes the patients imitated
orgasm. As the dose and frequency of drug injections increased
(two and more times a day), ejaculation rhythm decreased,
and sexual life discontinued.
Fourteen (30%) male patients had no pre-addiction experience
of permanent sexual partnership. Their sexual life was
within the ambit of promiscuity. It began during the period
of marijuana smoking, which preceded heroin addiction.
As physical dependence developed, sexuality reduced: libido
decreased, platonic affection was absent. These patients
demonstrated erotic behavior in the presence of other
young people, their addict-mates. After drug injection,
the patients usually had no sexual intercourse.
Nine (19%) male patients had minimal sexual experience
– virtually single sex intercourse with a casual female
partner; 7 (15%) patients never experienced sexual intercourse.
In the absence of drugs, they practiced self-abuse, 1
to 4 episodes a month; masturbation discontinued when
the drug was available.
It is interesting to note markedly different subjective
estimations given by heroin addicts to their feelings
during sexual intercourse following drug injection, and
to the negative sexual phenomena suggesting destruction
of their sexuality, such as breakdown of partnership with
a woman whom they cared much formerly, decreased rhythm
of sexual activity and promiscuity, long periods of total
abstinence, disordered menstrual cycle. Patients’ estimations
of sexual relations in the state of heroin intoxication
were exaggeratedly superb, while the attitude to the negative
symptoms of their intimate life was indifferent.
In 25 unmarried couples, both men and women used heroin.
Both wife and husband were drug addicts in only one of
seven married couples. In three families, it was only
wife who used the drug, and in the other three families
it was the husband. Behavior of addicted men and women
was characterized by the absence of emotional affection,
which is otherwise characteristic of “free love” couples.
Relations between addicted men and women cannot be described
as love because of absence of erotic behavior, low rhythm
of sexual intercourse, and absence of reproductive motives.
Brief description of other mentioned sexologic
categories, characterizing the studied group of heroin
addicts, is given in Table 1.
Table 1. Sexologic categories of heroin addicts
couple breaks down as one partner becomes addicted
to the drug. If the couple persists, the other partner
starts using drug as well. Advance to marriage is
breaks down. Or family relations are maintained
for motives other than sexual (usually for pragmatic
common (as payment for a dose of the drug)
become involved in drug use because of subjectively
important relations with an addicted individual.
Men are unable to feel love for women. They care
for heroin rather than for a woman.
erotic-sexual communication is usually interpreted
as an invitation for the drug.
drug first, then sex. Sexual intercourse is depreciated
as means of communication or the source of sexual
pleasure. Petting dominates the ways of attaining
orgasm. Coitus is abnormally long. The ability to
experience orgasm decreases in women, while men
develop the syndrome of the absence of ejaculation.
of sexual activity
rhythm (to complete cessation of sexual life in
cases of intense drug use).
Sex ratio of children and reproduction
Reproduction is extremely low. The
social group is eliminated from population.
Once we admit that our subjects started using heroin
in the pubertal and post-pubertal period, i.e., during
formation of sexuality, the destruction of sexuality
may be regarded as the result of specific process:
incompetent competition of libido (which dominates
motivation at this age) with motivation for using
heroin. The specific character of this pathology consists
in that heroin intoxication first only becomes an
element of the forming stereotype of erotic-sexual
behavior, but soon it displaces completely the erotic
component from behavior of an addicted individual.
The competing relations between eroticism and drug
addiction are shown in Fig. 3.
3. Formation of dependent behavior of heroin addicts
in competition with sexuality.
Motivation for heroin use (in red)
is first closely connected with motives oriented at
realization of libido (1). As postulated in the theory
of functional systems, these are the triggering stimuli.
Platonic, erotic, and sexual emotions in the state
of heroin intoxication depreciate erotic and sexual
behavior as the source of great pleasure because the
psychosomatic action of the drug reduces the level
of satisfaction during coitus and orgasm. A simplified
system of attitude to eroticism and sexuality thus
forms in an addict, and the motive for heroin use
strengthens instead. The subject develops these attitudes
as a result of the so-called central integration processes,
the essence of which consists in association of the
subject with a group of his or her addict-mates (discussion
aimed at digesting rules and standards is the mechanism
of central integration). The patient finally becomes
addicted to the drug - line (4); he or she may form
a couple with another addict (3), or part from the
other individual in the existing couple who does not
use heroin (5).
Use of heroin (6) in a pathological functional system
is an intermediate result, which simultaneously acts
as a triggering mechanism. This does not contradict
the theory: the result of action is the backbone system-forming
factor. In our case, the result includes the absence
of reproduction in the social group of drug addicts
and their elimination from population (9) owing to
low percentage of married couples and the low reproduction
level, and also because of high morbidity of AIDS
and other diseases transmitted by genital contacts.
Competition between sexuality and the pathological
biosocial system is also manifested by the damaged
mechanism of feedback and prognostication (the so-called
action acceptor). Patients with the disease in the
pronounced stage become desolated: their relations
with other people based on platonic, erotic, and sexual
motives break down.
What has been said above, may be used to work out
special programs for psychotherapy and sex education
aimed at rendering more effective aid to heroin addicts
during their rehabilitation. In a more general case,
such program may include three stages (as can be seen
from Table 2). The program can be aimed at supporting
sexuality in its competition with dependent behavior.
Table 2. Psychotherapy program
Patient involvement in the program.1
– 2 weeks.
Active training. 2
– 3 weeks.
Completion of therapy (Quantum satis)
Physician and psychologist communicate
with the patient and his/her family. Sexological
examination of the patient.
Studies in a psychotherapy group;
special program of sexologic education. Consultation.
Completion of studies in the group.
Reduced frequency of consultation.
Establishing diagnosis; selecting
a member of the family who might conduct psychotherapy.
Diagnosis and correction of motivation
and behavior aimed at helping the patient to realize
Estimation of results.
Purpose of psychotherapy by stages
Updating motivation for changing
Working out of negative attitude
to dependent behavior and favorable attitude to
his/her partner and the family .
Supporting patient’s motives for
realization of platonic, erotic, and sexual libido,
and also reproductive intentions of the formed couple.
Recreation and procrecreation sexuality
functions are specifically damaged in heroin addicts. This
is explained by the fact that libido is not involved in
organization of behavior. As a result, specific features
of character, owing to which a healthy subject becomes personality,
are not formed. Contrarily, a drug addict acquires known
negative features characteristic of all addicted individuals,
said features including indifferent attitude to destruction
A healthy person has no biosocial grounds for maintaining
drug-dependent behavior. Therefore, a pathological functional
system, which induces this behavior, exploits the biosocial
fundamentals of sexuality. As an individual is involved
in drug addiction, motives and behavior conjugate. In other
words, drug use is first included into realization of sexuality,
but later it displaces the latter. If an individual uses
heroin for years, he or she becomes devoid of experience
in a broad spectrum of emotions and feelings. This, in turn,
inhibits psychosexual development of a person. The process
proceeds unnoticed for an addicted individual. Examination
of heroin addicts shows that subjective estimation of their
sexuality differs substantially from virtual severity of
Heroin use produces a specific leveling of the erotic-sexual
sphere. But since the erectile function in men remains unaffected
in most cases, an illusion of welfare persists in a drug
addict. Libido becomes subject to heroin intoxication because
sexual intercourse occurs after drug injection. Subjective
estimation of sexual intercourse by the patient changes:
when in the state of heroin intoxication and decreased criticism,
an addict tends to interpret sexual emotions as if they
are induced by sex. Meanwhile these emotions depend on the
amount of heroin injected. These changes in self-criticism
promote formation of dependence at the initial stage of
addiction, which becomes apparent during discussion in the
psychotherapy group. This, in turn, contributes to motivation
for heroin use.
It is desirable that the course of rehabilitation of drug
addicts should include a psychotherapy program aimed at
restoration of patient sexuality. This program is designed
for a pair of specialists in psychotherapy, viz., a physician
and a psychologist. The program may consist of several stages
and include sexologic consultation for the patient himself
and his family, a course of special sexologic education,
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