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Sistema de Información Científica
Red de Revistas Científicas de América Latina y el Caribe, España y Portugal
Health and Addictions, Vol. 15, No.1, 39-48
39
© Health and Addictions 2015
ISSN 1578-5319 ISSNe 1988-205X
Vol. 15, No.1, 39-48
Recibido: Septiembre 2014 – Aceptado: Enero 2015
RELATIONSHIP BETWEEN DRUG USE AND SEXUAL ASSERTIVENESS IN A
SPANISH MALE DRUG-DEPENDENT SAMPLE
RELACIÓN ENTRE CONSUMO DE DROGAS Y ASERTIVIDAD SEXUAL EN
UNA MUESTRA DE VARONES DROGODEPENDIENTES
Pablo Vallejo-Medina
1
& Juan Carlos Sierra
2
1
Fundación Universitaria Konrad Lorenz, Facultad de Psicología, Colombia
2
Universidad de Granada, Centro de Investigación Mente, Cerebro y Comportamiento
(
CIMCYC), Spain
Abstract
Resumen
Current studies assessing sexual assertiveness in drug users
are sparse, despite the fact that it would be logical to expect
low sexual assertiveness in such patients. Present study had
the objective to compare sexual assertiveness between
consumers of alcohol, cocaine, cocaine+alcohol, heroin,
cannabis, and speedball and a control group. This was
assessed in a sample of 556 male drug users from 8 Spanish
provinces
and
356
non-user
males. Results
showed
significantly lower Initiation assertiveness in the 35-49 year-
old age group (particularly in the case of alcohol, heroin,
cannabis, and speedball) and worse Sexually Transmitted
Diseases and Pregnancy prevention assertiveness in drug
users (in the case of alcohol, cocaine, cocaine+alcohol,
cannabis, and speedball). Effect sizes ranged from low to
moderate. The implications of these results are discussed.
Keywords: sexual assertiveness, drug users, SAS, sexuality,
substance dependence.
Hasta la fecha prácticamente no existen estudios que
evalúen la asertividad sexual en consumidores de
drogas, a pesar de que sería lógico esperar una baja
asertividad sexual en estos pacientes. El presente
estudio, tiene el objetivo de comparar la asertividad
sexual entre consumidores de alcohol, cocaína,
cocaína+alcohol, heroína, cannabis y speedball con
un grupo control. Se evaluaron a 556 consumidores
de droga de 8 provincias españolas y a 356 varones
no consumidores. Los resultados muestran una
asertividad sexual de Inicio significativamente menor
en el grupo de
35-49 años (sobre todo para el
alcohol, heroína, cannabis y speedball) y una peor
asertividad sexual de Prevención de Embarazo-
Enfermedades
de
Transmisión
Sexual
en
los
consumidores
de
droga
(alcohol,
cocaína,
cocaína+alcohol, cannabis y speedball). Los tamaños
de efecto oscilaron entre bajos y moderados. Las
implicaciones de los resultados serán discutidas.
Palabras clave: a
sertividad Sexual, consumidores de
droga, SAS, sexualidad, dependencia de sustancias.
Correspondencia: Pablo Vallejo-Medina
Facultad de Psicología. Fundación Universitaria Konrad Lorenz.
Carrera 9 Bis No. 62– 43
Bogotá (Colombia)
E-mail: pablo.vallejom@konradlorenz.edu.co
The authors wish to thank the following institutions in Spain for their
cooperation in this research: ACLAD (A Coruña), CAD de Arganzuela (Madrid),
CAD San Blas (Madrid), Institut de Neuropsiquiatria i Addiccions del Parc de
Salut Mar-Hospital del Mar (Barcelona), Fundación Noray-Proyecto Hombre
Alicante (Alicante), UMAD (Santiago de Compostela), Proxecto Home Galicia
(Galicia), Proyecto Hombre Granada (Granada), and the “Cortijo Buenos
Aires” Resource of the Social Service Network of the Regional Government of
Andalusia (Granada).
PABLO VALLEJO-MEDINA & JUAN CARLOS SIERRA
40
Health and Addictions, Vol. 15, No.1, 39-48
In drug users, three areas of sexuality may imply a
serious sexual health problem if they are impaired: sexual
functioning, consensual-desired sex, and risk sexual
behaviors. As defined by Morokoff et al. (1997), sexual
assertiveness refers to people’s ability to initiate sexual
activity,
reject
unwanted
sexual
activity,
and
use
contraceptive
methods,
developing
healthy
sexual
behaviors. These three areas (
Initiation, Refusal
,
and
Sexual Transmitted Diseases and Pregnancy Prevention
{
STD-
P
}) are very closely linked to sexual functioning, sexual
victimization, and risk sexual behaviors, respectively
(Santos-Iglesias & Sierra, 2010). Despite its importance,
the role of sexual assertiveness has traditionally been
underestimated in males (Morokoff et al., 2009). In fact,
studies exploring sexual assertiveness in male drug users
are practically nonexistent, even though there are teorical
basis to to expect sexual assertiveness to be impaired in
such patients.
Sexual
assertiveness,
sexual
functioning,
and
substance use
Initiation sexual assertiveness is related to sexual
functioning. Numerous studies have proven the existence
of this relationship in the normal population (Haavio-
Mannila & Kontula, 1997; MacNeil & Byers, 1997; Ménard
& Offman, 2009; Sánchez-Fuentes, Santos-Iglesias, &
Sierra, 2014; Santos-Iglesias, Sierra, & Vallejo-Medina,
2013). At least in the long term and/or in high doses, drug
use has also been proven to decrease sexual functioning
(Bang-Ping, 2009; Johnson, Phelps, & Cottler, 2004; Palha
& Esteves, 2002; Vallejo-Medina & Sierra, 2013a, 2013b).
To the best of our knowledge no studies have assessed
sexual assertiveness from a clinical perspective. The first
approximation was Vallejo-Medina and Sierra (in press)
with a psychometric paper in this population, but they did
not use a control group to compare scores.
Sexual
assertiveness,
sexual
victimization,
and
substance use
Few
studies
have
explored
Refusal
sexual
assertiveness or sexual victimization, its counterpart, in
males (Santos-Iglesias & Sierra, 2010b). Low sexual
assertiveness can be both a consequence of victimization
and a risk factor for experiencing it (Folgar, Fariña Rivera,
Sierra, & Vallejo-Medina, in press; Livingston, Testa, &
VanZile-Tamsen, 2007). Being under the influence of
alcohol is also a contributing factor for experiencing
sexual victimization (Brecklin & Ullman, 2005). In males,
Shacham and Cottler (2010) reported that 8.60 % of the
drug users surveyed admitted having had unwanted
sexual
contact,
whereas
52.75
%
of
cocaine
and
methamphetamine users admitted having taken part in
sexual practices that were uncommon to them because
they were under the influence of the drug. Clinical
practice reveals that they later regret participating in
some of these practices. Although such behaviors may be
exclusively due to the withdrawal syndrome or to acute
use of the substance, Refusal sexual assertiveness may
play a modulating role in them.
Sexual assertiveness, risk sexual behaviors, and
substance use
The
prevalence
of
STDs/VIH
is
increasing
in
heterosexual males who use non-injection drugs (Bellis et
al., 2008; Booth, Kwiatkowski, & Chitwood, 2000; Raj,
Saitz, Cheng, & Winter, 2007). These men are less likely to
use a condom and have safe sex than men who have sex
with other men (Ross & Williams, 2001). The most
common risk behaviors in this population are trading sex
for drugs or money, having intercourse without condoms
or having sex with multiple partners (Booth et al., 2000;
Calsyn et al., 2010; Celentano, Latimore, Mehta, 2008; Raj
et al., 2007). STD-P sexual assertiveness may play an
important
protective
role
against
these
three
risk
behaviors.
This
variable
may
provide
a
better
understanding of the relationship between high-risk
behaviors and substance use, along with sexual arousal
(George et al., 2009; Gerrard, Gibbons & Buishman, 1996),
the context of drug use, the type of sex partner (Leigh,
Ames & Stacy 2008; Maisto, Carey, Carey, Gordon, &
Schum., 2004), and distress (Elkington, Bauermeister &
Zimmerman, 2010; Morokoff et al., 2009). This issue is key
both for prevention and treatment (Calsyn et al., 2010). In
fact, sexual assertiveness has proven to be a strong
predictor of risk sexual behaviors (Noar, Carlyle, & Cole,
2006, Schooler, Ward, Merriwether, & Caruthers, 2005;
Zablotsky & Kennedy, 2003) and is related to actual
condom use (Auslander, Perfect, Succop, & Rosenthal,
2007; Crowell, 2004; Morokoff et al., 2009; Vallejo-Medina
& Sierra, In press). In addition, alcohol use reduces the
skills required to negotiate safe sex (Maisto, Carey, Carey,
& Gordon, 2002). Stoner et al. (2008) observed that sexual
assertiveness can act as a modulator of the effect of
alcohol on insistence to use a condom. In Thailand, a
program with components of sexual assertiveness was
applied
to
methamphetamine
users.
Participants
RELATIONSHIP BETWEEN DRUG USE AND SEXUAL ASSERTIVENESS IN A SPANISH MALE DRUG-DEPENDENT SAMPLE
Health and Addictions, Vol. 15, No.1, 39-48
41
reduced their use of methamphetamines and moderately
increased condom use up to 12 months after the
program was over (Sherman et al., 2009).
Objectives
The present research objective is: to assess the
existence of differences in sexual assertiveness between
a drug user group and a control group, exploring possible
differences depending on the main substance used and
determining
the
possible
influence
of
low
sexual
assertiveness on the sexual health of participants.
METHOD
Participants
The control group was composed of 356 non-drug
user males. The drug user group was composed of 556
withdrawal male drug users (of which 109 consumed
alcohol, 143 cocaine, 137 cocaine+alcohol, 53 heroin, 37
cannabis,
and
70
speedball).
No
significant
age
differences were found between drug users (
M
= 35.27,
SD
= 8.61) and non-users (
M
= 35.20,
SD
= 11.55) (
t
(907) =
-.01,
p
= .92). Significant differences were found between
drug users and non-users regarding educational level (
χ
2
(4) = 300.39,
p
= .00) and marital status (
χ
2
(5) = 121.77,
p
= .00). In drug users, mean duration of use was 13.73
years (
SD
= 7.83) and mean time of abstinence was 1.05
years (
SD
= 2.01).
Requirements to be included in the drug user group
were being over 18 years old, being abstinent for at least
two weeks prior to the assessment, being able to read
and write, and being treated for a substance dependence
disorder (DSM IV-R). In the control group, the absence of
substance use was confirmed, although a maximum of 45
g of alcohol a day was allowed (about 1 l of beer) as well
as occasional cannabis use (1 joint a week).
Instruments
Sexual Assertiveness Scale (SAS; Morokoff et al.,
1997; Sierra, Santos-Iglesias, & Vallejo-Medina, 2012). The
adaptation for drug users developed by Vallejo-Medina
and Sierra (in press) was used. On this occasion, as
recommended by Vallejo-Medina and Sierra (In press),
the scores of the non-user and the user group were
compared using a 17-item version (1 item less than the
original version, as item 1 in the Initiation subscale was
highly biased between the drug user and the normal
population). Items are responded on a 5-point Likert
scale. They are clustered into three dimensions:
Initiation,
Refusal,
and
Sexual
Transmitted
Diseases-Pregnancy
Prevention
(
STD-P
). The English and Spanish versions of
the scale have shown good reliability, ranging from .66 to
.86 (Santos-Iglesias & Sierra, 2010b; Sierra, Vallejo-
Medina, & Santos-Iglesias, 2011). The adaptation for drug
users also obtained good reliability, a strictly equivalent
factor structure to the normal version and, except for
Item 1, which was excluded, no high Differential Item
Functioning was found in any other items. In the present
study, reliability coefficients were .73 and .63 in
Initiation
for the control and experimental groups, respectively; .82
and .73 in
Refusal
for the control and experimental
groups, respectively; and .89 and .80 in
STD-P
for the
control and experimental groups, respectively. Higher
scores indicate higher sexual assertiveness.
Changes in Sexual Functioning Questionnaire-Drugs
(CSFQ-D;
Vallejo-Medina
&
Sierra,
2013a).
This
questionnaire is an adaptation for drug users of the
CSFQ-14 (Keller, McGarvey, & Clayton, 2006), in its
Spanish version (Bobes, González, Rico-Villademoros,
Bascarán, Sarasa, & Clayton, 2000; García-Portilla et al.,
2011; Vallejo-Medina, Guillén-Riquelme & Sierra, 2010).
The CSFQ-D has shown an equivalent four factor-
structure (
Pleasure, Desire, Arousal,
and
Orgasm
) in drug
user and non-user populations. The scale has good
reliability, with alpha values ranging from α = .83 in
Pleasure
to α = .61 in
Orgasm.
The questionnaire has also
shown good external validity indicators. The following
Cronbach alpha values were obtained in the present
study:
Pleasure
= .80,
Desire
=.66,
Arousal
= .67, and
Orgasm
= .49 in the normal population and
Pleasure
= .82,
Desire
=.70,
Arousal
=.74, and
Orgasm
= .55 in the drug
user population. Higher scores indicate better sexual
functioning.
Cuestionario Consumo Sustancias
(Questionnaire on
Substance Use, CCS; Vallejo-Medina et al., 2011). This is a
short, simple, and clear 16-item questionnaire containing
the diagnostic criteria of the DSM-IV-R. It is useful to
diagnose problems of substance dependence, abuse and
intoxication. Items are responded on a dichotomous
(yes/no) scale. Spearman’s correlation with the diagnosis
made by the various institutions (using EuropASI and
PABLO VALLEJO-MEDINA & JUAN CARLOS SIERRA
42
Health and Addictions, Vol. 15, No.1, 39-48
personal interviews) was .85,
p
= .00. Reliability was .88 in
the original version and .89 in the present study.
Ratio of Protected Sex: Was created by dividing the
number of sexual partners in the past year with whom
condoms were used between the total numbers of sexual
partners in the last year. Maximum risk would be 0 and 1
would be minimal risk.
Questionnaire
on
substance
use
and
sociodemographic data. The variables assessed were
preferred
substance,
amount
of
substance
used,
frequency of use, and length of use. This information was
used to calculate severity of substance use. Time of
abstinence was also obtained through self-reports or
urine or blood tests, depending on the procedure used in
each institution.
Procedure
The user group was recruited by cluster sampling
from the following institutions: ACLAD in A Coruña, UMAD
in Santiago de Compostela, Proxecto Home Galicia in
Galicia,
Proyecto
Hombre
Granada
in
Granada,
Fundación Noray-Proyecto Hombre in Alicante, Institut de
Neuropsiquiatria i Addiccions del Parc de Salut Mar-
Hospital del Mar in Barcelona, CAD San Blas in Madrid,
CAD de Arganzuela in Madrid, and the “Cortijo Buenos
Aires” Resource of the Social Service Network of the
Regional Government of Andalusia in Granada. The
control group was recruited by convenience sampling
from adult training centers, community centers, training
courses for jobseekers, and universities. Anonymous
responses, voluntary participation, and the scientific
purpose of the study were guaranteed by written
informed consent in drug users and verbal informed
consent in control subjects. The assessment lasted
approximately 30 minutes.
This research was reviewed and approved by the
independent Ethics Board of our institution in accordance
with the 1975 Declaration of Helsinki, as revised in the
1983 Ethics Committee for Clinical Research.
RESULTS
A
t
-test was used to calculate the differences of means
between the user and non-user group in SAS
Initiation
(
M
user
= 10.91{
SD
= 4.10};
M
non-user
= 11.45{
SD
= 3.81}), SAS
Refusal
(
M
user
= 10.30{
SD
= 4.57};
M
non-user
= 10.89{
SD
= 5.25}), and
SAS
STD-P
(
M
user
= 11.11{
SD
= 6.38};
M
non-user
= 13.51{
SD
=
6.86})
.
No significant differences were found in Refusal
t
(897) = 7.77,
p
= .76. Yet, significant differences were
found in Initiation
t
(867) = 1.96,
p
= .05,
d
= 0.13 and STD-
P
t
(890) = 5.31,
p
< .01,
d
= 0.36.
Age-related
differences
were
found
in
sexual
assertiveness (Santos-Iglesias, Vallejo-Medina & Sierra,
2014; Sierra et al., 2012). Therefore, the analyses were
conducted again after dividing the sample into three age
groups: youth (18-34 years), adults (35-49 years), and
older
participants
(+
50
years).
This
clarified
the
differences as follows: in Initiation, differences between
the control group (
M
= 12.23,
SD
= 3.57) and the
experimental group (
M
= 10.91,
SD
= 43.86) were only
significant in the adult group (35-49 years)
t
(330) = 3.04,
p
< .01,
d
= 0.35. Similarly, differences in STD-P were only
significant in youth
t
(457) = 6.40,
p
< .01,
d
= 0.61 (control
group {
M
= 15.35,
SD
= 6.97} and experimental group {
M
= 11.20,
SD
= 6.56}).
Next, correlations were calculated between Initiation and
sexual functioning and between STD-P and the safe sex
ratio. Significant correlations were found in SAS
Initiation
(see Table 1), particularly in the adult and older age
groups. Significant correlations were also observed (
p
<
.01) between STD-P and the safe sex ratio
r
=
.
48,
r
=
.
42,
r
=
.
65,
respectively
for
youth,
adults,
and
older
participants. The mean of the safe sex ratio for each
group was .53 (
SD
= 0.43), .53 (
SD
= 0.45), and .50 (
SD
=
0.47), respectively.
Table 1. Pearson correlations between the dimensions of the CSFQ-D and
SAS
Initiation
in the three age groups
Pleasure
Desire
Arousal
Orgasm
Initiation
Youth
.15**
.20**
.13**
.07
Adults
.18**
.22**
.18**
.27**
Older
.30**
.18
.18
.25*
Note
: ** =
p
< .01; * =
p
< .05.
Finally, an ANOVA was performed to determine
whether there were differences depending on the main
substance used. As expected from the data shown above,
differences depending on the preferred substance were
only found in Initiation in adults
F
(6) = 4.00,
p
< .01, ω
2
=
.05 and in STD-P in youth
F
(6) = 7.86,
p
< .01, ω
2
= .08. To
determine exactly which users of which substances
showed differences compared to the control group, DMS
RELATIONSHIP BETWEEN DRUG USE AND SEXUAL ASSERTIVENESS IN A SPANISH MALE DRUG-DEPENDENT SAMPLE
Health and Addictions, Vol. 15, No.1, 39-48
43
post-hoc tests were performed (since the aim was only to
conduct comparisons with the control group). Results for
Initiation-adults are shown in Figure 1 and results for STD-
P-youth are shown in Figure 2. Statistical significance was
complemented by ω
2
, an indicator of effect size that is
less biased than η
2
for this type of tests (Young, 1993). It
was interpreted using the categorization made by Cohen
(1988), that is, .01 to .05, small association, .06 to .13,
medium association, and .14 or greater, large association
(see Table 2).
Figure 1. Initiation sexual assertiveness in the adult group. The Mean (
M
) and Standard Deviation (
SD
) are shown for each substance group. The statistical
significance of the differences compared to the control group (non-drug) is marked with asterisks (** =
p
< .01 and *
p
= < .05)
Figure 2
. STD-P sexual assertiveness in the youth group.
The Mean (
M
) and Standard Deviation (
SD
) are shown for each substance group. The statistical
significance of the differences compared to the control group (non-drug) is marked with asterisks (** =
p
< .01).
Table 2. Effect size (ω
2
) depending on the main substance used in Initiation-adults and STD-P-youth
alcohol
cocaine
cocaine+ alcohol
heroin
cannabis
speedball
methamphetamines
Initiation
.02
ns
ns
.09
.04
.03
ns
STD-P
.04
.07
.08
ns
.03
.08
ns
PABLO VALLEJO-MEDINA & JUAN CARLOS SIERRA
44
Health and Addictions, Vol. 15, No.1, 39-48
DISCUSSION
Based on the results obtained and considering
differences in age and type of substance consumed,
Initiation and STD-P sexual assertiveness seemed to be
lower in drug users than in non-users. In general terms,
Initiation sexual assertiveness, which is related to sexual
functioning, was found to be impaired in drug users,
although with a small effect size. A study of age groups
showed that Initiation was mainly impaired in the central
age group (35-49 years). In this age range, differences
were not only significant but also had a moderate effect
size. This study showed that, as expected, Initiation sexual
assertiveness was related to sexual functioning, with
significant – although low – correlations observed only in
the adult group in each area of sexual functioning
assessed (
Pleasure, Desire, Arousal
, and
Orgasm
). This
relationship had already been observed in the normal
population (Ménard & Offman, 2009; Santos-Iglesias &
Sierra, 2010b; Santos-Iglesias et al., 2013). Heroin was the
substance with the greatest impact on Initiation, with a
moderate effect size. In a recent comparative study,
Vallejo-Medina and Sierra (2013b) observed that opioid
users had the worst sexual functioning; Aguilar de Arcos
et al. (2008) and Bang-Ping (2009) obtained similar
results. Alcohol and cannabis users also seemed to have
problems initiating sexual relations. Only exciting drugs
did not seem to affect Initiation.
Refusal sexual assertiveness, related to undesired
sex and sexual victimization, did not seem to be impaired
in the sample studied.
Youth – the population at greatest risk for STDs
(Centers for Disease Control and Prevention {CDC}, 2005)
– were precisely the group with the worst sexual
assertiveness. This was shown by significant differences
with a moderate effect size. Having lower skills to
negotiate condom use has consequences: in the sample
studied, participants only used a condom with half of
their sexual partners. Only users of heroin, the archetypal
injection
drug,
did
not
show
worse
STD-P
sexual
assertiveness. As mentioned in the introduction, non-
injection drugs seem to be a new breeding ground for risk
sexual behaviors (Bellis et al., 2008; Booth et al., 2000; Raj
et al., 2007), as shown by the present study. Cocaine,
cocaine+alcohol, and speedball were the substances with
the lowest STD-P assertiveness scores, which were
significantly lower than those of non-users and had a
moderate effect size. Alcohol and cannabis also obtained
significantly lower scores (with a small effect size) than
those of non-users. When extrapolating the scores of
users of alcohol, cocaine, cocaine+alcohol, cannabis, and
speedball to the percentile ranking scores obtained in
Spain for males in the same age range (Sierra et al., 2012),
the mean ranged between percentiles 35 and 25.
Limitations,
conclusions,
and
future
research
directions
The main limitation of the present study is the
sampling method used, which was not probabilistic and
thus does not allow extrapolating the results to the
general population. Its design was also cross-sectional
and did not start from a baseline, so results must be
interpreted with caution and no causal relationships
should be inferred. In addition, it should be noted that
classifying drug users into specific substance groups
based
on
their
preferred
substance
is
just
an
approximation
that
disregards
multiple
use
issues.
However, this is an innovative study that used adapted
and validated instruments for its target population. To
date, studies on sexual assertiveness in drug users are
practically nonexistent. This study raises new questions.
For example, the potential relationship between low
sexual assertiveness and relapses in drug use should be
explored in the future. Finally, it seems that young non-
injection drug users have low skills to negotiate condom
use. The prevention work conducted on the AIDS/VIH
infection for decades seems to be successful in injection
drug users. Future work should explore in a similar way
differences
also
in
women
and
explore
different
intervention programs effectiveness in order to increase
sexual assertiveness in this population.
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