Sex for Drugs: Linking Drug Use to Syphilis & Other STDs

Syphilis was on the decline, but the opiate crisis is changing things


There is an opiate crisis in the United States. A growing number of individuals are addicted to prescription and non-prescription opiates. A growing number of people are also dying from them. According to the Centers for Disease Control and Prevention (CDC), between 2000 and 2013 the rate of deaths from drug-poisoning more than quadrupled. The death rate has likely only continued to increase since that time.

In part, this is because of heroin being mixed with the deadly sedative fentanyl. However, death is only one risk associated with illicit drug use. Illicit drug use can also have numerous other negative effects on a person's physical and mental well-being. One surprising one is that they can increase an individual's risk of sexually transmitted diseases.

Many people are aware of the association between injection drug use, HIV, and hepatitis. These diseases, which are found in the blood, can be spread through the use of shared needles and other injection supplies. There is another reason, however, that illicit drug use can increase a person's STD risk. Drug use is associated with risky sexual activity. 

Sex for Drugs

Maintaining an illicit drug habit can be expensive. For many addicts, suddenly stopping drugs is not an option, even if they can't afford them. They need drugs in order to function.

Therefore, some people end up exchanging sex for drugs, also known as "transactional sex." 

Sex can be exchanged for drugs either explicitly or implicitly. Explicit exchange of sex for drugs is when a drug dealer, or client, offers to trade drugs for sexual activity. For example, someone who is withdrawing might offer to have sex with someone in order to get the drugs that they need to feel better.

This is an explicit exchange because both parties are clear on what they are trading.

There are also times when the exchange of sex for drugs is implicit. In these circumstances, there is no negotiated arrangement. Instead, a person might just expect to have sex with someone who they've given drugs to. There is also sometimes the expectation that people who are using drugs together will have sex together, even if one of them does not actually want to. It can be very difficult to go against these expectations, for both men and women. 

Illicit Drug Use and Sexual Violence

Illicit drug use is also associated with sexual violence. Individuals who use drugs have an elevated risk of sexual assault, rape, and forced sex. Both men and women who use drugs are at risk of sexual violence. Women, in particular, are at risk of being assaulted when they are high, passive, and having difficulty moving or defending themselves. 

Syphilis Outbreaks and Sex for Drugs

Several cities in the United States have reported syphilis outbreaks that they have linked to illicit drug use. Outbreaks have been linked to use of a variety of drugs, including opiates, methamphetamine, and cocaine. A number of factors contribute to these syphilis outbreaks.

One of the major factors is exchange of sex for drugs. However, another big factor is mixing of sexual networks and sexual partners.

Individuals who use illicit drugs and exchange sex for drugs often have more sexual partners. In addition, in areas where outbreaks occur, those partners are mixed between sexual networks. In a closed sexual network, an STD would be contained to a few individuals who are interacting with each other. In an open, or mixed, sexual network, people can transmit the STD to a variety of groups who then transmit it among themselves. That means that a sexually transmitted infection can spread broadly and fast.


The Dangers of Mixing Sex and Drugs

Why is it so risky to mix sex and drugs? In some ways, the answer comes down to two words—agency and anonymity. Agency refers to a person's ability to make decisions and act on. Unfortunately, people who are using illicit drugs, or addicted to them, often lack agency. Their addiction makes it difficult, or impossible, to make clear decisions and act in their own best interest. With respect to sexual risk, this has a number of connotations. They are unlikely to be able to negotiate safe sex. They may not be able to choose whether or not they want to have sex. They may be easily pressured in their sexual choices.

Anonymity is another problem in arresting and preventing drug related syphilis outbreaks. One of the most efficient ways to interrupt the spread of an STD is through contact tracing. This is when public health agencies reach out to an infected individual's sexual partners in order to test and treat them.  This type of partner notification is often impossible in settings where sex and drugs are intertwined. Sexual assault is a common occurrence. That's not the only problem. Even when sex is theoretically consensual, there is a lot of anonymous or impaired sex. That means people may not know the names or identities of individuals who they have had sex with. When they do, identified partners may not have phones or addresses at which they can be found. Finally, it may put individuals in physical danger if they disclose the name of a dealer or gang member to a government agency for disease tracking. 

A Word From Verywell

Anonymity and the absence of agency are a dangerous combination. Together, they put individuals who mix sex and drugs at a greatly elevated risk of STDs. Even when someone gets treated properly, if they're still exchanging sex for drugs, they're in danger of reinfection. Risky sex in a population where it's difficult to track and treat infected individuals makes for a situation where it is very hard for people to get effective help. Combine that with the stigma associated with illicit drug use, and sometimes it's difficult for them to get any help at all.  


Doherty IA, Adimora AA, Muth SQ, Serre ML, Leone PA, Miller WC. Comparison of sexual mixing patterns for syphilis in endemic and outbreak settings. Sex Transm Dis. 2011 May;38(5):378-84. doi: 10.1097/OLQ.0b013e318203e2ef. 

Jessell L, Mateu-Gelabert P, Guarino H, Vakharia SP, Syckes C, Goodbody E, Ruggles KV, Friedman S. Sexual Violence in the Context of Drug Use Among Young Adult Opioid Users in New York City. J Interpers Violence. 2015 Aug 3. pii: 0886260515596334. 

Seña AC, Muth SQ, Heffelfinger JD, O'Dowd JO, Foust E, Leone P. Factors and the sociosexual network associated with a syphilis outbreak in rural North Carolina. Sex Transm Dis. 2007 May;34(5):280-7.