The Integration of Sexual Health Education in SUD Treatment

Substance use disorder (SUD) treatment services have the opportunity to intervene at a crucial juncture for many of their clients: the intersection of addiction and high-risk sexual behavior. Studies conducted in the last twenty years have highlighted a relationship between SUDs and risky sexual behavior (Rosengard, Anderson, & Stein, 2006). For men, sexuality and sexual health education has been shown to promote the formation of greater social supports and coping mechanisms that encourage cessation of substance abuse and risky sexual practices (Bartholomew, Hiller, Knight, Nucatola, & Simpson, 2000). In addition, a combination of HIV/STI and sexual risk assessment education has been shown to increase knowledge concerning disease prevention and risk avoidance techniques in both men and women (Lehman et al., 2015). This article will suggest the widespread integration of comprehensive sexuality education programming into SUD treatment settings. Considering the magnitude of the potential gains for clients in treatment services who also receive some form of sexual health education, the importance of pursuing an increase in integrated programs is paramount.

While the intersection of substance use and risky sexual behaviors has been researched for around two decades, an article entitled “Reducing Sex under the Influence of Drugs or Alcohol for Patients in Substance Abuse Treatment” has more concretely defined these high-risk sexual behaviors and how substance users connect sex and their use of drugs (Calsyn et al., 2010). In this article, several high-risk sex behaviors were listed, including “trading sex for drugs or money, vaginal and anal intercourse without condoms or sex with multiple partners,” (Calsyn et al., 2010, p. 100). Their research also found that drug use increased pleasure during intercourse and difficulty engaging in sexual acts without using substances. This important sex-use connection could result in higher rates of relapse because of the difficulties separating sex from substances.

This difficulty was also noted in a different article focused on the sexual behaviors of women who use methamphetamines (Lorvick et al., 2012). Lorvick’s group examined both qualitative and quantitative data, with thirty-four participants participating in both the qualitative and quantitative research along with 286 women participating in the quantitative research only. It was discovered that many of the women use methamphetamines while having sexual intercourse and associate their drug use during sex with a heightened sense of sexual pleasure and fulfillment. While some women still engaged in sexual activity without drug use, in this particular study, there was an overwhelming theme in the data summarized by one participants qualitative response: “When I am high, I enjoy sex more,” (Lorvick et al., 2012, p. 7). These data suggests that neither are high-risk sexual behaviors part of every instance of substance use, nor is substance use necessary to engage in high-risk sexual behaviors. However, substance use and high-risk sexual behaviors, when co-occurring, tend to magnify the problems associated with the behaviors individually.

The topic of sex is often a controversial and difficult subject for many therapist to discuss in a treatment setting. Recently, the World Health Organization (WHO) created a definition of sexual health that was used in a research article by McCave, Shepard, and Winter (2014) in order to discuss the importance of including sex in social work. WHO defined sexual health as

This definition shows that sex and sexual decisions are centered on not only people’s internal characteristics, but also their environments and their histories. This definition also illustrates that sex and sexuality are a human right and everyone deserves a pleasurable and healthy sex life. McCave, Shepard, and Winter also cited the National Association of Social Workers, suggesting that a “special focus should be on the marginalization of individuals and groups by understanding the societal mechanisms that regulate aspects of human sexuality” (2014, p. 410).  This means that not only is sex and sexual pleasure a human right, but it is also an ethical responsibility for social workers and other professionals to understand how clients’ sex and sexuality is being impacted by their health and environment. Steps by organizations like these have helped to push sexuality forward as an integral subject of discussion in therapy. However, there are still many instances where, rather than discussing sex in a pleasure oriented way, sex is discussed as part of the problem, especially in many SUD facilities.

There are two major reasons why professionals are taking a problem-focused approach to sexual education and sexual health: a lack of sexuality education themselves and sexual privilege. Sexual privilege was described in McCave, Shepard, and Winter’s article as “the ability to experience your sexual attitudes, identities, or behaviors, as ‘normal’ or ‘healthy’ . . . [It] is maintained at the expense of ‘others’ who will be taught that their sexuality and sexual decisions are ‘abnormal’ or ‘unhealthy,’” (2014, p. 410). This is particularly true in a field such as SUD treatment where sexual behaviors are often defined as high-risk or problem behaviors. Dunk claimed that it is often easier for professionals to see sexual behaviors and characteristics as they appear in a particular groups of clients, such as substance users, rather than treating sexuality as something affecting every human (2007). If Dunk’s statement is translated into SUD treatment and its intersection with sexuality education, sex may be perceived as a behavior that increases drug use and risk-taking behaviors, rather than as a normal part of being human. This results in viewing the sexual behaviors of this population as problem behaviors that need to be stopped all together instead of a space for education and growth.

The utility of sex education is further highlighted when considering the evidence supporting its efficacy in reducing the transmission of HIV and sexually transmitted infections (STIs). Winhusen et al. (2014) found that providing sex education which communicates the benefit of condom use for preventing the contraction of HIV leads to an increase in safe sex practices, which in turn lowers rates and risks of HIV and STI transmissions. The study further discovered that the provision of only one counseling session which provides HIV education, led to a significant increase in condom use during future sexual interactions with casual partners. The provision of three HIV prevention counseling sessions was associated with a significant increase in condom use during future sexual interactions with monogamous partners, interactions which tend to involve lower rates of condom use in general (Winhusen et al., 2014).

Because individuals who abuse substances are likely to practice safe sex less often, one might expect SUD treatment services to include sex education in their programs (Rosengard et al., 2006). While educating SUD clients about the benefit of practicing safe sex—and the risks of neglecting to do so—is important, it is also important that the overall tone of that sex education communicates that sex is a natural and healthy act. Normalizing the act of sex avoids shaming clients and communicates that sex is a topic which is always open for discussion.

There are some limitations for the evidence supporting the efficacy of sex education for reducing the transmission of HIV and STIs amongst clients in SUD treatment. For example, data indicates that current HIV education counseling interventions are less effective for Hispanic populations due to the lack of intervention’s cultural considerations (Crits-Christoph et al., 2014). This reality highlights the need to always consider whether a sex education intervention is appropriate for use with particular clients according to their unique identities. Not only should race be considered, but also gender, sexual orientation, religious affiliation, and other factors. Unfortunately, there appears to be a lack of research examining the effectiveness of HIV prevention interventions for people of nondominant identities.

There is some evidence pointing to the likelihood that sex education helps promote the recovery process. For example, providing sex education to men who abuse substances can be particularly helpful if it focuses on the themes of “self-esteem, intimacy, and sexuality . . . [which are] . . . central issues for men in recovery . . . [since] . . . men often have difficulty acknowledging their needs, fears, and concerns in these areas because of male gender-role socialization” (Bartholomew et al., 2000). Helping men gain confidence surrounding discussions of intimacy and sexuality can empower them to deepen their romantic partnerships. The deepening of relationships in that sense is important since close, supportive relationships are associated with increased chances of recovery from substance abuse (Bartholomew et al., 2000). Despite the likelihood that such comprehensive sex education programs increase chances of recovery, these programs are typically not included in usual SUD treatment plans (Bartholomew et al., 2000).

Recognizing the multifaceted relationship between sex and substance abuse (e.g. substance use increasing sexual desire or performance), a number of SUD treatment programs have incorporated sexuality education into their extant programs, or developed new programs incorporating both areas of concern (Caslyn et al., 2010). The following three examples highlight models that have demonstrated success in increasing participants’ sexual self-efficacy, sexual health knowledge, and communication skills, in attempts to decrease participants’ substance use and increase their sexual health. The authors of this article note these program models largely conform to heteronormative scripts and offer no explicit concern for inclusion of individuals who identify as gender nonconforming (GNF). The recommendations section of this article details simple modifications to these exemplars that would broaden their applicability to more diverse populations.

Time Out! for Men (TOFMEN) is an eight-session, manualized educational module developed to supplement substance abuse treatment programming (Bartholomew et al., 2000). As its title suggests, TOFMEN was designed for treatment groups comprised solely of those who identify as male. Curriculum content focuses on concepts that promote positive interpersonal and romantic relationships, including communication and conflict resolution skills, sexual attitudes, sexual health education, and gender roles. Researchers selected these components for two reasons: to help address the socialized restricted emotional expression and rigid gender roles that have been found to interfere with men’s ability to pursue emotionally supportive relationships (Bartholomew et al., 2000). Secondly, program developers sought to dispel the sexual myths and lack of knowledge about sexual health issues that promote unsafe sexual behavior. Further, research has demonstrated that strong social supports are integral in helping men reduce substance use (Booth et al., 1992). With romantic partners having the potential to promote the continuation of abstinence, providing male substance users with tools to make these relationships successful could have a strong positive effect on sobriety (Bartholomew et al., 2000).

TOFMEN’s eight-session model moves from a heavy emphasis on communication skills (sessions one through six) to exploring healthy sexual behaviors. Specific topics include active listening, assertive conflict management training, identifying emotions, reproductive health, and self-esteem. Homework assignments are used to reinforce knowledge acquisition. In addition, participants are encouraged to discuss homework and in-session topics with their significant others, as well as practice new communication skills during these conversations. Based on pre- and posttest self-report, participants displayed increased knowledge of “sexuality, sexual health, communication skills, and gender role and socialization issues.” Additionally, participants showed “less rigid attitudes toward gender roles, sexual relationships, and societal expectations” (Bartholomew et al., 2000, p. 219).

Concentrating on the sexual and intravenous transmission of HIV and hepatitis B and C, WaySafe is a six-session, manualized risk-reduction curriculum developed to supplement drug abuse treatment conducted in the prison setting (Lehman et al., 2015). The program is specifically tailored to inmates nearing the ends of their sentences, thus preparing to confront a host of challenges upon release. Foci include helping participants identify risky behaviors and consequences as well as developing alternatives to such practices, even when indulging in risk represents their preference. Program developers utilized Texas Christian University (TCU) mapping-enhanced counseling, a visual, interactive processing technique used to improve participants’ engagement and information recall (Dansereau, Dees, Chatham, Boatler & Simpson, 1993). Researchers also used handouts and workbooks for intersession assignments to help clients absorb and contemplate risk reduction skills and facts concerning dangerous communicable diseases. Notably, WaySafe was piloted in both female and male prisons, boasting a three to five split, respectively. Further, one treatment group was composed of individuals with special needs.

Five knowledge areas were measured before the WaySafe program was completed:

1. HIV knowledge confidence
2. Avoiding risky sex
3. Avoiding risky drug use
4. HIV services and testing
5. Risk reduction skills

Participants were then introduced to TCU Mapping, followed by six sessions in which participants worked in small groups to discuss ways in which HIV and hepatitis are spread; how to reduce their risk of contracting and spreading the illnesses; the differences between their “shoulds” and “wants” and how to use “shoulds” to navigate risky, tempting situations; and proactive problem-solving (thinking, planning, rehearsing) to cope with familiar triggers for substance use and unsafe sexual practices (Lehman et al., 2015). Inmates were then retested on the five aforementioned knowledge areas. Compared to inmates who received the standard substance abuse treatment offered in their correctional facilities, those who participated in WaySafe showed significant improvement in all five subjects. Further, WaySafe graduates demonstrated higher motivation to reduce risky behaviors, reported that they understood “it may be necessary to reduce their enjoyment in order to avoid risky sex,” and felt that “their confidence in managing emotions in sexual situations had increased” (Lehman et al., 2015, p. 31).

Real Men Are Safe (REMAS) is a five-session, manualized educational program developed by the National Institute of Mental Health (NIMH; Calsyn et al., 2009). Like WaySafe, one of the program’s primary focus is the transmission of HIV. However, in addition to identifying and coping with highly sexually risky scenarios, REMAS incorporates discussions about the perceived benefits of engaging in sex under the influence. These participant-reported benefits are acknowledged and explored as triggers for substance use and treated as potential causes for relapse. The first sessions open with basic education about the transmission and prevention of HIV, moving on to risky sexual and injection practices, and identifying triggers for sexually risky behavior (Calsyn et al., 2009). The final three sessions center on how substance use impacts sexual pleasure, how to cultivate pleasure without using drugs and alcohol, committing to practicing safer sex, and negotiating safer practices with partners. Roleplays and skills practice such as using “I” statements with a partner reinforce newly acquired knowledge and foster participant engagement.

Compared with a control group that received a single session of HIV education, men who participated in REMAS were less likely to report engaging in unsafe sex three and six months after completing the program (Calsyn et al., 2009). In addition, a study conducted in 2010 using the same model found that program participants reported fewer episodes of sex under the influence at three months after program completion (Caslyn et al., 2010). Further, researchers investigated the satisfaction level of those men who reported last having sex under the influence versus sober, revealing that men whose last encounter was carried out without the aid of substances reported higher satisfaction (Caslyn et al., 2010).

Comprehensive, nonjudgmental, and supportive sexuality education has the potential to amplify the effects of SUD treatment. Such education can help decrease the impulse to use substances in order to engage in sexual behaviors; the desire to engage in sexual behaviors in order to use; and decrease the overall risk of contracting an STI or other sexually transmitted diseases. Stated simply, recommendations are to expand widespread access to sexual education within SUD treatment settings and to standardize the integration of sexual education programming into those same treatment settings.

Based on current successful programming, the most effective integration of sexual education is multisession, manualized, and structured (Bartholomew et al., 2000; Calsyn et al., 2009; Lehman et al., 2015). The existing programs, however, are largely designed for men, specific to heterosexual monogamous relationships, and focused on prevention of STI contraction. The apparently successful characteristics of being multisession and manualized can therefore be applied to the development of a more inclusive, novel sexual education program for implementation in substance abuse treatment programs. It is strongly suggested that any educational efforts should be inherently sex positive. Rather than shaming participants for engaging in sexual behaviors, sex can be conceptually reframed as a positive and natural human experience that can occur without the use of substances. Education provided, therefore, encompasses both safer sex practices and more broad-spectrum education on consent, healthy relationships, masturbation, and sexual pleasure that does not trigger the impulse to use. Finally, the sexual education proposed should make efforts to actively include individuals of varying racial and ethnic backgrounds, sexual orientations, gender identities, ability statuses, and body types. With the following recommendations, a safe space can be created to address the challenges of the intersection of substance use and sexual behavior in a way that will be more effective than abstaining from both or attempting to treat them as separate, discounted behaviors.

Bartholomew, N. G., Hiller, M. L., Knight, K., Nucatola, D. C., & Simpson, D. D. (2000). Effectiveness of communication and relationship skills training for men in substance abuse treatment. Journal of Substance Abuse Treatment, 18(3), 217–25.

Booth, B. M., Russell, D. W., Yates, W. R., Laughlin, P. R., Brown, K. & Reed, D. (1992). Social support and depression in men during alcoholism treatment. Journal of Substance Abuse Treatment, 4(1), 57–67.

Calsyn, D. A., Hatch-Maillette, M. A., Tross, S., Doyle, S. R., Crits-Christoph, P., Song, Y. S., . . .  Berns, S. B. (2009). Motivational and skills training HIV/STI sexual risk reduction groups for men. Journal of Substance Abuse Treatment, 37(2), 138–50.

Calsyn, D. A., Crits-Christoph, P., Hatch-Maillette, M. A., Doyle, S. R., Song, Y. S., Coyer, S., & Pelta, S. (2010). Reducing sex under the influence of drugs or alcohol for patients in substance abuse treatment. Addiction, 105(1), 100–8.

Crits-Christoph, P., Gallop, R., Sadicario, J. S., Markell, H. M., Calsyn, D. A., Tang, W., . . . Woody, G. (2014). Predictors and moderators of outcomes of HIV/STD sex risk reduction interventions in substance abuse treatment programs: A pooled analysis of two randomized controlled trials. Substance Abuse Treatment, Prevention, and Policy, 9(1), 3.

Dansereau, D., Dees, S., Chatham, L., Boatler, J. & Simpson, D. D. (1993). Mapping new roads to recovery: Cognitive enhancements to counseling. Fort Worth, TX: Texas Christian University.

Dunk, P. (2007). Everyday sexuality and social work: Locating sexuality in professional practice and education. Social Work & Society, 5(2), 135–42.

Lehman, W. E. K., Rowan, G. A., Greener, J. M., Joe, G. W., Yang, Y. & Knight, K. (2015). Evaluation of WaySafe: A disease risk curriculum for substance-abusing offenders. Journal of Substance Abuse Treatment, 58, 25–32.

Lorvick, J., Bourgois, P., Wenger, L. D., Arreola, S. G., Lutnick, A., Wechsberg, W. M., & Kral, A. H. (2012). Sexual pleasure and sexual risk among women who use methamphetamine: A mixed methods study. The International Journal of Drug Policy, 23(5), 385–92.

McCave, E., Shepard, B., & Winter, V. R. (2014). Human sexuality as a critical subfield in social work. Advances in Social Work, 15(2), 409–27.

Rosengard, C., Anderson, B. J., & Stein, M. D. (2006). Correlates of condom use and reasons for condom non-use among drug users. American Journal of Drug and Alcohol Abuse, 32(4), 637–44.

Winhusen, T. M., Somoza, E. C., Lewis, D. F., Kropp, F., Theobald, J., & Elkashef, A. (2014). An evaluation of substance abuse treatment and HIV education on safe sex practices in cocaine-dependent individuals. ISRN Otolaryngology, 2014, 1–7.