“Like the first time, all over again”: sex, relationships, and risk for relapse to substance use after release from prison

Abstract

Background

Sex, relationships, and substance use often go hand in hand. Despite this, the impact of sex and relationships on recovery are often overlooked in the field of substance use disorder treatment (SUDT). This study aims to explore sex, relationships, and relapse risk for people in recovery and as an overlooked area of importance in SUDT.

Method

This qualitative study uses semi-structured interviews with people currently and/or formerly in prison, together with ethnographic field data from four high security prisons in Norway, collected between July 2021–April 2022.

Results

Common sources of anguish around sex after release and recovery included both forming new and maintaining long-term relationships with partners at a different stage in their recovery, dating and initiating sexual relationships with new partners, concerns about sexual performance and fears around attaining sexual pleasure without chemical enhancements.

Conclusion

The implications that sex, dating and intimate relationships may have for individual relapse to substance use, can and should play a greater role in both SUD treatment and preparation for release from prison. These problems are exacerbated in carceral settings and should be considered when planning re-entry to the community and in the development of individual relapse prevention strategies.

Keywords:

• Sex
• relationships
• substance use disorders
• addiction treatment
• prison

Introduction

Sex is a fundamental part of life for many. It connects us to others, is instrumental in forming relationships and families, and relieves stress. Sex, whether by ourselves or with others, is significant not only for our physical and mental wellbeing, but also for society. As Clark (2016) states, sex is “a cultural force that fascinates us, dominates our thinking, and drives us to act in ways that help us, hurt us and complicate our lives.” Although depicting and discussing sex has become more normalized in Western media, sex and related problems are still often considered taboo or shameful. As such, these topics are neglected in arenas where they are nevertheless relevant, such as in prison, where the lack of sex seems to only increase its power, and in the treatment of substance use disorders (SUDT). This is in spite of the fact that sex and substance use have always had a deeply complex and often contradictory relationship (Skårner et al., 2017). Drugs help initiate, influence, and improve sexual experiences. Both drugs and sex serve purposes of pleasure, euphoria, release, and neutralizing negative emotions. On the flip side, both drugs and sex can be addictive and harmful, and the complicated relationship between both means that sex is a potential trigger for relapse in SUD recovery. However, research exploring the role of sex in SUDT and as a risk factor for SUD relapse is limited.

In this study, sex and relationships were often conceptualized as essential parts of a satisfying life, as well as symbolic of positive change, recovery, and re-entry into the community. At the same time, sex, relationships, and the potential for relapse in conjunction with these, represented a source of anxiety. Common sources of anguish around sex revolved around both anticipated sexual performance, and perceived sexual pleasure, without the influence of drugs. These concerns were expressed differently when described in the context of dating and new relationships, and in that of maintaining long-term, established relationships.

Sex, relationships, and recovery

Relapse prevention models acknowledge recovery as an ongoing process and emphasize the importance of identifying factors that may trigger a relapse, and proactive development of intervention strategies (Gorski, 2000; Kabisa et al., 2021; Smith, 2020; Witkiewitz & Marlatt, 2007). Researchers have identified common potential triggers and how these factors influence and interact with each other: these range from individual, interpersonal, and environmental, to physiological and psychological factors (Kabisa et al., 2021). Sex and interpersonal relationships fall naturally into several of these categories.

In SUDT programs, relationships, and sex are thematized to varying degrees. The most widely used models are based on Narcotics Anonymous and the 12-step model (Kemp, 2019). Consistent with NA is a focus on community and positive social relationships in recovery, group therapy, and mentorship (Delucia et al., 2016; Sussman, 2010). In modern NA, making reparations to social relationships is part of steps eight and nine (Kemp, 2019; Sussman, 2010). Individual providers may interpret these models differently, although some evidence suggests that sex in recovery is a topic in certain NA circles (Green et al., 2005; Hoffmann, 2006). A recent study by Andersen and Thing (2021) also demonstrates that recognition of sex in Danish SUDT programs is becoming more widespread.

Social and familial relationships are acknowledged as important to recovery but also undergo undeniable change through the influence of substance use (Inanlou et al., 2020; Kemp, 2019; Panebianco, 2015; Pettersen et al., 2019). When only one partner in a relationship is in recovery, other partner/s may inhabit a supporting role, which can be beneficial both for individual recovery processes and for the “shared identity” of the relationship itself (Crowley & Miller, 2020; Ferrari & Borloti, 2021; Simmons & McMahon, 2012; Simmons & Singer, 2006). The stigma around substance use and associated socioeconomic problems can also negatively affect and put stress on intimate relationships (Rodriguez & Prestwood, 2019). In relationships where multiple partners use drugs, relationships can be highly intimate and protective in the face of this societal stigma, but also insular and co-dependent, further complicating recovery (Rhodes et al., 2017). Relationships have been shown to be sources of positive support in recovery, but can also represent a double-edged sword as potential sources of relapse connected to conflicts and emotional shifts (Bradshaw et al., 2021; Johnson et al., 2013; Kabisa et al., 2021, Xia et al., 2022).

Said relationships, and substance-using partners, are often framed in terms of risk (Rhodes et al., 2017). Research shows that SUDT programs differ as to whether they use an individualistic approach, whereby one partner inhabits the main role of patient, versus a holistic approach, treating relationships or families as complete “systems” affected by substance use (Bradshaw et al., 2021; Crowley & Miller, 2020). Individualistic approaches to relationships in SUDT may be a barrier to treatment for some (Berg et al., 2022). So-named couples’ SUDT, where partners can enter inpatient treatment together at the same facility, is still relatively uncommon (Simmons & McMahon, 2012). These concerns can be legitimate: intimate partners may be initiators of substance use, suppliers of drugs, and/or involved in substance use themselves: partners and relationships can also thusly contribute to relapse risk (Simmons et al., 2012; Simmons & Singer, 2006; Weatherburn et al., 2017). This is known from existing research on chemsex, whereby intimate partners often take the role of initiator or supplier, adding further layers of complexity to dealing with relationships in SUDT.

Chemsex: chasing better sex

Chemsex is the intentional ingestion of drugs (of any type, but usually stimulants such as cocaine, amphetamine, and GHB, among others) before or during sex with the specific aim of improving the sexual experience (Edmundson et al., 2018; Maxwell et al., 2019; Skårner et al., 2017). Scholars argue that chemsex, its cultural significance within the LGBTQ+ community, and associations with partying, casual sex, and recreation drug use (also referred to as “party and play” cannot be reduced to a clinical, “neutral” definition (Edmundson et al., 2018; Hickson, 2018; Santoro et al., 2020; Souleymanov et al., 2019; Weatherburn et al., 2017). Both chemsex and “slamming” (injecting drug use during sex) are shared social phenomena among men within the LGBTQ+ community (Bourne et al., 2015; Hickson, 2018; Maxwell et al., 2019; Trouiller et al., 2020), who are also overrepresented for SUDs (Haik et al., 2022). Research is now recognizing the ubiquity of chemsex outside of the LGBTQ+ community and as a phenomenon within wider substance use communities and in relationships where substance use is involved (Hibbert et al., 2021).

Motivations for engaging in chemsex include increased access to desired sex acts such as by increasing physical stamina or reducing pain. Chemsex narratives often mirror those of addiction, where the desire for euphoric sexual experiences requires increasingly higher doses, combinations of drugs or riskier behaviors such as slamming (Bourne et al., 2015). The practice is associated with various risks, including an increased risk of SUDs, STDS and overdose (Bourne et al., 2015; Hibbert et al., 2021; Li et al., 2021; Souleymanov et al., 2019). Risks associated with chemsex are acknowledged as a problem within the LGBTQ+ community (Hibbert et al., 2021; Stuart, 2019), however, implementing suitable initiatives to support this group proves challenging. SUDT providers may lack specialized knowledge on chemsex, whereas sexual health services may be familiar with the practice and lack training in identifying and/or treating SUDs (Bourne et al., 2015; Hibbert et al., 2021; Maxwell et al., 2019; Platteau et al., 2020; Weatherburn et al., 2017). How chemsex initiatives may be adapted in order to support the needs of people transitioning back into the community after release or implementing chemsex as a theme in prison-based SUDT programs, is an area requiring further research. The issues of sex, relationships, and the added, complex phenomenon of chemsex may be even more significant factors for potential relapse after release from prison, due to the additional pressures people in prison experience on their intimate lives.

Systemic frustration? Sexual deprivation in prison

People in prison are generally overrepresented for SUDs in addition to diverse socioeconomic disadvantages (Bukten et al., 2020; Pape et al., 2021). The period immediately after release from prison is known as the most precarious for relapse and overdose (Bukten et al., 2017; Kabisa et al., 2021; Nichols et al., 2021; Watson et al., 2022). This is also true of the period immediately after exiting inpatient SUDT (Gossop et al., 2008). Norwegian prisons are considered relatively liberal by international standards (Ugelvik & Dullum, 2012). This extends to making certain allowances for the sex lives of people in prison: such as by providing supplies for safe sex in private visiting rooms and purchase of pornographic films (Kriminalomsorgen, 2020). A pilot project on sexual health and positive sexuality has also been recently started in Oslo men’s prison, providing information on such topics, and making a limited range of sexual aids available for purchase (Kriminalomsorgen, 2020). Such opportunities were a popular topic of discussion during fieldwork, although the potential impact of these interventions on relapse is unknown at this stage.

Scholars have identified the conceptual overlap between narratives of SUD recovery and desistance from crime (Best et al., 2017; Chen, 2018; Todd-Kvam & Todd-Kvam, 2021; Warr, 2020). Processes of recovery, re-entry, and desistance take place in a variety of settings such as work, familial and social spheres which interact and influence each other (Bahr et al., 2010; Kabisa et al., 2021; Sandbukt, 2021; Todd-Kvam & Ugelvik, 2020). The Good Lives Model cites pleasure, including sexual gratification, and closeness to others, as primary goods essential to desistance processes (Andrews et al., 2011; Ward & Stewart, 2003). This model is challenged by the fact that sexual frustration is often touted as a natural consequence of incarceration, although many countries allow some forms of contact and visitation. Sykes (1958 posited that even with mitigating factors such as visitation and mail privileges, relationships will inevitably be weakened over the course of imprisonment, resulting in involuntary isolation and celibacy, terming this process “systemic castration”. Thus, the significance of sex and relationships for relapse and recovery is further complicated by incarceration and the loss of diverse freedoms, including the liberty to organize one’s intimate life as one sees fit. People in prison as a group have received little focus in the existing literature on sex and substance use. This study seeks to explore the important connections between sex, recovery, relapse to substance use and desistance from crime, through the perspectives of people with lived experience of prison.

Method

Data was obtained while I undertook ethnographic fieldwork over a period of ten months in four high-security prisons in Norway, as part of a larger study on prison-based SUDT. The majority of the data used in this article comes from 25 in-depth semi-structured interviews with three women and 22 men aged between 27-58 who were either imprisoned (22) or had previously been released (2). Interviews were obtained during the course of this fieldwork, and the criteria for interview participation were lived experience of both prison and substance use. In the wider study, staff were also interviewed, however, these interviews have been excluded from this analysis in order to focus on perspectives from persons with lived experience and how they described their own intimate lives within the context of substance use. Field notes from participatory observation on prison wards were used to inform the main analysis. These wards included specialized drug rehabilitation units (DRUs) focused on addressing substance use issues and preparing residents for entering SUDT, to use Mjåland’s (2014) definition. This data also included intake interviews for new DRU residents, run by staff, and participatory observation in group therapy sessions. Interview participants reported having used different illicit substances, as shown in Table 1.

Table 1. Participants’ self-reported substance use.

Gender	Alcohol	Cannabis	Benzodiazepines	Amphetamines	Cocaine/Crack	Heroin/Other opioids	GHB	Psychedelics	Polysubstance use
Female	3	2	1	2	0	0	0	0	2
Male	22	6	6	14	1	6	3	1	22

Separate interview guides were used for participants currently imprisoned, and for post-release. These guides focused on similar overall themes to do with prison life, re-entry after release, and experiences of substance use and treatment. Questions about social networks and contact with family and friends were included, providing room for participants to bring up intimate relationships if they so wished. Questions about sex were not included in these interview guides. On some occasions, these guides were adapted prior to specific interviews with the addition of follow-up questions specific to a particular participants’ situation or location (such as a specific DRU).

This study uses a grounded theory approach, by first gathering the data, then developing analytical categories and drawing conclusions based on what this data “tells” (Brunson & D’Souza, 2021). Interviews were audio recorded, transcribed, and subject to thematic analysis along with field data via coding (Gibbs, 2018). Specific thematic codes were developed to identify relevant excerpts for analysis in field notes and interviews and recorded in a codebook, such as “sex”, “chemsex”, “relapse” and “relationships”, these excerpts were sorted further into two main categories, “sex” and “relationships”. From this, the four main categories of analysis were developed, as shown in the results section. Interviews and analysis were conducted in Norwegian, with excerpts translated into English for the purposes of this article. Procedures of informed consent (oral and verbal) were completed with participants.

A limitation of the study is that participants were not asked which drugs they associated specifically with sex. Typical chemsex drugs such as amphetamines are well represented in the above table, however, this table reflects participants’ overall patterns of drug use, as self-reported. For research going forward, it would be useful to know if participants’ experiences reflected typical chemsex patterns shown in prior research. Different drugs also carry the weight of different associations and stigmas. Injection drug use and associated stigma, for example, can have influenced participants’ experiences and concerns differently than for participants who used primarily amphetamines, as shown by Rodriguez and Prestwood (2019). This information provided in the table is nevertheless useful for understanding participants’ experiences within the context of their substance use histories.

Ethics

Talking about sex and relationships in the context of substance use seemed both natural and relevant for many participants, yet the sensitive nature of these topics necessitated ongoing ethical reflection during the research process. Participants were not asked directly about their sexual experiences but were encouraged to elaborate if they themselves addressed the topic. Importantly, data on sexual trauma in connection with substance use or stories where the nature of consent was unclear, have been excluded after careful consideration. These topics were ultimately determined to be outside of the main four categories addressed in this article and are in themselves deserving of an article devoted to the larger issue of sexual trauma and substance use, as these issues are nonetheless highly relevant in the context of relapse. People with SUDs and people in prison, in particular women, are disproportionally affected by sexual trauma and violence; histories of substance use are often intertwined with intimate partner violence and sexual abuse (Hakkak et al., 2022; Gilbert et al., 2001; Jones et al., 2018). As the interview sample selected for this article is predominantly men, it was also difficult to draw conclusions about these complex issues, which adversely affect women with SUDs.

The gender disparity present in the sample is also a limitation of this study. Only one women’s prison was included in the study, in order to complete fieldwork in a relatively limited timeframe that was relatively representative as possible of the Norwegian prison system. A larger, more equal sample would allow for a more in-depth discussion of potential gender implications, such as prior experiences of sexual trauma, as highlighted above. The findings within this article nevertheless highlight the complex nature of the relationship between sex and substance use, particularly for persons with experience of both prison and substance use, and further illustrate specific areas of peoples’ sexual and romantic lives that bear significant meaning for relapse and recovery from SUDs.

Reflexivity around researcher positionality and influence is important in qualitative research and analysis (Mauthner & Doucet, 2003). Across the study, most prisoners I spoke to were male, in sex-segregated facilities, whereas prison staff were both female and male. As a female, early-career researcher, my own gender and age, among other factors, can have influenced relationships formed with participants during ethnographic fieldwork and their responses to interviews, given that the majority were men and spoke about heterosexual experiences. In general, I found that topics such as sex and intimacy came up more naturally over the course of my stay in different prisons after spending more time in the field, suggesting that being able to establish trust and rapport over a longer period was conducive to gathering data on often private topics and that in these situations, dynamics such as gender and power asymmetries became less relevant. I also spoke two of the most common languages at a level that made it easier to converse, reflect, joke, and use slang with many participants. Participants with experiences of DRUs also reflected at times that they were “used to sharing” from their private lives, as they were regularly asked to share and reflect upon their lives within the group. As discussed earlier, one prison involved I visited during fieldwork implemented a pilot project on positive sexuality and sexual health during that time, meaning that the topic of sex was already “on the table” in that prison, which may have influenced participants’ readiness to discuss the topic.

Identifying details, such as participants’ names and the names of partners and other third parties, and other demographic information that could lead to identification have been removed and replaced with aliases. The data used in this article is part of a larger qualitative study on SUDT in the Norwegian prison system. The study was approved by the Norwegian Centre for Research Data (NSD) on behalf of the Norwegian Data Protection Authority.

Results

Participants described sex and intimate relationships as highly important to recovery and reentry into the community, as well as a source of anxiety for many due to the anticipated potential for relapse they perceived within these situations. These concerns have been organized into the following analytical categories: firstly, those specifically to do with sex, including 1) worries about sexual performance while not under the influence of drugs; and 2) fears of not being able to attain the same level of sexual pleasure without chemical enhancements. Secondly, participants expressed concerns around sexual performance and pleasure differently when described in the context of relationships, categorized as 3) dating and initiating new sexual relationships with partners without a prior history of substance use; and 4) maintaining long-term intimate relationships with partners who were at a different stage in their recovery process.

Sober sex: concerns around sexual performance without the aid of drugs

Participants’ accounts support findings from previous studies as to the main functions drugs perform during sex (Weatherburn et al., 2017). Firstly, drugs perform facilitatory functions: allowing for successful physical performance, such as removing inhibitions, inciting arousal, and calming nerves. Drugs are also used during sex for their hedonistic potential, by increasing perceived pleasure from sex and making euphoric sexual heights achievable.

From a harm reduction perspective, recovery does not necessarily equal abstinence (Bartram, 2021; Brekke et al., 2018), however, many participants anticipated being completely abstinent at their next sexual encounter. This anticipated sex and associated facilitatory problems was often referred to as “sober sex”. Sober sex was framed as a risk factor for relapse, making anticipation or expectation of sober sex a considerable source of anxiety, regardless of when in the future it might occur. Stefan, who had been in custody for six weeks, remarked, “I”ve never had sex sober, suddenly I’m just expected to get out there and know how to do that? Of course, that’s a huge risk factor, that pressure, but they don’t talk about it.̈ DRU resident Daniel, who had been in prison for over ten years, recalled how most of his adult life, including his sexual experiences, had been lived in an almost constant state of substance use:

I haven’t done anything since 1998 without being on drugs. I haven’t had any social company without being on drugs… it’s like you have to learn to walk again. I haven’t been in a relationship, couple or had sex without drugs.

Methods for dealing with anticipated sober sex were often framed around processes of relearning, as described by Daniel. Another common refrain was that sober sex was like having one’s sexual debut for a second time, with familiar concerns around performance and providing a good experience for one’s partner/s. Martin offered a retrospective view: having previously been released from prison, he confirmed his first forays into sober sex as anxiety provoking and “…like having my first time, all over again.” However, with the benefit of prior experience, Martin also provided a more positive outlook where others were apprehensive, stating that his own “relearning process” had been worth it. Indeed, Martin’s sex life ultimately improved in recovery: he felt “more present and in control” during sex, reflecting that sober sex was “different… but ultimately just as, if not more pleasurable.”

Martin’s confidence in the possibilities of good sex in recovery came from prior experience, which not all shared. The majority of participants commented that they had “never had sex sober”, which exacerbated trepidation around anticipated sex. This is likely the case for many people with SUDs. The majority also reported that they began using drugs around 12–13 years old. The average ages for onset of puberty in Norway are between 9–14 and 8–13 years for boys and girls, respectively (Norsk barnelegeforening, 2006). Addiction narratives in Darke (2011) show that substance use often occurs in conjunction with other adolescent milestones, many peoples’ sex lives are subsequently entwined with alcohol and drugs from a young age (Bogren et al., 2023; Clark et al., 2020).

Anxiety around relapse during sex often reared its head in particular in the context of furlough from prison. Furlough generally ranged from a few hours to a few days at most, increasing pressures to perform sexually in a short window of time. As drug tests post-furlough were standard practice, a relapse could mean losing future furlough or other privileges. Several participants commented during fieldwork that it was common knowledge that many men planned to obtain “furlough Viagra” in anticipation of upcoming leave¹.

Many participants expressed a desire for a greater focus on the process of relearning sex, and finding strategies to avoid relapse while doing so, in SUDT. Daniel remarked, “using drugs and having sex… never gets talked about in treatment. And it’s really weird actually, because that’s what people are most stressed about, I think… it’s maybe a bit taboo?” This sentiment was also echoed by DRU resident Harald, who said “another theme [I would like more focus on in the DRU] is the relationship to sex. It’s a big question mark that there isn’t more focus on that.”

Participants’ accounts placed a strong emphasis on the need for more specialized support around sex, drugs and relapse. Lacking specialized knowledge or resources to implement further support was shown to be an existing barrier to addressing concerns around sex in SUDT. Facilitatory concerns around sexual performance without the use of drugs were framed in various ways, such as “sober sex” and “first-time” sex. Both in the context of furlough and when imagining life after prison, participants reflected that outside the constraints of prison walls was a world where sex, drugs, alcohol, and other temptations were easier to access, making preventing relapse even more challenging.

Many participants’ accounts also illustrate generally held anxieties around performing well and potentially, meeting others’ expectations of sex, or their own. Sober sex was characterized as starkly different from sex on drugs, a concept and physical process that had to be learned anew, as yet another challenging element of recovery and learning how to navigate different social spheres in a new phase of life. These findings do hint towards a growing acknowledgment of the importance of discussing sex more frankly, to find methods of dealing with the pressure and discomfort associated with learning to have sex anew.

Chasing better sex: concerns about sexual pleasure without the aid of drugs

In an ideal world I would like to use a little bit here and there, because I do love getting high, you know… Sometimes it’s to get away from reality, other times it’s to be part of a reality which is…something else… For example, sex, sex is pretty hefty with different drugs. Sometimes it’s okay to not sleep […] But I know my brain, and the [way it works] on drugs, so there are one million excuses and one million situations [to use] and having to work with it all the time is fucking annoying, firstly… Yeah, I am very scared to start using again.

- Jarl

Anxieties around facilitating sex in recovery were often expressed in conjunction with concerns about losing the enjoyment associated with the hedonistic function of sexualized drug use. In anticipation of future sex, participants wondered if previous experiences combining sex and drugs would hinder their recovery and put them at risk of relapse, should sober sex turn out to be not only awkward or difficult, but also less pleasurable. Jarl’s comments reflect both acknowledgement of problems in other areas of his life and relationship directly linked to substance use and fear of relapse, as well as frustration with the ongoing process of recovery work in a less than ideal environment.

Although not all participants described their encounters as chemsex specifically, accounts of sexualized drug use were similar to those found in previous studies on the practice. Jarl reflected upon positive and negative sides of engaging in chemsex with his long-term partner:

We use drugs to have sex–buy GHB, buy Viagra, we buy speed or cocaine or whatever. And I buy and she buys, and we take it home and she dresses up and… Otherwise, we’d have very normal, calm sex… we all have our things, right. I’m fifty and she’s forty and after a while you have to spice shit up, you know, she has fetishes and all those things… It’s a bit easier after taking drugs, because you lose your inhibitions a bit more… but, if there weren’t drugs [involved] we’d have a lot fewer problems.

Harald also described chemsex and its hedonistic potential as a “good” that substance use made available. He explained that the complex relationship between substance use and sex, ultimately made recovery more complicated. Previous studies show that experiences with “goods” such as chemsex can reinforce the positive sides of substance use, creating ambivalence towards recovery (Bourne et al., 2015; Skårner et al., 2017). The duality of chemsex and concerns around the loss of said positive effects, and ambivalence towards recovery and quitting drugs entirely was clear in participants’ reflections. Many, like Jarl, recalled that chemsex had had a positive influence on their relationships and sex lives. Jarl’s account also reflected ambivalence towards recovery. When asked, “so you think it’s impossible to have a healthy relationship to substance use?”, he replied, “for me? At the moment, not really.”

The “extraordinary feelings and sensations” achievable through chemsex, as described by Jarl and others, and the desire to keep achieving new heights of pleasure can be a powerful motivator to continue substance use, or a significant risk factor for relapse. While Jarl’s account reflects ambivalence around total abstinence and the costs and benefits associated with chemsex, Petter was secure in his ability to continue using drugs to achieve these benefits, while ceasing all other drug use post-SUDT. When asked if he thought complete abstinence was necessary to his own recovery, he replied “I think I will keep using marijuana only, for some activities that will remain between my girlfriend and I, if you get my meaning.” Petter viewed marijuana as a means to enhance his sex life without risking relapse to other substances. By contrast, Jarl feared that relapse might be unavoidable. These different attitudes reflect different methods of potentially managing chemsex behavior while in recovery. Many participants who spoke about chemsex, reflected upon a complicated reality, where a key problem was assessing whether one could responsibly engage in chemsex while in recovery, and in a broader sense, whether “true” recovery necessitates abstinence.

Chemsex exemplifies the dual nature of substance use: the agony and the ecstasy. Certain drugs grant the temporary power to go beyond one’s physical and hedonistic potential and achieve exceptional pleasure, yet often at a mental and physical cost. Some people are likely also able to engage in chemsex occasionally without developing an SUD or continue engaging in chemsex while in recovery, without relapsing to other, more harmful forms of substance use. Assessing risk and finding harm reduction strategies for dealing with chemsex in recovery seem to be a potential way forward, but in order to do this, people with SUDs may need support in unpacking their own relationship to chemsex and the different functions of substance use within their lives.

In limbo: dating and forming new relationships in recovery

Not just the sex–being part of a couple, eating dinner, watching a movie, without using something… it’s not just the sex.

- Daniel

For those not already in relationships, getting back on the dating market often featured in plans for after release from prison and while in recovery. Where some expressed that having a partner would directly strengthen their recovery process and support against relapse, others felt that it was beneficial to wait and focus on their own recovery first. In the latter case, relationships were additional or bonus goods, a success symbol and prize after doing the work of SUDT. Vilde was awaiting transfer to complete the rest of her sentence in inpatient SUDT and described having felt deprived of relationships ever since after her initial arrest, while waiting to receive her court summons and again to be called into prison. The negative consequences of waiting to enter prison in the Norwegian system have been identified by Laursen et al. (2019). For Vilde, this waiting made her feel as though her social and romantic life was on indefinite hiatus:

It made it impossible to live a normal life, travel, be in a relationship, anything… if I went on holiday with my dad… it was like, well this might be the last holiday. I couldn’t start a relationship with anyone, because at any point I might get called in… that waiting was worse than actually being [in prison].

When Vilde described her desires for the future, after completing both her prison sentence and SUDT, being free to establish a romantic relationship with "a man I am in love with" was as important as finding suitable employment, meeting friends, a steady income, and stable residence. The idea of dating post-release and while in recovery also represented a source of turmoil for many. Anticipating sober dating after a romantic hiatus such as Vilde’s, was often–as with the specific act of sex itself–referred to in the context of relearning: learning how to approach potential partners, date or be in a long-term relationship without using drugs were subsequent sources of anxiety. Compounding these concerns, dating is often linked to cultural norms around substance use, with bars and clubs some of the most common arenas for meeting potential partners (Pedersen et al., 2017). Martin, reflecting on his dating experiences in early recovery, stated that it felt like having a "gap in my CV", explaining further:

Other people have been working, starting families, and it’s like, what have you been doing for the last five years? You don’t have that much in common with your [former] friends, maybe, after cutting out drugs… but you don’t have anything in common with new people either, so you’re in limbo.

Several participants described the feeling of being "in limbo" or on hiatus as they attempted to navigate between former and new, chemically enhanced, and sober, intimate contexts. DRU resident Harald reflected upon how his substance use and dating life influenced each other. For Harald, closeness and emotional connection were vitally important, saying “I don’t like to be alone.” Substance use helped dull negative emotions associated with being alone, but also aided Harald in feeling more connected to his partners when in relationships, affecting what he termed the “in between”, the bond between himself and his partner. As his relationship with substance use evolved over time, so did this in turn direct his romantic life and choice of partners, saying that “one is…out after a partner that accepts that [substance] abuse, and as soon as you’re two, things can go even more wrong.’ Daniel saw the only solution, ultimately, as being transparent with future partners: “The only solution is to be open with the person you meet… about everything. … And they have to see, if they can accept me for what I am.”

For many participants, it was clear that various aspects of intimate relationships and how to interact with future partners in recovery weighed heavily on their minds. Although anxieties around sex also featured heavily in these concerns, concerns around dating and relationships often went beyond the physical and, as phrased by Daniel, “not just the sex”. Dating and meeting new partners and forming intimate relationships in recovery, featured prominently in descriptions of the good life post-prison and in individuals’ goals for after release. This entailed a process of navigating uncharted territory, both sexually and emotionally (Skårner et al., 2017). Getting back on the dating market without drugs also often meant attending bars and clubs sober, being exposed to others’ substance use, and finding ways to connect with partners through typical shared activities without drugs. Participants reflected upon this process and the challenge of opening up and sharing their past experiences with new, “straight” (without lived experience of substance use) partners and finding common ground, whilst risking potential rejection.

Holding out: maintaining established relationships in recovery

If there weren’t drugs [involved], we’d have a lot fewer problems.

- Jarl

For those in established relationships while in prison, maintaining these was seen as both a challenge and source of support. Substance use had a significant impact on the life of the relationship, which in turn could affect one’s individual relationship to their recovery (Ferrari & Borloti, 2021). Differing motivations or attitudes towards substance use in an existing relationship might trigger a relapse, such as continuing substance use to appease one’s partner. Alternatively, differing motivations regarding recovery might cause conflict or result in a breakup, also potential risk factors for relapse.

Harald’s opinion was that seeking treatment as a couple could be more beneficial than trying to go it alone, stating “I believe it’s easier to become drug free as a couple… Some people are independent… but some people need a cheerleader, a teammate.” For DRU resident Fredrik, his partner had been a positive catalyst for seeking treatment. In his DRU assessment interview, he expressed that she was not involved in the drug scene at all and had given him an ultimatum regarding ceasing his own involvement before he entered prison. Fredrik spoke positively of this ultimatum and his partner’s support, as crucial to his own recovery process. Other participants spoke of committed relationships with partners with a shared history of using drugs together. Jarl recounted examples of such relationships, which had been instrumental in his most recent relapse:

I have been in rehab for a year, but before I came in here there was a fair amount of drugs, in my relationship too… I had one and a half years clean before I met the woman I got together with, who I’ve been together with the last two years… But my [ex] partner… I got home from [abroad] and had been off [drugs] for one and a half years. Then I found my ex … sitting in the basement with a needle in her arm, and a blood clot… I said, I’m sorry, […] I can’t have anything more to do with you. But [current partner], also used a lot of drugs without me being aware of it which also turned into me using again, two years of straight drugs, pretty much, on and off. I’m very committed… but it was so little that got me [to relapse] that time, even though I felt quite strong, and even though it had been one and a half years… makes me pretty insecure, to be honest.

Both Jarl’s and Harald’s accounts highlight the challenges involved in negotiating relationships with partners who also used drugs. Despite breaking off his previous relationship in order to prevent a relapse, Jarl described being pulled back into substance use by his current partner after a period of abstinence, despite having felt strong and committed to recovery. For participants in existing relationships, it seemed unrealistic to only focus on one person’s individual recovery process without partner involvement.

For participants had partners who were also in prison, logistical challenges compounded an already difficult emotional situation, as they were subject to further restrictions on contact and furlough privileges. For those whose partners were also in prison, being on the same page regarding motivation for recovery was important to feeling supported. Petter, whose long-term partner was serving her sentence at another prison, explained that they had a mutual goal of distancing themselves from existing networks and entering inpatient treatment as a couple, together with reducing their substance use to occasionally using marijuana in conjunction with sex. The support available to both Fredrik and Petter, despite their partners being in radically different situations, was highly important for staying motivated while in recovery. By contrast, Jarl’s descriptions of his relationship reflect possible ambivalence towards his own recovery while his partner continued to use drugs.

In intimate relationships where partners disagreed about substance use, the partner who was still actively using drugs was often framed as a risk, or as dangerous to the partner desiring change. In these cases, relationships could ultimately meet their end. DRU resident Alex described being heartbroken when his long-term girlfriend continued using opiates, saying “we are on different paths, I had to let her go her own way, for my own sake.” Alex explained that he had tried many times to encourage his partner to enter SUDT, and worried about her health. He eventually severed the relationship for the sake of his own recovery, as he had felt heavily tempted to continue using opiates. His decision, despite being emotionally painful, allowed him to focus on himself going forward, something he saw as positive.

Participants’ accounts reflect both diversity and disparity in attitudes towards maintaining intimate relationships while in recovery, particularly relationships where more than one partner used drugs. Although attitudes to partner involvement versus ‘going it alone’ in recovery differed among participants, many leaned towards addressing the reality and complexity of relationships in the process, taking into account not only individual experiences of and attitudes towards substance use, but also those of any existing partners.

Conclusion

During this study, participants were vocal about both the significance of sex and intimate relationships in the context of recovery and relapse, and what they felt was an overall lack of emphasis on this topic in SUDT. The stories depicted reveal that within this group, there are widespread concerns about the potential for relapse during sex, dating or in the context of long-term relationships. Many participants envisioned future intimate relationships free of drugs as symbolically necessary to recovery. Others felt conflicted or ambivalent towards recovery, due to the pleasurable, and painful, impacts of drugs on their intimate lives. Intimate relationships were shown to be important in moving away from crime and substance use, as shown by the Good Lives Model (Andrews et al., 2011).

Links between sex and substance use throughout participants’ lives were shown to be widespread, complex, and diverse. Although the types of relationships and experiences described varied, several common themes arose. Having a satisfying sex life and being able to enter or maintain loving relationships were, for many, at the forefront of how they anticipated and imagined their lives after release from prison and while in recovery. Being able to be intimate with others was seen as symbolic of successful recovery and of doing well post-release, a pillar of everyday “A4” life. This ideal may have been enhanced by the lack of intimacy and control over one’s own intimate life, felt keenly by people in high-security prisons. The lack of both intimacy and the liberty to organize one’s own intimate life, combined with time away from the occupations of daily life, might make existing desires for and fantasies around sex stronger. This in turn may increase underlying anxieties around performance, pleasure, and potential relapse when the opportunity for intimacy finally presents itself. This finding is particularly relevant for both SUDT programs in prison as well as inpatient treatment programs.

Underlying the four risk factors around sex and relationships described in the analysis was the problem of lacking experience, as the majority of participants stated that they had little experience of “sober sex”. This study illustrates specific problems that commonly arise within this context: learning how to have sex anew, sexualized drug use, dating in new recovery and managing existing intimate relationships impacted by substance use. The meaning attributed to sex and relationships in SUDT needs further development to allow for these issues to managed in a constructive way (Andersen & Thing, 2021). These problems are thrown into starker relief in the context of prison, where relationships and sexual gratification are challenged by the nature of a prison sentence and the tyranny of distance, or the “limbo” state of waiting to enter prison (Laursen et al., 2019).

Imprisonment, illicit substance use, addiction, and treatment are also associated with significant societal stigma (Gunn et al., 2018). It is likely that many in this group had experienced various forms of stigma connected to both their substance use and imprisonment, in addition to sexualized drug use and their intimate lives. The findings highlight that many anticipated being stigmatized further on the dating market, which has implications for how people in recovery may approach dating and new partners. Participants remarked upon having previously chosen partners who either “accepted” or shared their substance use, potentially to avoid stigma and avoid having their substance use challenged by an intimate partner, as well as reap positive effects from sexualized drug use (Rhodes et al., 2017).

These findings show that for many, finding ways to address and manage their sexual and romantic lives while in recovery could be key to reducing relapse risk and thus reducing overall harms associated with substance use, particularly for people in prison and in the re-entry period, when relapse and overdose risk is known to be highest. Hence, these findings are relevant for both the prison and substance use treatment fields and suggest that prison staff, healthcare personnel and SUDT providers should all consider these issues in their work. However, they also raise important questions as to how these problems should be appropriately addressed.

In harm reduction terms, it makes sense for healthcare personnel and SUDT providers to find ways of addressing their clients’ intimate lives prior to entering, or within treatment programs (Bourne et al., 2015). For some SUDT providers, asking about a client’s sex life might not represent a radical change in their practice. Doctors and psychologists are also used to hearing their patients’ most private problems and are more likely to be equipped with the skills to deal with issues around sex and addiction. Prison staff, on the other hand, are often employed as public servants (such as in Norway) or by private contractors (as in some US prisons). Although they are trained to provide first aid, are often responsible for doling out medicine, have everyday close contact with prisoners and report to healthcare personnel when medical attention is required, prison officers are not expected to be healthcare workers with specialized competence on addiction or sexual health. On specialized DRUs that provide addiction-centered programs and preparation for in- and outpatient SUDT, as well as on other more ‘general population’ wards, prison officers work side by side with trained healthcare and social workers in Norwegian prisons, and perform different roles. Importantly, prison officers represent carceral authority, and are primarily responsible for security, surveillance, and control, in ways that healthcare workers are not. Even when positive, prisoner-officer relationships and interactions will undoubtedly be affected by the inherent power imbalance between the parties and by the prison context (Ugelvik, 2022). One can also ask whether, and to what degree, prison officers should involve themselves in the private lives of people in prison at all. Should prison officers be required to, or indeed be able to, ask questions about prisoners’ sex lives, and what implications do asking those questions have? Should the state’s sphere of control, of which prison officers can be seen as an extension, also extend to prisoners’ most private desires and fantasies, or are these hypothetical discussions inherently unethical and potentially harmful when viewed within the context of penal power? These ethical issues need to be continually examined going forward.

Ultimately, from a harm reduction perspective, both prisons and SUDT providers should pay attention to these issues. Many participants in this study expressed a desire to be able to address these issues directly and find ways to manage the anticipated risk of relapse in these situations; often remarking that they wished to simply just talk about their experiences and fears openly and frankly, and to discuss potential strategies together with staff. These insights reflect an atmosphere where these concerns appeared to be constantly simmering below the surface, creating anxiety and stress, yet were not often spoken aloud or addressed in useful ways that could lessen these anxieties. This is indicative of the difficulties involved in talking about sensitive and complex issues like sex, which for many are private and connected to feelings of shame, stigma, and embarrassment, and are not necessarily normal or everyday topics of discussion. This article aims to shed light on the importance of talking openly about these issues and working to reduce existing stigma, shame, and taboos around sex and intimacy.

This study demonstrates the power of sex, pleasure, connection, and intimacy as fundamental forces in peoples’ everyday lives and significant motivators for continuing substance use, as well as the complexity of recovery processes. The stories depicted here also reflect that intimate relationships can be both supportive in recovery from substance use, and potential catalysts for deciding to enter recovery and treatment, even at the cost of the relationship. Many of these stories reflect the importance of a harm reduction approach, where relapse or continued usage does not necessarily mean failure but can be seen as one of many steps on a longer journey. At least in jurisdictions where most of the substances described in this article remain illegal and highly stigmatized, both prison and healthcare staff will continue to need to strike a balance between the laws of the state, and what recovery realistically looks like for people in and returning from prison, in order to fully acknowledge and work alongside the complex realities of peoples’ intimate lives.

Acknowledgements

The author wishes to thank Sveinung Sandberg, Thomas Ugelvik, Ben Crewe, David Rodriguez Goyes and the two anonymous reviewers for valuable comments on earlier versions of this manuscript. I would also like to thank Simen Iskariot Larsen, Sylvia Høyborg, and Knut Wold for helpful discussions on the topics involved.

Disclosure statement

The author declares that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Additional information

Funding

This work was financed by The Research Council of Norway (grant number 301535).

Notes

1 Sildefanil (Viagra) was descheduled in 2019 in Norway and can now be purchased over the counter under the supervision of a pharmacist.