Sexual Health in Recovery

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Link between substance use and sexuality

Substance misuse/addiction is often linked to other dependent behaviors and attitudes, such as addiction to people and relationships. At the roots of the addiction tree is the underlying damage of shame, abuse, anger, grief, loss, fear, and loneliness. This link of sex and substance results in the need for specific sexual health relapse prevention skills and interventions. A relapse prevention plan that includes sexual health aims to identify patterns of linked behaviors and takes steps towards minimizing sexual health risks that may trigger substance use relapse. A dialectic prevention plan can prevent a slip turning into a relapse and should consider these domains*:

  • Sex/drug-linked behaviors: Dating, relationships patterns, sexual decision making while high/drunk.
  • Sexual past: Sexual development, non-consensual sex, out of control sexual behavior.
  • Sexual values and attitudes:  Motivation for sex, talking about sex, spirituality, relationship expectations and ideas of sexual pleasures/taboos.
  • Sexual health:  Sexual functioning, boundaries and the relationship with my body.

On this page you will find these topics to explore in regards to sexual health in recovery:

  • Addressing sex/drug linked behavior and making  a plan that suits your relapse risk
  • Individuality and co-dependent relationships
  • Transferring short-term gratification to long term goals
  • health facts about sexuality in recovery

All of the following sections include tips and suggestions to include in relapse prevention and living life in recovery.

Sex and substance linked behavior

Ask yourself:

  • In the last 12 months, have you had sex while high, intoxicated or drunk?
  • Do you feel freer to be sexual when you are high on drugs or alcohol?
  • Do you feel self-conciseness to have sex when you are sober?
  • Is your sexual activity a significant concern in your recovery?

Identify the challenges: Which of the following factors of sexual health in recovery concern you the most? consider all that apply to you:

  • Pregnancy
  • HIV/AIDS     
  • STI’s          
  • Sexual Dysfunction
  • (Psychiatric/MAT) Medication Side Effects
  • Non-consensual Sex
  • Out of Control Sexual Behavior
  • Co-dependent relationships

Make a plan:  Given your factors of concern, which of these skills and actions will you include in you relapse prevention plan?

  • Using condoms/protection during sex
  • Burning bridges that will trigger relapse
  • Not having sex while high or drunk
  • Getting tested for STI and HIV
  • Avoiding intimacy
  • Not using sex to avoid/escape emotions
  • Having sex only when sober
  • Setting and keeping clear boundaries
  • Using mindfulness to regulate my thoughts, emotions, and behaviors
  • Using birth control
  • Radically accepting my addiction
  • Radically accepting my addiction
  • Talking to my doctor about side effects
  • Accepting and experiencing my emotions
  • Practice delayed gratification
  • Developing behavioral skills to manage impulsivity
  • Talking to my therapists about sex
  • Avoiding co-dependent relationships
  • Avoiding sexual activity that might trigger relapse

Individuality and Co-Dependency  

Did you ever hear of someone saying “My partner is my other half”, or “They complete me”? However, each person is an entire life of individuality, a complete circle on their own. You don’t need anyone to complete you. 

When we join with another person in an intimate relationship, the unity can take on different forms and the distance between the two people can vary. This connection can positively or negatively affect our emotional regulation, decision making, and impulsive behaviors. 

Codependency is a relationship that restricts an individual’s freedom and satisfaction. An overly enmeshed relationship creates a unity to such a degree that there is no individuality left, and can lead to abuse, control, emotional dysregulation, poor decision making, impulsivity, and may damage your recovery process. 

In codependent relationship, both people’s identity, values, worth, goals, and needs are all defined by the relationship or the other person in the relationship. In this kind of relationship you can see how manipulation, insecurity and bad habits, can lead to controlling someone’s behavior, engaging in activities to excess, and feeds the need to be needed. 

Commit to Avoid Co-dependency and Become Independent

  • Stop being a victim
  • Trust yourself
  • Prioritize your needs
  • Distinguish between wants & needs
  • Exercise your rights
  • Feel your feelings
  • Be compassionate and kind to yourself
  • Stop tormenting yourself
  • Be independent
  • Control self-doubt
  • React mindfully
  • Set boundaries
  • Practice communication
  • Be responsible
  • Stop codependent behaviors
  • Connect to your spirituality
  • Live your life in recovery

Transferring short-term gratification to long term goals

Some short term gratification, like using substances or engaging in sexual and /or risky behavior, can interfere with your long term goals of recovery. Instant gratification is a habit where you indulge in short-term pleasure (like sex) that might eventually lead to long-term pain (like relapse, or STIs). You find reasons (excuses) to do something even if it damages your objective.

Reasons why folks choose short term pleasure over long term goals:

  • Low  distress tolerance  (ex: giving in, ending a relationship to avoid emotions, not using skillful behaviors)
  • Failure to consider consequence  (ex: reacting with rage, sexual impulsivity)

Your goal is to tolerate short-term pain that will eventually lead to long-term pleasure. In recovery, it is sometimes best to give something up (sex, substances, relationships….) in order to gain something back (a job, a home, money, health, your family, happiness…)

What to do When You Get Caught in the Instant Gratification Trap

Be Mindful – Will this decision help or hurt me? What’s the long-term impact of this fleeting moment of pleasure? Is it worth indulging in this temptation? What will be the long-term impact if I get into the habit of indulging in this behavior/pleasure?

Focus on the Big Picture – What’s the big picture? Why is it important to achieve this outcome? How will I benefit from achieving this outcome?

Eliminate Temptations – You must now leave this temptation behind and get back on track as quickly as possible. Don’t ignore what just happened but rather plan for the future so this temptation is even more distant and it will become difficult to fall back into the old traps.

Learn from Your Experience – What can I learn from this experience? How could I do better next time? Reflect on your actions.

8 Ideas to Avoid Falling into the Instant Gratification Trap

  • Stop Thinking About Short-term Pleasures
  • Invest in future gains
  • Keep Yourself Accountable
  • Learn to Manage Self-Control
  • Prepare for Short-Term Pain
  • Develop Long-Term Motivation
  • Create Visual Reminders of Your Goals
  • Quit justifying your actions

Sexual Health Facts on Substances and Sexuality

The relationship between drugs and sexual dysfunction is not always direct, but depends on the social, cultural and other peripheral factors of the individual. Alcohol consumption, tobacco smoking, and other substance use and dependency have long been associated with sexual dysfunction, combined with a significant decrease in sexual desire, intercourse frequency, masturbation, sexual health, and quality and frequency of orgasms.

FACTORS IN SEXUAL DYSFUNCTIONS– Non biological and biological factors play a role in sexual function. Sexual dysfunction may be due to drug use or current MAT (Medication-Assisted Treatment)  use, and could also be caused by harmful sexual relations in the past, past sexual abuse, associated psychiatric conditions (such as anxiety, depression, or eating disorders), insomnia and other social, cultural, economic, and health challenges.

Typically for women, but may challenge all genders,  sexual dysfunction is a common disorder, not only for substance users, and is a complex multi factor phenomenon that encompasses emotional intimacy and relationship satisfaction, along with other psychosocial factors across cultures, sexual orientation and socio-economic statuses, with a potential to negatively affect relationships and impair quality of life.

THE BRAIN AND SEX- Psychoactive drugs have an adverse effect on the brain, which in turns decreases sexual health. They negatively influence neurotransmitters, which relate to behaviors of impulse control, inhibition, emotions, moods, and pleasure, all areas tied to sexual health.  The drugs also adversely affect various parts of the sexual regulatory system:

  • The central inhibitory neuroendocrine mechanisms (which regulate reproduction, metabolism, eating and drinking, energy utilization, and blood pressure), which is linked to sexuality,
  • The local neuromuscular junction (where motor neurons transmit a signal to the muscle fiber, causing muscle contraction), which may affecting the muscles of the sexual organs,
  • The hormone system, which may decrease sexual function, arousal and drive.

Overall, the reward system in a brain on substances usually experiences significant decrease in sexual responsiveness, as well as adverse changes to the limbic system that controls mood and attitude.

In addition, opioids specifically inhibit the hypothalamic-pituitary-gonadal axis, which is the important control mechanism mainly involved in the development and regulation of the reproductive system and immune system, and increase prolactin levels, which affect both the male and female sexual response.  

SEXUALITY ATTITUDES – Homophobia, transmisogyny,  sexism, sexual taboos and the emotionally charged atmosphere that often surround sexuality can affect the personal beliefs and skills of service providers and clients alike. This charged value and belief system may incur adverse effects on the client’s access to discuss and problem-solve health concerns or issues related to sexual practices.

General types of sexual dysfunction –

  • Desire disorders: lack of sexual desire or interest in sex
  • Arousal disorder – inability to become physically aroused or excited during sexual activity (erectile dysfunction in males and lack of vaginal lubrication in females)
  • Orgasm disorder – delay or absence of orgasm (climax)
  • Pain disorder – pain during intercourse/ sexual activity

Issues / side effects typically found in people with substance abuse disorders

Males –

  • Erectile dysfunction is common among substance abusers. Erectile dysfunction is the inability to achieve or maintain an erection suitable for intercourse and may decrease quality of life.  Erectile dysfunction as a side effect of MAT in substance abusers can be of concerns, and should be treated on a case by case basis.
  • Absent or delayed ejaculation despite adequate stimulation and pleasure.

Females –

  • Low vaginal lubrication, revealing problems with sexual arousal or hormone levels. (note: vaginal lubrication does not necessarily signify arousal)
  • Dyspareunia – painful sexual intercourse due to medical or psychological causes. The pain is primarily on the external surface of the vagina/vulva, or deeper in the pelvis triggered by intercourse and pressure on the cervix.

In addition, for all sexes/genders:

  • Challenges with intimacy – difficulty in maintaining effective intimate relationships, typically in early recovery, and may require specific and individualized relapse prevention plan.
  • High risks of STIs, as many IV drug users are positive for one STI or another or engage in impulsive sexual behaviors.
  • Genitourinary health problems – issues in the reproductive systems and the urinary system.
  • Other mental health medications (such as SSRI) may decrease sex drive significantly.

Managing the problems

For some, there is a direct link between substance use and sexual behaviors and health. Managing issues with sexuality and intimacy is especially important when someone is in recovery. One may relapse as a relief of symptoms related to sexual dysfunction or numb negative feelings in response to the inability to achieve and maintain sexual pleasure.  

Discuss this matter with your clinician, doctor, mental health counselor, substance abuse specialist and/or whoever you feel will be open to discussing these issues without shame or difficulties. Discuss sexuality in the context of your life, your partner/s, your community, and most importantly – your recovery.

Forms of treatment –

  • Medication – Having your doctor check for hormone levels and perform a complete physical may assist in finding solutions individualized to your health needs.
  • Behavioral treatments- Involving various techniques, including insight into harmful behaviors in relationships, or skills building focused on sexual health in recovery.
  • Psychotherapy – Therapy with a trained counselor or sex therapist can help a person address sexual trauma from the past, as well as the effect of anxiety, shame, guilt, or fear around sexuality, all issues that may have an impact on sexual functions, behaviors and health. Make sure to find a sexuality competent therapist that you feel comfortable discussing sexual health matters and who will respect your identity and sexuality.

*Some of the ideas presented here are adapted from: Braun-Harvey, D. (2011) Sexual Health in Recovery, The Harvey Institute