Foxman, Betsy PhD*; Aral, Sevgi O. PhD†; Holmes, King K. MD, PhD‡
AMONG ADOLESCENTS AND YOUNG adults, drug use, particularly alcohol and marijuana use, has been associated with engaging in behaviors that increase risk of acquiring a sexually transmitted infection (STI). Among 210 black male adolescents being held in juvenile detention facilities, those reporting marijuana use were less likely to discuss sexual risks with their partners and more likely to not use condoms.1 Among 522 black female adolescents, those who tested positive for marijuana metabolites were 3 times more likely to test positive for gonorrhea, almost 4 times more likely to test positive for chlamydia, and almost 3 times more likely to have never used condoms in the previous 30 days.2
Drug and alcohol use reportedly occurs more frequently among gay men, lesbians, and bisexual than among heterosexuals. In a study of 10,301 sexually active college students, binge drinking and marijuana use were reported more frequently by women with both same- and opposite-sex partners compared to those with only opposite-sex partners; women with only same- or only opposite-sex partners reported similar rates of binge drinking and marijuana use.3 By contrast, men with both same- and opposite-sex partners or with only same-sex partners were less likely than men with only opposite-sex partners to binge drink but were equally likely to use marijuana. However, in a study of men who have sex with men, unprotected anal intercourse was associated with sexual situation-specific use of marijuana and ecstasy.4 Sexual identity was a strong correlate of ecstasy use in a study among 3606 college students; students who self-identified as gay men, lesbian, or bisexual were twice as likely as those self-identifying as heterosexual to use ecstasy in the previous month.5 Sildenafil citrate (brand name, Viagra) has also been associated with risky sexual behaviors among men who have sex with men.6
Although numerous studies have examined drug and alcohol use, their correlates, and associated STI risk, we found no studies that directly examined whether drug or alcohol use was intended to enhance sexual experience. Individuals may use drugs or alcohol to decrease inhibition (thus enhancing their sexual experience), to reduce anxiety about or as an excuse for engaging in risky sexual behaviors, such as not using condoms or choosing risky sexual partners or sensation seeking (thus increasing STI risk), or for other reasons.7 A person whose drug use was intended to enhance his or her sexual experience may be somewhat different from the habitual user or one who uses a drug for another reason.
Vibrators, beads and balls, dildos, pumps, extenders or rings, and other items are widely available on the Internet, via mail-order catalogs, and are now being marketed at “in-home” parties.8 In-home marketing has been effective in normalizing purchase of sexual enrichment aids,8 but little is known about the prevalence or correlates of use. There has been at least 1 case report of human immunodeficiency virus (HIV) transmission via use of a sexual enrichment aid.9
As part of a random-digit dialing survey of Seattle residents, we assessed the self-reported use of drugs to enhance sexual experience and sexual enrichment aids. We describe the prevalence of ever and current use of sexual enrichment aids and of using drugs to enhance the sexual experience, and correlates of that usage.
We analyzed the results of a random-digit dial (RDD) survey conducted in the Seattle area between 2003 and 2004 among residents age 18 to 39 years of age with fluency in the English language. The RDD sample was randomly selected from a sample frame consisting of all possible combinations of telephone numbers for exchanges for the city of Seattle obtained from Genesys Sampling System. Up to 6 attempts were made to contact all working residential numbers at different times of the day. The survey was conducted by the Social & Economic Sciences Research Center in Pullman, WA.
In the survey (conducted between October 2, 2003, and January 26, 2004), we were able to contact 31,617 (84.1%) of the 37,000 in the initial sampling frame: 21,294 (55.4%) numbers were either nonresidential or disconnected, 1527 (4.1%) were a data or fax line, 1939 reached only answering machines (5.2%), 2448 (6.7%) never answered, 482 (1.3%) were always busy, and 80 (0.2%) had telecommunication technical barriers. Of the 8683 remaining households contacted, 6101 (70.2%) did not meet eligibility requirements, leaving 2582 eligible individuals. One thousand one hundred ninety-four of the 2582 eligible individuals contacted (46.2%) agreed to participate and completed the interview. We limited our comparison to the 1114 (93.3%) participants who reported ever engaging in vaginal, oral, or anal intercourse.
The survey instrument included questions on lifetime sexual history, partner and partnership characteristics, STD history, and demographics. The survey was pretested on a sample of the study population and revised before initiating data collection. The telephone survey required approximately 20 minutes to administer using computer-assisted telephone interviewing software, which standardized the interview and minimized data entry errors. Respondents were given the option to select the gender of available interviewers. For the purposes of this survey, sexual activity was defined as oral, vaginal, or anal intercourse. To determine use of enrichment aids, respondents were asked “Have you EVER used sexual enrichment aids, such as vibrators, beads and balls, dildos, pumps, extenders, or rings?” A follow-up question asked about use during a typical 4-week period. To determine use of drugs to enhance sexual experience, respondents were asked “Have you ever used a drug to enhance your sexual experience, such as alcohol, Viagra, ecstasy, ginseng, or pheromones?” Follow-up questions asked about use during a typical 4-week period and drug type.
We used proportions to describe the frequency of using sexual enrichment aids and drugs to enhance the sexual experience. To identify correlates of using sexual enrichment aids and drugs to enhance the sexual experience, we used contingency tables with the χ2 test to assess statistical significance. A logistic regression model was fit to the data to assess associations after adjustment for other correlates. The software package SAS was used to assist in summarizing the data and to conduct the analyses.
Association With Demographic Characteristics
Among this sample of 1114 sexually active Seattle residents aged 18 to 39, almost half (45.1%) had ever used a sexual enrichment aid, such as a vibrator, beads and balls, dildos, pumps, extenders, or rings (Table 1). Twenty-seven percent used a sexual enrichment aid at least once during a typical 4-week period. Slightly more than one-fourth (27.7%) reported ever using a drug to enhance their sexual experience; 13% did so at least sometimes during a typical 4-week period. Among those reporting using a drug to enhance their sexual experience, the most commonly used drugs were alcohol (83.7%), marijuana (34.7%), ecstasy or “sextasy” (ecstasy combined with sildenafil) (8.2%), and sildenafil (7.5%).
Females (33.1%) were more likely than males (20.3%) to report use of a sexual enrichment aid during a typical 4-week period, and black and Asian participants less frequently than other groups (Table 2). By contrast, use of drugs to enhance the sexual experience in a typical 4-week period was reported more frequently by males (15.1%) than by females (11.8%), and there was no association with racial group. In addition, single, never-married individuals were most likely to report use of drugs to enhance the sexual experience. Other demographic variables, including education and income, were not associated with either use of sexual enrichment aids or drugs to enhance the sexual experience in a typical 4-week period. Frequency of alcohol use was strongly associated with using sexual enrichment aids and with using drugs to enhance the sexual experience in a typical 4-week period.
The use of sexual enrichment aids (aids) and use of drugs to enhance the sexual experience (drugs) in a typical 4-week period were significantly associated with several STI risk factors, including younger age at first sex, increased numbers of lifetime sex partners and of sex partners in the last 12 months, and with having same sex partners or concurrent partnerships (a partnership was considered concurrent if the respondent reported engaging in sexual activity with another individual during his/her time of sexual involvement with his/her most recent partner and/or if the respondent reported his/her partner engaged in sexual activity with another during that period), and with diversity and type of sexual repertoire (Table 3). Although the only significant association with a history of a specific STI was between self-reported history of human papillomavirus (HPV) and use of drugs, history of any STI was significantly associated with both use of drugs and use of aids. Persons reporting use of aids and use of drugs more often reported HPV, chlamydia, and nongonococcal urethritis; persons with a history of genital herpes more often reported use of aids. The use of aids was strongly associated with use of drugs.
Characteristics of Most Recent Sex Partnership
Use of aids was significantly associated with reporting a current sexual partnership and engaging in vaginal, oral, or anal sex 1 or more times with the most recent sex partner during a typical 4-week period. Persons meeting their most recent partner on the Internet or in a gym or health club were most likely to report using an aid during a typical 4-week period. Use of drugs was also more common among those finding partners on the Internet or at a bar, although the differences were not statistically significant. Use of drugs was significantly more common among unmarried persons, those whose partner did not know their family, and those who had short times from meeting their partner to engaging in sexual activity, short partnership durations, or who engaged in oral or anal sex (Table 4).
After adjustment in a logistic regression model, most factors correlated with use of sexual enrichment aids in the bivariate analysis remained significantly correlated, with the exception of engaging in vaginal sex with most recent sex partner, which was therefore removed from the model (Table 5). Meeting the most recent sex partner via the Internet was associated with a twofold increase in use of aids (P = 0.05) after adjustment for other variables. Use of drugs was no longer significantly correlated with being female and having same- and opposite-sex partners after adjustment in a logistic regression model (Table 5).
To our knowledge, this is the first report describing the prevalence of use of sexual enrichment aids (vibrators, beads and balls, dildos, pumps, extenders, or rings) in a random sample of the general population. These may increase the potential for local trauma, which may enhance STI transmission or acquisition; aids used on multiple partners without proper cleaning in between may transmit infection; aids used with a partner and with oneself may transmit infection even without intercourse; and use of aids on oneself repeatedly over time without interim cleansing might result in reinfection after treatment for genital or rectal infection.9,10 The widespread experimentation with sexual enrichment aids, reported by 45% of our population from all sociodemographic and economic groups, and the associations with high-risk behaviors suggest that investigators of STI risk factors in individual patients or a research study should ask about use of sexual enrichment aids. For example, Marrazzo et al.10 identified failure to always clean an insertive sex toy (dildo or vibrator) as a risk factor for bacterial vaginosis among women who have sex with women. Further studies determining the frequency and types of aids used among populations at high risk for STIs will identify whether sexual enrichment aids are an important modifier of STI transmission.
Our study suggests that many individuals choose to take drugs in order to enhance their sexual experiences. Thus, the previously noted associations of alcohol and marijuana and higher-risk sexual behaviors may be explained, in part, by the motivation for use.3 Consistent with this hypothesis, drugs to enhance the sexual experience were not associated with lifetime number of sex partners, but those who reported using them were twice as likely to report having concurrent partnerships. Use during a typical 4-week period was highest among participants reporting both same- and opposite-sex or same-sex-only partnerships; after adjustment for other correlates, including use of sexual enrichment aids, engaging in anal sex was associated with a twofold increase in use of drugs to enhance sexual experience. Laumann et al.,11 in their 1994 study of 3432 men and women, found that 6.5% of men and women aged 18 to 39 reported frequently drinking before or during sex and 0.8% reported using any drug before sex. By contrast, 1.4% of our respondents reported frequently or always using a drug (including alcohol) to enhance their sexual experience during a typical 4-week period. We specifically asked about use of drugs to enhance sexual experience, whereas Laumann et al.11 asked about using drugs before or during sex. Differences in method of data collection (face to face versus telephone), question phrasing, and study populations or a true secular change may account for the inconsistencies between surveys.
The use of sexual enrichment aids and drugs to enhance sexual experience was strongly associated with each other. Those who engaged in both use of aids and use of drugs were more likely to engage in other behaviors that put them at higher risk of acquiring and transmitting STI, suggesting that these behaviors combined may potentially indicate high STI risk. This is consistent with a case-control study of HIV conversion among gay men in Sydney that found use of drugs highly correlated with use of sex toys and other practices aimed at enhancing sexual pleasure; both drug use and these sexual practices were independently associated with risk of HIV conversion.12 However, our study found no significant association between either of these behaviors and self-reported history of any of the STIs measured. This is not surprising, as we were correlating current use with STI history. Future prospective studies in STI populations are needed to determine if there is a direct temporal association with STI acquisition.
The participation rate for random-digit dialing surveys has fallen with time.13 Further, the use of answering machines and mechanisms to screen calls and block calls from unidentified numbers increases the number removed from the sample before screening, potentially creating difficult-to-measure selection biases. We contacted 84% of those in the initial sampling frame; however, only 46.2% of eligible respondents agreed to participate, consistent with other recent reports.14,15 Those initially contacted were told that the study purpose was to learn how often people engage in behaviors that might put them at risk of acquiring a sexually transmitted disease. It is therefore possible that participants who believe that their behaviors put them at higher risk were more likely to participate, resulting in an overestimate of the frequency of sexual enrichment aids and use of drugs to enhance the sexual experience. We have, however, no evidence that this was the case; indeed, the frequency of several higher-risk behaviors had decreased from a previous random-digit dialing survey conducted in Seattle in 1995.16 As with all random-digit dialing telephone surveys, we have no way, other than checks for internal consistency and interviewer assessment, to determine the validity of responses. Previous research suggests, however, that anonymous surveys elicit higher reports of stigmatized behaviors.17 Further, we have used several of the batteries from this questionnaire in a previous random-digit dialing surveys and found comparable estimates.16,18,19 Nonetheless, the impact of these limitations on the prevalence of reported use is difficult to assess; however, as long as the limitations have not resulted in differential selection for both outcome and exposure of interest, the estimated relationships between variables should be unbiased.
Persons reporting use of sexual enrichment aids and drugs to enhance sexual experience were more likely to engage in sexual behaviors associated with a higher risk of acquiring and transmitting an STI, such as having nonmonogamous partnerships and multiple partners in the previous 12 months. Whether use of sexual enrichment aids and drugs to enhance sexual experience are causally associated with STI risk or merely additional markers of high-risk behavior or sensation seeking cannot be discerned from a single cross-sectional survey. However, these behaviors occurred frequently, and usage was common across all age, gender, ethnic, sexual, and income groups. Thus, clinicians might query patients regarding these behaviors as a screen for whether in-depth risk assessment and STI testing might be warranted. Further studies in persons with STI and other populations that assess if attention to enrichment-aid cleansing reduces risk of STI transmission or reacquisition are required.
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