Substance-Linked Sex

Substance-Linked Sex in Heterosexual, Homosexual, and Bisexual Men and Women: An Online, Cross-Sectional “Global Drug Survey” Report

Will Lawn PhD, Alexandra Aldridge MPhil, Richard Xia BS, Adam R. Winstock MD

FIRST PUBLISHED: April 2, 2019 – The Journal of Sexual Medicine



Substance-linked sex (SLS) – sexual activity that occurs under the influence of at least one licit or illicit drug (which may include alcohol) – has been receiving attention, but little is known about it beyond the context of harmful practices among men who have sex with men (MSM).

This exploratory study looked at the extent that different drugs are combined with sex, the frequency of intentionally combining drugs and sex, and users’ perceived effects of drugs on sexual experiences and overall enjoyment of sex.


Data were collected from the 2012 Global Drug Survey. All questions pertained to the previous 12 months.

The following outcome measures were recorded:

(i) Percentage of each group reporting last-year use of each drug with sex,

(ii) Mean subjective rating (-10 = ‘massive reduction’, 0 = ‘no change’ and +10 = ‘massive increase’) from each group for each drug on each aspect of the sexual experience.

Respondents were divided into six groups:

  • Heterosexual men
  • Homosexual men
  • Bisexual men
  • Heterosexual women
  • Homosexual women
  • Bisexual women



A total of 22,289 people age 18 and over responded to the survey. Sixty-three percent were men, 28.8% were women, and 8.2 preferred not to say their gender.

Among the men, 82.4% were heterosexual, 8.7% were homosexual, 6.7% were bisexual, and 2.2% preferred not to say or did not say their gender.

Among the women, 77.4% were heterosexual, 4.4% were homosexual, 15% were bisexual, and 3.2% preferred not to say or did not say their gender.

About a third of the respondents were from the United Kingdom. Thirty-five percent were from Australia. Almost 17% were from the United States, 9.7% were from the Euro-Zone, and 2.8% were from Canada.

The average age of the respondents was 31.4 years.

General Drug Use

Rates of drug use during the previous year were high for all groups. Over 90% of each group had drunk alcohol. Cannabis use ranged from 48% (heterosexual women) to 77.2% (bisexual men.) About a quarter of homosexual women had used MDMA (ecstasy); 41.4% of bisexual men did the same.

Drugs with Sex

Alcohol was the most commonly reported drug used with sex followed by cannabis and MDMA.

Using Drugs Intentionally to Enhance Sex

More men (31.2%) said they had used drugs with the intention of enhancing sex, compared to 22.9% of the women.

Drugs and Aspects of Sex

Highlights of the findings include the following (Higher scores points toward an enhancing effect):

  • Erections and moistness. Viagra was rated highest for men’s erections; MDMA was rated for women’s moistness highest by 50 women or more.
  • Sexual desire. Women rated alcohol more highly than men did. Heterosexual respondents rated it more highly than homosexual respondents.
  • Time to orgasm. Men gave methamphetamine the highest rating. For women, it was cannabis.
  • Multiple orgasms. Cannabis was rated more highly for women than for men. Bisexual respondents rated cannabis more highly than heterosexual respondents.
  • Intensity of orgasm. MDMA was more highly rated for men than for women and for bisexual respondents compared to heterosexual respondents.
  • Overall performance. Women rated alcohol more highly than men did, as did heterosexual respondents compared to both homosexual and bisexual respondents.
  • Emotionality/Intimacy. Both and women rated MDMA highly.
  • Sensual aspects. Both men and women rated MDMA highly.
  • Confidence in trying new things. Methamphetamine received the highest rating from by men and by 27 of the women.
  • Feelings of shame. Women rated alcohol more highly than men did for this category.
  • Enjoyment/Capacity for sex. GHB/GBL received the highest rating from both men and women, but few respondents took this drug. MDMA was rated by more respondents and was rated second by both men and women.


During the previous year, more than half of the respondents had had sex while under the influence of alcohol, a third had had sex after using cannabis, and just less than one-sixth did so after using MDMA. Overall, younger people, those with a higher income, and those from the United Kingdom were more likely to combine drugs with sex.

Combining drugs and sex was more common in men than in women, in homosexual and bisexual men than in heterosexual men, and in bisexual women than in heterosexual women.

At least 20% of each group said they had used drugs for better sex; this was more common in men than in women. All groups said that, in general, drugs improved their sexual experiences.

Overall, MSM were at highest risk for using drugs for sex.

Drugs appeared to affect men and women differently. For example, men rated cocaine, cannabis, MDMA, mephedrone, methamphetamine, and poppers more highly than women did for intensity of orgasm. This finding “suggests that men’s intensity of orgasm is more easily affected by drug use than women’s intensity of orgasm.”

“The different biology and psychology underpinning arousal and sexual function in men and women would also likely contribute to these differences,” the authors wrote.

The following limitations were acknowledged:

  • The Global Drug Survey uses a self-selecting sample and does not reflect global prevalence.
  • The survey’s respondents were mainly from Western countries, and results do not necessarily reflect other areas like China or India.
  • Fewer people rated less-common drugs.
  • Sex and sexual identity groups “could have been improved.”

“Our results have implications for harm reduction,” wrote the authors. “That the most popular SLS drugs (alcohol, cannabis, and MDMA) were consistent across groups provides a useful direction for the focus of harm reduction attention.”


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