Published in


The Interrelationship Between Sexuality and Drug Abuse: Sexual health as an important component in women’s recovery from trauma and substance abuse

VOLUME 6, ISSUE 4 – Winter 2012

Germayne B. Tizzano, Ph.D., President and Founder

Views From a Tree House, Inc.


Sexual health for women in recovery is critical to the prevention of relapse and an improved quality of life. For women who enter substance abuse treatment programs, over 70% have histories of sexual abuse. (1,2) Yet healthcare professionals at treatment centers are reluctant to discuss sexuality while women are in treatment. This article discusses the risks in not addressing sexuality and the importance of providing at-risk women with the tools and knowledge they need to make informed healthy sexual choices while in a supportive treatment setting. Human service agencies must be proactive in providing ongoing training and supervisory and clinical support for addressing the special needs of trauma survivors.


women, substance abuse, addiction, trauma, sexuality, recovery, sexual health

Women, Addiction, and Sexuality

In the throes of active addiction, a woman’s life can be consumed with the dire need to find, use, and conceal her drug abuse. (3) Basic survival needs of food, shelter, and safety are marginalized by the shadow of her disease. A woman impacted by drug abuse may experience a rapid decline in her physical, emotional, and mental health. Feelings of anxiety, hopelessness, and despair may dominate her existence. Trivial as well as life changing decisions can overwhelm her.

The intent of recovery is to reinstate the woman’s sense of self compromised by the disease of addiction. The pattern of vicious recycling of substance abuse and personal harm, driven by shame and guilt from addiction and/or trauma, can be replaced with the affirmation of herself as a kind, gentle, and worthy person. The recovering woman moves from knowing herself as a stranger to reacquainting herself with who she was always intended to be – self-deserving.

Women who enter drug and alcohol treatment centers frequently arrive with a long history of sexual, physical, and emotional abuse and of having used substances to self-medicate, mediate anxiety, hide their fears associated with sex, and feel sexy. (1,2,4,5,6) In decisions regarding safety and welfare such as sexuality, women affected by substance abuse often have become entangled in destructive relationships that mirror their feelings of self-contempt.

In addition, women with addiction histories fear that sober sex is not fun or sexually satisfying; therefore, they cannot imagine having sex sober. (5) Furthermore, they may have relied on sexual partners as drug suppliers, and they often do not know how to date a person without having sex with him or her. Feeling valued and respected as a person, let alone a sexual person, is unfamiliar to them.


The complexities of substance abuse, addiction, sexuality, and recovery are portrayed in the case example of Justine:

Justine was admitted to a women’s residential treatment program at age 22 for multiple substance addictions (alcohol, marijuana, crack cocaine). She had turned to sex work to support her drug habits. Her boyfriend, whom she does not consider a pimp, procures tricks for her. She primarily prostitutes out of cars and has been beaten and raped by johns multiple times as well as by her boyfriend, particularly when she fails to bring in enough money to support his drug habit, crack cocaine.

Young women like Justine frequently abuse substances to cope with the stress of traumatic event(s). (7,8,9) And since usage often begins at an early age, developmentally, Justine and others like her do not cultivate knowledge of their sexuality, personal choices, values, and/or beliefs. Their self-image as a worthy person deserving of respect and recognition is often crippled by trauma and addiction.


This results in powerlessness over communication about sexuality and sexual decisions, dissociation from feelings, difficulty with attachments or long-term relationships, sexual passivity, attraction to aggressive partners, and fear of negotiating safer sex practices. (10,11)

The Paradox for Treatment Centers

All too often, in the spirit of recovery, alcohol and substance abuse programs follow the policy of asking a woman to leave her sexual self at the door. They ask women to set aside their sexuality and that it will be dealt with at a later time. In the perceived cloak and protection of recovery and sobriety, providers expect chemically dependent women to abstain from being a sexual person for a minimum of one year. They thus communicate to at-risk women who come for treatment that the central focus now is sobriety. (12)

In addition, agencies that attempt to intervene on trauma and substance abuse have limited resources, role models, and trained professionals who are comfortable and prepared to support women’s exploration of their sexuality. (12,13)

Oftentimes, providers are not sure how to discuss the sexual portion(s) of recovery, are hesitant to bring up sexuality for fear that the woman may be re-traumatized, and/or are concerned that the chemically dependent woman may want to engage in sexual activities that may interfere with her recovery. (12,13)

Yet, the “no-sex and no-discussion-of-sex ” policy, to which treatment centers adhere, poses a paradox: It denies at-risk women with histories of sexual trauma the freedom to reclaim a healthy sexual self, which is their birthright. However, simply by limiting any discussion of sexuality to one that is fear-based, such as fear of HIV transmission or pregnancy, (12) treatment centers are unwittingly asking women to suppress the conflict and shame they feel regarding past sexual behaviors and experiences.

Without equipping survivors with sufficient tools, knowledge, and personal understanding of what got them to where they are in the first place, alcohol and substance abuse programs force at-risk women to efface their personal histories. They assume that survivors can magically regain their power and choice in sexual relationships.

The “no-sex and no-discussion-of-sex” policy communicates to women that it is not safe to discuss their sexuality. In turn, women further hide their shame and guilt, and thereby are placed at greater risk of relapse or early termination from treatment. (12)

Yet, to fully heal, survivors who have experienced wretched situations need to reveal and work through all aspects of themselves.

Strategies for Healthy Sexuality for Women in Treatment

In treatment, survivors’ ascent through the ravages of past experiences and choices often begins with a focus on their abstinence from drugs and sex. However, the noticeable lack of discussion of the interrelations of sexuality and substance abuse in the women’s lives creates a very lonely and shameful existence. These conflicts may or may not be resolved outside the treatment center, making the risk of relapse readily apparent. (14)

As an alternative, when an at-risk woman like Justine enters a substance abuse program, she could be given safe opportunities to voice her story of trauma. Beginning on day one, Justine could be greeted kindly with information on the importance of sexuality and sexual health as part of her treatment process. Through discussion with her admissions counselor, she would hear, perhaps for the first time, her right to choice regarding her sexuality. She would be informed of a “sex positive approach” (12) to recovery, which views sexuality as a normal, life-enhancing experience that allows women to choose when and when not to be sexual and with whom and under what conditions.

Within a developing relationship with her therapist, Justine would then examine her own sexual past and would learn the triggers she associates with sexual encounters that include substance abuse. She would explore common indicators of trauma such as anxiety, depression, out-of-body experiences, memory lapses, difficulty sleeping, and other general reactions. (15) An information sheet on posttraumatic stress along with physical, emotional, and cognitive symptoms would be presented to her. (16) Justine would be asked to circle applicable symptoms as a concrete way for her to begin to connect any of her trauma history with drug/alcohol use and her need to numb out.

Through a psycho-educational approach, Justine would learn about the basics of sexuality, would explore positives regarding her body image, gain information on the impact of alcohol and drug use on sexual functioning, (12) and acquire the communication skills of self-efficacy, boundary management, assertiveness, negotiation, and delay skills. Components of a healthy relationship, safety planning, self-soothing strategies, and tools to manage triggers within emotional and sexual intimacy would be offered, as well. (4,5) In this alternative approach to sexual recovery, Justine, who is in a relationship, would develop with her therapist an intimacy and sobriety plan as a means to cope with sexual trauma-and drug-linked

Justine’s Personal Recovery Plan

In her sexual recovery group, Justine shared the following about her planned encounter with her boyfriend, Canard:

Now that I’m about to see Canard, I realize I’ve been growing a lot, learning things about myself I never really knew before except in the back of my head. How scared it made me every time the johns came, even though I did it so often it shouldn’t have mattered. How much I hated it when Canard wanted to have sex after a long night. I never felt like I had the right to say “No.” Maybe that’s why I drank so much, and why I used the drugs. . . so I wouldn’t have to feel all this. It’s hard to feel, hard to admit that I lived like that. Hardest of all to realize that because of that, I let go of my children, Delmar and Kacia.

When I got my first 48-hour pass my counselor and I made a plan for my meeting up with Canard. Being in a public place was the first part, but she told me to carry a picture of Delmar and Kacia with me when I talked with him, to remind me of why I wasn’t just going back to using again. I was scared of what Canard would do, scared he wouldn’t want me anymore if I tried to change things. Especially if I told him I didn’t want to have sex.

“Canard,” I said. “I gotta tell you some things. I’ve changed. I don’t want us to just go back to how things were before.” I tried to get the words out, tell him how I’ve learned I have value, how I’m learning to listen to my needs. He stopped me. “Baby you know I love you. Let’s go back to my place and just be together, without all these people, you know? We can talk in the morning.” He pulled me closer, and I resisted.

The picture of Delmar and Kacia was still in my hand. Somewhere in the back of my mind, I knew that I was making the choice right then between him and my kids. I saw their adorable faces like the last time I saw them, and I pulled away from Canard. I could hardly get the words out. “We’re not having sex.” He looked like I had just slapped him.

I grabbed my purse, holding onto the picture of my kids. His threats followed me to the door. I knew, as I walked out of that building, he would have another girl that night. The thought almost killed me. But I knew I needed to do this. I knew that it’s worth it. For myself, for my children.


To break the cycle of chronic relapses experienced by women like Justine, it is imperative to give women the right to talk about their past sexual histories which drive them to substance abuse. However, healthcare professionals may feel ill prepared and may be reticent to address the sexual trauma of at-risk women. Therefore, human service agencies must be proactive in providing ongoing training and supervisory and clinical support for addressing the special needs of trauma survivors.

It is imperative to give women with substance-abuse histories and who have been sexually exploited, a safe haven and permission to talk with their counselors and peers about their past sexual behaviors and trauma, without judgment, shame, and/or guilt. (14,17). Doing so can help women move beyond being victims of their sexual past and discover within themselves avenues to personal health and safety so that they can reclaim their pre-trauma identities as sober, happy, and healthy beings.


For more than 25 years, Dr. Germayne Tizzano, owner and founder of Views From a Tree House, Inc., has presented nationally and internationally on trauma, drug and alcohol addiction, sexuality and sexual health, body image, and mental health, in over 400 educational programs for health care professionals and university students.

As President and Founder of Views From a Tree House, Inc., Dr. Tizzano offers training and consulting in comprehensive sexual health to agencies that serve women impacted by trauma, sexual violence, and substance abuse. Her most recent publications include a Participant Workbook and Facilitator Guide, Sanctuary for Change, designed to provide women with histories of substance abuse and trauma with the tools to prevent relapse and high-risk transmission of HIV/sexually transmitted infections. In addition, Ms. Tizzano has co-authored and implemented an innovative, skill-focused curriculum, Seeds of Inspiration, Discovery and Hope: A Training Curriculum for Community Support Specialists , aimed at providing training to professionals on educational technologies to improve quality of services to persons with mental health disabilities. Dr. Tizzano has a Ph.D. in Health Education with a specialty in Preventive Medicine from The Ohio State University.

Conflict of Interest Statement:

I declare that I have no propriety, financial, professional or other personal interest of any nature or kind in any product, service and/or company that could be construed as influencing the position presented in, or the review of, the manuscript entitled, The Journal of Global Drug Policy and Practice.

Germayne B. Tizzano, Ph.D.
December 5, 2012


1. Ouimette PC, Kimerling R, Shaw J, Moos RH. Physical and sexual abuse among women and men with substance use disorders. Alcsm Treat. Quart. 2000;18(3):7–17.

2. Teusch R. Substance-abusing women and sexual abuse. In: Straussner SLA, Zelvin E, editors. Gender and Addictions: Men and Women in Treatment. Northvale, NJ: Jason Aronson; 1997. pp. 97–122.

3. Covington S. Helping Women Recover. In Straussner S, Brown S, editors The Handbook of Addiction Treatment for Women: Theory and Practice. New York: Jossey-Bass; 2002. p. 52-72.

4. Covington S, Burke C, Keaton S. Evaluation of a Trauma-Informed and Gender-Responsive Intervention for Women in Drug Treatment. J. Psychoactive Drugs. 2008 Nov (SARC Supplement 5): 377 – 385.

5. Covington, S. Awakening Your Sexuality: A Guide for Recovering Women. Center City (MN): Hazelden; 2000.

6. Covington S. Women, Addiction, and Sexuality. In: Straussner L, Zelvin E, editors. Gender Issues in Addiction: Men and Women in Treatment. Northvale NJ: Jason Aronson; 1997. p. 1–18.

7. Ullman SE, Filipas HH, Townsend SM, Starzynski LL. Trauma exposure, posttraumatic stress disorder and problem drinking in sexual assault survivors. Journal of Studies on Alcohol. 2005;66(5):610–619.

8. Herman, J. Trauma and Recovery: The Aftermath of Violence – From Domestic Abuse to Political Terror. New York: Basic Books, 1997.

9. Yuan N, Koss M, Stone M. The Psychological Consequences of Sexual Trauma [Internet]. Harrisburg (PA): VAWnet; 2006 March [cited 2012 Nov 14]. Available from: http://www.

10. Testa M, Livingston JA, Leonard KE. Women’s substance use and experiences of intimate partner violence: A longitudinal investigation among a community sample. Addict. Behav. 2003;28(9):1649–1664.

11. Blume S. Sexuality and stigma. Alc. Hlth Res. World. 1991;15(2):139–146.

12. Braun-Harvey, D. Sexual Health in Recovery. New York: Springer; 2011.

13. Nelson S, Phillips S. Beyond Trauma: Mental Health Care Needs of Women Who Survived Childhood Sexual Abuse. Edinburgh: Edinburgh Association for Mental Health; 2001.

14. Covington SS. Helping Women Recover: A Program for Treating Addiction. (Rev. ed.) San Francisco: Jossey-Bass; 2008a.

15. US Department of Veteran Affairs [Internet]. Washington, DC: Veterans Affairs; c 2009 [updated 2012 April 25; cited 2012 Dec 2]. National Center for PTSD. Available from:

16. Tizzano G. [Internet]. Westerville, OH: Views From a Tree House, Inc. c 2012 – [cited 2012 Dec 5]. Available from: .

17. Elliott D, Bjelajac P, Markoff L. Reed B. (2005). Trauma-Informed or Trauma-Denied: Principles and Implementation of Trauma-Informed Services for Women. J Community Psychol. 2005; 33(4); 461–477.

Contact Germayne at Views From A Treehouse today Phone:(614) 448-7623 E-mail: