This is the first study to establish associations between sexual expectancies and inhibitions and high-risk sexual behaviours among young PSU in the informal settlements of Kampala. Young PSU in this study on average had an early sexual debut (15.2 years). These findings imply that young people using psychoactive substances, engage in early sexual intercourse compared to the national median age in the general population of 17.6 years for females and 18.0 years for males (39). This finding is similar to that of Doku (40) among those in Ghana who had an average age at sexual debut of 14.8 years. In an era, where several young people are living with HIV, some due to vertical transmission, it is critical to institute strategies to reduce the transmission of infections among young people who may assume that their peers and sexual partners are HIV negative.
Our study revealed significant differences in the proportion of males and females who felt that being under the influence of psychoactive substances made it difficult for them to use condoms. A higher proportion of males found it difficult to use condoms, compared to females. This could be due to the varying effects of psychoactive substances on sexual behaviour or perhaps more emphasis on the girl child in most sexual and reproductive health and rights programs (41, 42). Some psychoactive substances may deprive male users, the ability to wear a condom while others may think that sexual intercourse is more pleasurable without condoms. There is also evidence that some psychoactive substances could deprive male users the ability to sustain an erection, hence difficulties in putting on a condom (43). In addition, Calsyn, Peavy (44) in their study reported that men often pointed out the negative effects of condom use on sexual experience. Young PSU in their study reported not feeling good or natural, condoms not fitting well, change in orgasm, interruption of the sexual mood, and interference with feelings close to one’s partner. A significantly higher proportion of females felt that sex was more pleasurable when under the influence of psychoactive substances. Although each psychoactive substance has its varying effects, it is believed that substances such as alcohol increase the sexual libido of women, and consequently pleasure (45, 46).
Nearly a quarter of the sexually active young PSU in this study had ever made some one intoxicated with psychoactive substances in order to have sex with them. In addition, nearly half of the young PSU or their partners used a psychoactive substance before last the sexual intercourse. This is because a considerable proportion of the young PSU expect that the use of psychoactive substances would improve sexual performance, give courage or confidence to approaching a partner for sex, and make sexual intercourse more pleasurable as evidenced by the study findings. Similar findings have been reported elsewhere (36, 47, 48). Furthermore, getting someone intoxicated would make it easier for the partner to engage in sexual activity even against their consent, mainly due to impaired cognition and decision making (49, 50). Using psychoactive substance prior to the last sexual intercourse could also have been thought to improve their confidence to approach sexual partners. The use of these substances has been reported to improve aggression among users (51, 52). These expectancies are likely to have lured some respondents into intoxicating their partners with psychoactive substances or even using psychoactive substances during their last sexual intercourse.
Respondents who felt that they were likely to engage in sex under the influence of psychoactive substances were more likely to engage in multiple sexual relationships compared to those who did not think so. Users of psychoactive substances are significantly more likely to have sexual intercourse compared to non-users (53). Therefore, psychoactive substances may have increased the sexual urge of young people in our study, thereby prompting multiple sexual partnerships. Similarly, an increase in the sexual urge or libido, which often characterises psychoactive substance use, may have been an important driver for young people who find it difficult to refuse sex while under the influence of psychoactive substances for engaging in multiple sexual relationships. Having multiple sexual partners in Kampala’s informal settlements, a setting that already has a high prevalence of sex work and HIV among young people (54, 55) and the general population (56), is likely to escalate the transmission of sexually transmitted infections (STIs), including HIV/AIDS.
Respondents in our study, who felt they were likely to forget to use a condom, while under the influence of psychoactive substances, did not consistently use condoms. These findings reaffirm the fact that the use of psychoactive substances impairs judgment and cognition (57). Once under the influence of psychoactive substances, young people often fail to make the correct decisions or choices as far as the use of condoms. The failure to have protected sexual intercourse could exacerbate the spread of STIs not only among young PSU but also among the general population in the informal settlements. Our findings therefore implore the need for risk reduction interventions for sexual and reproductive health among this high-risk group.
This study also indicates that sexual expectancies such as improved sexual performance, confidence or courage, and increased sexual desire increased the likelihood of engaging in sex under the influence of psychoactive substances. Young PSU often resort to the use of these substances as a way of sustaining erections and bettering sexual performance (36). Given the fact that a significant proportion of young girls and women in the informal settlements of Kampala engage in commercial sex (54), female users could as well resort to the use of these substances to get the energy to have as many sexual clients as possible.
Young PSU in this study were less sexually inhibited. Those who endorsed that they were likely to engage in sex when under the influence of psychoactive substances were actually more likely to have sex while intoxicated compared to those who did not think so. This as well, could be attributed to the effects of psychoactive substance use of sexual urge, desire, and anticipated expectancies such as better sexual performance. There is evidence for instance that alcohol makes women more sensuous and more romantic (58). It could be this feeling that propels young PSU to further engage in sexual intercourse when intoxicated. Our findings should be an eye opener to policy makers and those who engage in HIV/AIDS programming on the immediate risk posed by young PSU as far as the transmission of HIV is concerned. It is therefore important to extend HIV prevention services such as testing and enrolment into HIV care of young PSU living in informal settlements. This would help tame the transition to injecting drug use, which is more complex to manage (28), and the immediate risk of transmission of STIs, including HIV.