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Year : 2015  |  Volume : 24  |  Issue : 1  |  Page : 29-34  Table of Contents     

Co-relationship between sexual dysfunction and high-risk sexual behavior in patients receiving buprenorphine and naltrexone maintenance therapy for opioid dependence

1 SDM College of Medical Sciences and Hospital, Sattur, Dharwad, Karnataka, India
2 Department of Psychiatry, National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication16-Jul-2015

Correspondence Address:
Santosh Ramdurg
SDM College of Medical Sciences and Hospital, Sattur, Dharwad, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0972-6748.160930

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Introduction: People suffering from substance dependence suffer from various sexual dysfunctions and are at risk for indulging in various high-risk sexual behaviors and thus are vulnerable to acquire various infections such as HIV/AIDS and other sexually transmitted infections. AIM: The aim of the study was to evaluate the correlation between sexual dysfunction and high-risk sexual behavior in opioid-dependent men receiving buprenorphine and naltrexone maintenance therapy. Materials and Methods: Semi-structured questionnaire, brief male sexual functioning inventory and HIV-risk taking behavior scale was administered to a sample of 60 sexually active men, receiving buprenorphine (n = 30) and naltrexone (n = 30) maintenance therapy for opioid dependence. Results: The main outcomes are correlation between severity of sexual dysfunction and HIV-risk taking behavior. The study results showed 83% of the men on buprenorphine and 90% on naltrexone reported at least one of the sexual dysfunction symptoms. There was a negative correlation between sexual dysfunction and HIV-risk taking behavior that suggest severe the dysfunction, higher the risk taking behavior. Significant correlation was present with overall sexual dysfunction and HIV-risk taking behavior (P = 0.028 and in naltrexone receiving group premature ejaculation versus HIV-risk taking behavior however, (P = 0.022, P < 0.05) there were no significant differences among both the groups except above findings. Conclusion: Conclusion was treatment is associated with sexual dysfunctions and HIV-risk taking behavior, which has clinical implication. Future research should explore this further using biochemical analyses.

Keywords: Buprenorphine, naltrexone, opioid dependence, sexual behavior, sexual dysfunction

How to cite this article:
Ramdurg S, Ambekar A, Lal R. Co-relationship between sexual dysfunction and high-risk sexual behavior in patients receiving buprenorphine and naltrexone maintenance therapy for opioid dependence. Ind Psychiatry J 2015;24:29-34

How to cite this URL:
Ramdurg S, Ambekar A, Lal R. Co-relationship between sexual dysfunction and high-risk sexual behavior in patients receiving buprenorphine and naltrexone maintenance therapy for opioid dependence. Ind Psychiatry J [serial online] 2015 [cited 2018 Mar 17];24:29-34. Available from: http://www.industrialpsychiatry.org/text.asp?2015/24/1/29/160930

Drug abuse adversely affects the sexual health of the users. People suffering from dependence on drugs - either under the influence of addictive drugs or because of other social/economic/cultural factors - are at risk for indulging in various high-risk sexual behaviors and thus are vulnerable to acquire various infections such as HIV/AIDS and other sexually transmitted infections (STIs). On the other hand, people suffering from drug dependence, particularly opioids dependence also suffer from sexual dysfunctions in the short- and long-term (Ramdurg et al. 2012). [1],[2] Indeed, for some, sexual dysfunction may be a factor associated with initiation, continuation or relapse of drug abuse.

Certain studies have indicated that men in India are more concerned about performance issues related to semen-loss than they are about STIs. [3] One of the motives for seeking out sexual partners and being involved in risky sexual contacts (with sex workers or with multiple partners) is to avoid the perceived dangers and debilitating effects of excessive semen-loss believed to be result from masturbation: There is a widespread belief among Indian men that the loss of semen during sex with partners is less, and therefore not as "dangerous" as the loss of semen in masturbation. [4] Concerns about sexual performance are a primary reason for nonmarital sexual experience in India. [3] A study in Pune reported that young men had sex with sex workers before marriage due to performance anxiety. [5] Sexual dissatisfaction in the marriage, resulting from husband's sexual dysfunction has been cited as a reason behind extramarital sex and sex with female sex worker, both of which are risky sexual practices. [6]

The review of literature indicates that there may be an association between perceived sexual dysfunction, dissatisfaction in sex with regular partners (i.e., spouse) and engaging in high-risk sexual behavior (i.e., extramarital or paid sex). So far, this phenomenon has been studied in "general" population of Indian men without taking into account of their substance use pattern. Moreover, rather than overt sexual dysfunction such as erectile dysfunction or premature ejaculation (PME), the perceived sexual inadequacies such as performance anxieties or semen-loss anxieties have been studied in the context of high-risk sexual behavior. The present study has been designed to study high-risk sexual behavior in the context of sexual dysfunction such as erectile dysfunction or PME among opioid-dependent males on maintenance treatment with buprenorphine and naltrexone.

   Methodology Top

Subjects of the study

A total of 60 sexually active, opioid-dependent, male patients - 30 receiving naltrexone maintenance therapy and 30 receiving buprenorphine maintenance therapy - were selected from the outpatient department of National Drug Dependence Treatment Centre (NDDTC), All India Institute of Medical Sciences, New Delhi. The inclusion criteria were, age: 18-45 years, should be receiving their maintenance medications (buprenorphine or naltrexone) from the NDDTC pharmacy for more than 4 weeks; sexually active that is, attempted or had penetrative intercourse with a partner of either gender in preceding 1-month; willing to participate in the study and giving informed consent. Patients with major physical or psychiatric comorbidity or a disability hampering communication or with dependence on other drugs (except nicotine dependence due to nonavailability of exclusive opioid-dependent in clinical setting) were excluded. Informed consent was taken from those who fulfilled the inclusion and exclusion criteria, and they were assessed initially by applying a semi-structured questionnaire that included sociodemographic profile, drug use profile, history regarding sexual behaviors and regularity of follow-up. For assessment of sexual functioning: Brief male sexual functioning inventory (BMSFI) [7] and for assessment of Sexual behavior, sexual behavior section of the HIV-risk taking behavior scale (HRBS, [8] was used. BMSFI scales internal consistency and test-retest reliability coefficient are all in the acceptable range. [9] Major advantages of this scale are: (a) A relatively high degree of internal consistency and test-retest reliability; (b) adequate discriminate validity; (c) ease of use. HRBS scale's reliability, validity, and other psychometric properties are all in the acceptable range. (Darke et al., 1991) [10] All the interviews were conducted by the first author under the supervision of consultant psychiatrists. Ethical clearance was obtained from the Ethics Committee of All India Institute of Medical Sciences, New Delhi.

   Results Top

Sociodemographic characteristics

The mean ages of the 30 buprenorphine maintained patients were 35.8 (±7.49) while it was 33.4 years (±8.9) for the patients maintained on naltrexone. As seen in [Table 1], there were no striking differences in both the groups on any of the sociodemographic parameters.
Table 1: BMSFI score of buprenorphine subjects-last one month

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Substance use profile

As the subjects were diagnosed cases of opioid dependence, opioids were the primary substance of use for all the 60 subjects. In buprenorphine maintained patients, 90% reported using heroin "ever" while the figure was 60% in naltrexone maintained patients. In contrast, among the naltrexone maintained patients, more subjects reported using other opiates (i.e., opium, poppy husk, capsule dextropropoxyphene or injectable opioids) "ever," compared to the buprenorphine group. More than 90% of study subjects used alcohol at least once in lifetime. A major proportion (77% and 67% in buprenorphine and naltrexone group respectively) of the subjects also used cannabis. Use of other substances (mainly benzodiazepines) was reported by 60% of buprenorphine, and 40% of naltrexone maintained subjects.

Subjects were also asked about their ages when they used different substances for the first time in their life. Data showed that among different substances, tobacco had the earliest age at first use followed by alcohol, cannabis, and heroin. Thus, both the groups had remarkably similar sociodemographic and substance use profile.

Brief male sexual functioning inventory score

[Table 1] shows the range of possible score in different domains of sexual functioning, the mean score of the subjects in respective domains during the preceding 1-month period as produced by administering the BMSFI and the ratio of mean against the maximum possible score in each domain. Lower score and lower ratio represent greater dysfunction. In buprenorphine receiving subjects mean score of sexual desire is 5.37 ± 1.9 out of maximum possible score of eight indicates some degree of decreased in sexual desire mean score of erectile function was 11.17 ± 2.3 out of maximum possible score of twelve means not much decreased in erectile function. The mean score in ejaculatory function was 6.77 ± 1.6 out of maximum possible score of eight, and that of problem assessment was 9.90 ± 3.1 indicates certain degree problem in ejaculation and problem assessment. A subject scored a mean of 2.77 ± 1.3 in overall satisfaction out of maximum possible range of four indicates these individual are not satisfied with their sexual function. In naltrexone receiving subjects the scores were 5.20 ± 2.1 in sexual desire, 6.57 ± 1.8 in ejaculation, 10.00 ± 2.7 in problem assessment and 2.72 ± 1.5 in overall satisfaction shows some degree of dysfunction in all parameters while this was less in erection with score 11.10 ± 2.1. Subjects showed greatest dysfunction in sexual desire (0.67 and 0.65 in buprenorphine and naltrexone subjects) and overall satisfaction reflected by the lowest ratio (0.69 and 0.68) of mean against the maximum possible score. Dysfunction was relatively lesser in ejaculation (0.84 in the buprenorphine group and 0.82 in the naltrexone group) and problem assessment domain (0.83 in both groups) in both the subjects and it was least in erectile function (ratio = 0.93 and 0.92 in buprenorphine and naltrexone receiving subjects). In ejaculation domain, the naltrexone group showed higher dysfunction then the buprenorphine group but it was minimal. In problem assessment, it was similar in both the groups.

HIV-risk-taking behavior scale score

Indulgence in high-risk sexual behavior of the study subjects was measured by administration of sexual behavior subscale of HRBS with a score range of 0-25 and higher scores indicating a greater degree of the risk-taking sexual behavior. In buprenorphine receiving subjects the mean score of the subjects' risky sexual behavior in the preceding 1-month was 5.43 ± 1.56 with a range of 2-9 while in naltrexone receiving subjects it was 4.63 ± 1.9 with range of 2-8 [Table 2].
Table 2: HRBS score-last one month

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Correlation between sexual dysfunction and risk sexual behavior

The  [Table 3] and [Table 4] show the correlation between the scores of sexual behavior and sexual dysfunction. They are negatively related to each other with the value of −0.24. Lower the BMSFI score, (higher the sexual dysfunctions) higher-risk for high-risk sexual behavior and overall score is statistically significant with P = 0.028 (<0.05) Similar things holds good for buprenorphine receiving group and naltrexone receiving group but not statistically significance. We also try to look subsection of HRBS and that of five subsection of BMSFI. None of the correlation between high-risk sexual behaviors and five domains of sexual functioning is statistically significant in buprenorphine receiving subjects while in naltrexone receiving subjects a statistically significant negative correlation was present in ejaculation domain with HRSB and in rest, there was no significant correlation.
Table 3: correlation betwenn BMSFI and HRSB

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Table 4: Correlation between sexual behavior and sexual dysfunction

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   Discussion Top

By administration of BMSFI, we tried to quantify the magnitude of sexual dysfunction of the subjects in different domains during a period of 1-month preceding the assessment in both - buprenorphine and naltrexone groups. Scores in both the groups showed that sexual desire had been the most severely affected among three domains of sexual functioning. Erectile function had been the least affected while ejaculation was in between in both the groups. Subjects had been distressed about overall satisfaction on their sexual performance to an extent equal to that of reduced sexual desire. The pattern of the severity of dysfunction in different domains of sexual functioning was dissimilar across these two groups with slightly higher dysfunction in buprenorphine receiving subjects.

We also looked into the dysfunction independently in all five domains (sexual drive, erection, ejaculation, problem assessment, satisfaction) taking cut-off point one-fourth of maximum points in both groups for severity of assessment of dysfunction. Even though the scale does not provide any cut-off for significant dysfunction, we have chosen operationally the cut-off point below this the dysfunction could be considered to be significant. In the buprenorphine group, about 6.6% subjects reported decreased in sexual drive, no one reported erection difficulty, 3.3% reported ejaculation difficulty, no one reported problem assessment and in overall satisfaction 20%. In the naltrexone group, 10% reported sexual drive problems, no one erection, ejaculation, problem assessment, and overall satisfaction was 16.7%. Even though there was no significant dysfunction noticed in the first four domains, still in the domain of "overall satisfaction" a sizable proportion of subjects reported less satisfaction with their sexual activity while on medication in both the groups. The study carried by Quaglio et al. [11] has used International Index of Erectile Function-15 scale for assessment of sexual dysfunction, and they divided the results into mild, moderate and severe dysfunction depending on the lesser number of score in few similar parameters.

Current study findings-relation between different variables

For assessment of the relationship between sexual dysfunction and high-risk sexual behavior correlation statistics were applied. Overall, there is statistically significant negative correlation. That is, higher the sexual dysfunction more the high-risk sexual behavior. In case of buprenorphine receiving subjects and naltrexone receiving group, no statistically significant correlation was found. Negative correlation was present between individual items of BMSFI with HRBS in both buprenorphine and naltrexone receiving groups. In naltrexone receiving subjects, a statistically significant negative correlation was present in the ejaculation domain with HRSB and in rest, there was no significant correlation. This indicates that higher the severity of PME more the risk taking behavior in subjects receiving naltrexone. As of now there is no existing literature that studied quantitative correlation between the severity of sexual dysfunction, and risk taking behavior to enable comparison with the findings of the current study. This absence of a significant relationship between degree of sexual dysfunction and that of risky sexual behavior in our study could be explained by our inclusion criteria. As we included only the sexually active subjects, persons who had more severe sexual dysfunction, rendering them unable to perform a sexual activity were excluded from this study. This might contribute for not finding any significant correlation among the severity of dependence, sexual dysfunction, and risky sexual behavior. Another factor that might contribute for not finding correlation is the limitations of the instruments used. BMSFI and HRBS provided score only for last 1-month sexual functioning and behavior. Using only 1-month status instead of a longitudinal picture of these variables might have limited the chance of finding significant findings on these assessment instruments, as well as any significant correlation among them.

The previous studies suggest sexual dysfunction was very rarely discussed or studied in the context of sexual behavior. Many authors have highlighted the anxieties associated with sexual matters among Indian males. Particularly, noteworthy have been the findings regarding concern about the sexual performance issues related to semen-loss among men. Previous studies have described the phenomenon of being involved in risky sexual contacts (with sex workers or with multiple partners) to avoid the excessive semen-loss from masturbation. Men's sexual dysfunction has been cited as a reason behind extramarital sex including sex workers. Three categories of men's sexual problems in India have been described (Schensul et al. 2004): [6] Dhat (semen-related problems), kamjori (performance-related problems), and garmi (STIs and STI-like symptoms, i.e. the "contact problems"). Most studies, examining the relationship between sexual dysfunctions and risky sexual behavior have found such an association between the semen-loss concerns (i.e. Dhat) and high-risk sexual behavior. [3],[6] In addition, these studies differ from our study on various methodological counts. First, none of the earlier studies have examined the sexual dysfunction or high-risk sexual behavior using standardized instruments (like we did). In fact, most studies have relied primarily on qualitative or categorical data. Second, the type of sexual dysfunction (or rather the broad rubric of "male sexual health problems") studied had also been different. In these studies, the perceived sexual inadequacies (like fear of semen-loss, performance anxiety) have been studied rather than the overt sexual dysfunctions. Third, these studies have been conducted among the general population (i.e., substance use pattern of the subjects was not the focus), unlike our study which was focused on opioid-dependent subjects receiving buprenorphine and naltrexone maintenance therapy.

Thus, the hypothesis generated from the review of literature that "the sexual dysfunction is associated with high-risk sexual behavior in subjects receiving buprenorphine maintenance therapy" could not be proved in the current study using the methodology employed by us. This hypothesis was proved with PME and high-risk sexual behavior to a certain extent in naltrexone receiving subjects but on most of the other parameters it remained unproved. It is evident from the findings that to explore this hypothesis a different methodology may have to be employed. While recommendations for the future have been listed later, one recommendation for future research would be to examine this issue using rigorous qualitative techniques. The issue of sexual dysfunction and sexual behavior may be too complex to be examined using just two standardized quantitative scales alone. During this study period, subjects also discussed about Enhancing sexual performances or overcoming perceived sexual inadequacies was the only reason for starting heroin use for some patients. Increased ejaculatory latency was the most common alteration in sexual functioning associated with heroin use. After taking heroin, some patients had sexual intercourse regularly for as long as 1-2 h. Most of the subjects were not distressed because of this, rather perceived the delayed ejaculation as an enhanced state of sexual functioning and enjoyed the situation. They were distressed if there had been anorgasmia or complete absence of ejaculation or because of PME during the withdrawal phase. Some reported that their partners were also happy because of their ability of prolong intercourse. Some subjects reported that their spouses did not like prolong intercourse, so they would usually make sexual contact after a gap of few hours, just before the intoxication effects of heroin would fade out. Despite perceived enhanced sexual performance due to delayed ejaculation; most of them were not satisfied with their sexual life. The primary reason of poor sexual satisfaction was reduced or loss of sexual desire which was the most distressing to the subjects among different symptoms suggestive of sexual dysfunction. This was reflected in statements of some patients - "Heroin has taken away my sexual urge," "heroin has replaced my sexual partner," "heroin is strong enough to delete sex from your mind," etc. In general, the longer the duration of heroin use the severe the problem of reduced sexual urge. After the initiation of maintenance treatment, either buprenorphine or naltrexone many subjects decreased the contact with commercial sex worker (CSW). This was particularly with naltrexone treatment. They believed that when they are having sex with CSW, they were paying money to them. Due to this, they would enjoy sex by prolonged intercourse caused by heroin or other opium products. After starting naltrexone, this prolonged intercourse was not present or few had PME. Due to this, subjects felt that it is waste of their money. With respect to buprenorphine, many subjects felt this also prolongs sexual performance but less then what was done by use of heroin. Even after initiation of maintenance therapy, many subjects continue to have sexual contacts with multiple casual partners or CSW. During this period, they would use either alcohol or cannabis to enhance their sexual activity but the frequency was irregular and less. Most of the subjects heard about AIDS, and a substantial number knew that condom use could prevent the chance of getting infected. Still a major proportion never used a condom because they believed that their sexual partners were not infected. Some even claimed that they could understand whether a sexual partner had been infected or not just by looking at their external appearance. Some subjects reported decreased sexual enjoyment with use of condom. This experience would happen with all the partners particularly with casual partners and regular partner. None of them ever checked their HIV sero-status. Despite enduring reduction in sexual drive, the frequency of indulgence in high-risk sexual behavior gradually decreased. Very few had sex with CSWs or casual partners in recent past though many of them would try their best to make sexual relation with a casual partner or would regularly visit CSWs in the distant past.

Many subjects welcomed the purpose of the current study and opined that medical science should develop some effective measures to take care of their sexual dysfunction that arises as a sequel of chronic drug use. Whatever be the reason of onset, a major negative reinforcement for their continued use of heroin was an apprehension of PME after quitting heroin. Most of them would also believe that doctors have very little to offer to alleviate their sexual dysfunction.

   Acknowledgments Top

Source of funding


Conflict of interest

There are no conflict of interest.

   References Top

Ramdurg S, Ambekar A, Lal R. Sexual dysfunction among male patients receiving buprenorphine and naltrexone maintenance therapy for opioid dependence. J Sex Med 2012;9:3198-204.  Back to cited text no. 1
Meade CS, McDonald LJ, Weiss RD. HIV risk behavior in opioid dependent adults seeking detoxification treatment: An exploratory comparison of heroin and oxycodone users. Am J Addict 2009;18:289-93.  Back to cited text no. 2
Pelto J, Joshi A, Verma R. The development of Indian male sexuality. New Delhi, India: Population Council, South and Southeast Asian Regional Office; 1999.  Back to cited text no. 3
DCT: Deepak Charitable Trust. Male semen loss concerns. Baroda, India: Deepak Charitable Trust; 2000.  Back to cited text no. 4
Raju S, Leonard A, editors. Men as Supportive Partners in Reproductive Health: Moving from Rhetoric to Reality. Population Council 2000. New Delhi, India. 2000. p. 68.  Back to cited text no. 5
Schensul SL, Verma RK, Nastasi BK. Responding to men's sexual concerns: Research and intervention in slum communities in Mumbai, India. International Journal of Men's Health 2004:3;197-220.  Back to cited text no. 6
O'Leary MP, Fowler FJ, Lenderking WR, Barber B, Sagnier PP, Guess HA, et al. A brief male sexual function inventory for urology. Urology 1995;46:697-706.  Back to cited text no. 7
Ward J, Darke S, Hall W. The HIV risk-taking behaviour scale (HRBS) manual. Australia: National Drug and Alcohol Research Centre; 1990.  Back to cited text no. 8
Derogatis LR, Laban MP. Psychological assessment measures of human sexual functioning in clinical trials. Int J Impot Res 1998;10 Suppl 2:S13-20.  Back to cited text no. 9
Darke S, Hall W, Heather N, Ward J, Wodak A. The reliability and validity of a scale to measure HIV risk-taking behaviour among intravenous drug users. AIDS 1991;5:181-5.  Back to cited text no. 10
Quaglio G, Lugoboni F, Pattaro C, Melara B, Mezzelani P, Des Jarlais DC. Erectile dysfunction in male heroin users, receiving methadone and buprenorphine maintenance treatment. Drug Alcohol Depend 2008;94:12-8.  Back to cited text no. 11


  [Table 1], [Table 2], [Table 3], [Table 4]


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