essay sex drugs

Sex, Drugs, Disasters, and the Extinction of Dinosaurs by Stephen Jay Gould Article Analysis Essay Example

Sixty-five million years heretofore, dinosaurs prowled the face of this Earth. Until one day, the entire population of dinosaurs evaporated into the air. Currently, anthropologists are still searching for why the dinosaurs went extinct. Regrettably, a concrete reason still has not been accumulated. Stephen Jay Gould, an American paleontologist and the author of many scientific articles published, “Sex, Drugs, Disasters, and the Extinction of Dinosaurs.” In this article, Gould illuminates how dinosaurs became extinct. He portrays an authentic account of how the dinosaurs dissipated. Gould elaborates on these theories, providing a sound argument on why dinosaurs vanished. He uses logos to help aid the testicular sterilization theory, rhetorical questions, and his audience’s perception. However, Gould has flaws in his argument due to his contradicting himself and lack of evidence. To a greater extent, even with Gould’s struggles to make a case for the flowering plants, he predominantly maintains a compelling argument on why the dinosaurs were terminated. 

Gould endorses a logical connection with scientific studies to assemble an argument on how the sterilization of the testes could have led to the extinction of the dinosaurs. Gould supports his article with a study that analyses the body temperature of alligators. With alligators being the directest common ancestor to dinosaurs, researchers theorize that they could forecast the optimum temperature for dinosaurs and juxtapose the changes to their bodies. To enhance his argument, Gould cultivates, “Cowels suggested that a rise in global temperatures just before the Cretaceous extinction caused them to heat up beyond their optimal temperature” (12). The logical facility incorporated inside the quote is an essential support beam to his argument, enhancing his credibility. Gould uses logos anon, stating, “Testicles simply do not fossilize, how could we infer their temperature tolerances even if they did? In short, Cowles’s hypothesis is only intriguing speculation leading nowhere.” (20). Gould handles the appeal to logos in his argument heightening his integrity because he does not possess a fact without evidence. Throughout the entire article, Gould employs rhetorical knowledge to gain validity in his argument. 

The adoption of rhetorical questions and recognition of his audience is an essential backbone to Gould’s argument. For example, Gould formulates, “What temperatures were optimal for dinosaurs? Could they avoid the absorption of excess heat by staying in the shade, or caves?” (20) The manipulation of rhetorical questions is vital because of the audience of his article. Gould blueprints the article to grasp the attention of scientists that specialize in anthropology. Furthermore, his benefit of rhetorical questions leads readers to attain interest and involve themselves. The audience of Gould’s articles is indispensable for his argument because he accosts his audience with information that piques their interest, which causes the reader to invest themselves in the article. The awareness of the audience and the wielding of rhetorical questions is evident throughout Goulds’ article, which coaxes the audience to continue reading and ask questions themselves, then overall promotes Goulds’ argument. 

Gould undermines his argument in his article a couple of times. The primary way he did this was by contradicting himself. When Gould blunders his attempt to illustrate why flowering plants were not a reason dinosaurs went extinct, he scribes, “Flowering plants did not evolve until late in the dinosaurs’ reign” (14). This quote solely does not weaken the argument; however, what does is what Gould states later on, “The hypothesis does not even make any sense in its own context. Angiosperms were in full flower ten million years before the dinosaurs went the way of all flesh. Why did it take so long?” (22). These two quotes are detrimental to Gould’s argument. Gould’s claim that plants do not represent a cause for the demise of the dinosaurs because they had not evolved yet, then clearly contradicts his claim later in the article. It took a long time for the flowers to push dinosaurs to extinction. If Gould had stuck to the claim, he believes more or eliminated this; his overall argument would have mended better. 

Gould uniformly dearths evidence in the case of the flowering plants aiding in the extinction of the dinosaurs. Gould tends to manipulate his own opinion when discussing the flowering plants. Gould discloses, “It is simply a gratuitous, attention-grabbing guess. It cannot be tested for how can we know what dinosaurs tasted and what their livers could do.” (21). The controversy with this quote is that Gould does not back up his opinion as he does with the other theories. Jean-Pierre Chigne, a reporter on scientific studies and journalist, denounces his claim. Chigne writes the article, “Turns Out Dinosaurs Were Killed Off By Flowers, Then The Asteroid Put The Nail In The Coffin.” published in Tech Times. Chigne supports the hypothesis by including studies by the University of Baltimore and the University of Albany. Chigne elucidates, “Dinosaurs were not able to learn to associate toxic plants with tastes and smells. This could have managed the dinosaurs to consume harmfully, or lethal doses of noxious plants.” (5) Chigne safeguards his claim by exhibiting research on the evolution of dinosaurs and juvenile birds and how their taste differed from one another. Bringing his article to a halt, Chigne concludes, “This theory doesnt dispute that the asteroid killing off the dinosaurs during the impact off the coast of Mexico. Instead, what remains shows is that the asteroid was what finished off the dinosaurs. Instead. dinosaurs were already starting to decline because of the emergence of flowering plants” (6). Gould neglects his argument, unlike his colleague Chigne, who further explained how flowers led to the extinction of dinosaurs. Providing more evidence would bolster Gould’s argument on how dinosaurs mysteriously went extinct.

Goulds’ premise on why the dinosaurs became extinct was extensive and tangible. Gould expands upon how sex, drug, and disasters nursed the extinction of the dinosaurs by utilizing factual information from scientific studies and proposing rhetorical questions. Nonetheless, Gould did lack scientific evidence on how drugs could have helped lead to the extinction of the dinosaurs and contradicts himself. Gould’s lack of logical fallacies and his inconsistency of what could have occurred in the flowering plant theory leave readers befuddled. Howbeit, Gould’s instruction about the testicular frying theory and his use of rhetorical questions to engage his audience strengthens his credibility.

SEX, DRUGS, AND COCOA PUFFS: A Low Culture Manifesto

Chuck klosterman, . . scribner, $23 (256pp) isbn 978-0-7432-3600-3.

Reviewed on: 05/19/2003

Genre: Nonfiction

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Back to Dmytro Taranovsky's home page . Author: Dmytro Taranovsky Date: 2007-2012 Last Modified: July 10, 2012 (Last Small Change: September 17, 2015)

An Essay about Sex

List of Sections: The Nature of Sexual Feelings , Sex in an Ideal Society , Sex and the Law , Morality and Sex , Cultural Beliefs about Sex , Sex versus Drugs , Sex and Fundamental Rights

The Nature of Sexual Feelings

Sexual feelings are defined as feelings with a very strong localized physical pleasure component, or feelings that are closely connected/associated with such feelings. Evolutionary, sexual feelings are closely connected with reproduction; however, the connection is not ordinarily a part of the feeling. Sexual feelings are closely connected towards love and attraction, but these are not necessary for feelings to be sexual. As with all feelings, the essence and identity of sexual feelings lies in the understanding and perception of the feelings. As such, sexual pleasure cannot exist without an appropriate mental context. For example, otherwise pleasant feelings may be not truly enjoyable when the sex is coerced, and the victim may be confused over whether he or she enjoyed the encounter. It is also possible for a victim to enjoy the physical feelings, yet suffer much more from the emotional distress.

Sexual conduct refers to conduct with a sufficient nexus to sexual feelings. Throughout this essay, sex will be used to mean touching with intense sexual feelings, especially touching by another person. This differs somewhat from the standard usage. In particular masturbation, especially mutual masturbation, is treated as a type of sex. The term "sexual intercourse" is used in the conventional way.

As the definition suggests, sexual feelings are not special. The primary difference between sexual and non-sexual feelings is cultural, and the primary non-cultural difference is in the magnitude of the feelings. Consequently, the correct morality for sex is similar to morality for ordinary non-sexual massage. Although sexual feelings may be very strong, sexual behavior can quickly become a normal part of life, with the person's personality largely undisturbed.

Sexual feelings are likely to be stronger when equivalent stimulation is done by another person rather than oneself because with stimulation by another person, you lack a mental preimage of the feelings. Feelings are likely to be stronger when having sex first time (assuming that the physical behavior is equivalent to subsequent times) because of lack of mental constructs to deal with the feelings, and similarly for particular sexual behaviors/situations.

Physical feelings from comparable physical contact tend to be stronger in children partly because to some extent the strength of feelings is relative to other feelings experienced, and partly because of a reduced capacity to internalize feelings into routine mental constructs. (However, biological changes such as puberty may make analogous stimulation incomparable.)

The strength of sexual feelings can create a temporary mental state of altered reality. Basic properties of objects such as shape and color will be remain the same, but the perception will be different, the sexual experience will be the dominant feeling, and the physical world may appear less real.

Physical risks of sexual behaviors are not discussed here. The reader is encouraged to learn about the risks elsewhere, especially if the reader is planning on having sex. Here, it suffices to note that strong sexual feelings and interactions are often physically safe.

Most people in most situations sexually prefer a person of opposite sex. (By contrast, on average people tend to socialize with people of the same sex.) However, it is not possible for one to be sexually attracted to just males or to just females. Sexual orientation is a matter of degree, and your primary sexual orientation does not extend to all possible situations.

On an abstract level, homosexuality has the benefits of equality and inclusiveness. Specifically, in homosexual sex, (when desired) one partner can have approximately the same physical experience as the other. Furthermore, mutual attraction is possible even if there are more than two people. However, there are practical advantages to heterosexuality, such as are diversity (having two types of bodies may provide richer experience), certain biological adaptations, commonness of partners, cultural acceptance, and possibility of procreation.

Sexual feelings are on average pleasurable, but even then, they are not just pleasure. Sexual feelings contain other components and may even include significant pain.

Sexual urges are sexual feelings with a significant desire/suffering component: desire for sexual feelings, and suffering from lack of these sexual feelings. Sexual urges can be satisfied by creating these sexual feelings, usually through some type of genital massage (such as masturbation or sexual intercourse). Sexual urges are generally caused by sex-related thoughts and feelings and can be quite strong. For many people, sexual urges occur quite frequently. Although sexual urges involve suffering or something closely related to suffering, they may have pleasurable aspects as well. Suffering is necessary for pleasure to exist, and sexual pleasure is not an exception. When done in moderation, unfulfilled sexual desire and sexual abstinence can increase sexual pleasure.

Sex in an Ideal Society

Eventually, technological advances may make human biology irrelevant, but until then, sex as we know it will play an important role. Here is my vision of its role. The role represents both freedom and restraint.

On the one hand, sex is practiced openly, publicly, and casually. Sex is guilt-free. Most people are not shy about soliciting strangers for sex. Exchange of sex for money or favors is generally accepted. The right of everyone to have sex is respected both by law and private parties. Among other things, parents do not prevent children from having sex. A spouse does not get mad when the husband or wife has some casual extramarital sex. Sexual images are uncensored.

On the other hand, a majority are in (mostly) monogamous relationships. The family as we know it continues to be important. Sex is practiced in moderation, with people confident in declining it. The right to privacy and individual objections to sex and even (to a reasonable extent) sexual images are respected. Generally, no money is exchanged for sex--sex is generally enjoyable to both/all participants.

While humans will eventually transcend biological bodies, sex-like experiences will likely remain because of their emotional value. Future technology will overcome the limitations of wrong gender and of physical ugliness that currently prevent people from enjoying sex with each other.

Sex and the Law

Consent to sex.

• The conduct has no unacceptable physical risks (including any physical pain that persists after the activity).
• The conduct can be terminated immediately upon request.
• The person is either aware of the feelings that the interaction will involve, or the feelings are introduced gradually and the person is not deceived about the feelings involved.
• The conduct is not in exchange for money or other consideration, and the person knows that (see the next subsection about sex for money).
• The person is not deceived about the benefits of the conduct, or about any suffering that occurs during the conduct.
• The person is conscious and is readily capable of making and communicating an objection and knows or expects that an objection will be honored.
• The person makes no objection to the conduct or all objections are honored.
• The person affirmatively grants consent.
• Physical risks should be acceptable in sex if they are acceptable in other activities such as sports. Which physical risks are acceptable strongly depends on the presence of informed consent (or partial informed consent) to such risks. Psychological risks are excluded here since psychological harm is caused primarily by thoughts, and the right to have harmful thoughts is protected by the core freedom of thought. In addition, the concept of psychological risk is too amorphous, and psychological risks of safe consensual sex are mostly cultural and unpredictable.
• The second requirement refers to the technical ability to stop the conduct, and is usually satisfied for sex. By contrast, most mind altering drug use does not meet this requirement since drug effects ignore the user's request to become sober.
• Given the strength of sexual feelings, even with the availability of immediate termination, an additional protection is needed, namely a basic understanding of what feelings to expect. The person has to understand the feelings well enough to decide whether they are enjoyable or otherwise evaluate the feelings. Understanding the expected feelings as if from memory is sufficient. Also, gradual introduction of feelings in a state where the person is ready to object is sufficient, as the person is given ample opportunity to evaluate the feelings. However, a person may not be deceived into painful sex through a misleading promise of pleasure at the end. Real moral or psychological understanding of the feelings is not required; as of 2012, very few people have such understanding.
• Money can be a strong coercive force.
• It is not acceptable to trick a person into having sex by fabricating various benefits of sex (such as "sex will make you rich", "sex will make your skin beautiful"). 'Benefits' is construed broadly to include moral benefits and benefits to third parties. Moreover, deception can be indirect.
• Without an expectation that an objection will be honored and not trigger penalties, a person may be unlikely to object even to unwanted sex. Also, some psychological states make a person unlikely to object; if a person in such a state is unlikely to object to moderate pain, the person may be deemed incapable of objecting to sex. Also, a person may be incapable of objecting if he or she does not connect the sexual act with the other's intent; an example is when the person is deceived into believing that the sexual touching is unintentional.
• This is the basic element of consent.
• The requirement of affirmative agreement should be waived in the ordinary case where the person is expected to enjoy conduct and there are no special risks.
• In defining legal consent, the key factor is what the person is consenting to. In case of safe sex, the consent is to the immediate feeling. The issue of informed consent arises in case of tangible harm that cannot be undone. Because safe sex involves no such harm, consent to sex is treated more like consent to an amusement park ride than a consent to surgery. No intelligence test is required for consent to safe sex.
• Meeting the conditions of legal consent may require communication, explaining to the person certain aspects of the interaction.
• It is difficult for a person having sex the first time or having a new sexual experience to know exactly how it will feel, which necessitates the right to introduce unexpected feelings gradually. However, sudden sexual conduct (even when an objection is immediately honored) can still be criminalized; without affirmative consent, touching should be started gradually. Conditions (2) and (3)--to the extent they are required by law--may not be construed so as to prohibit ordinary orgasm, including the first orgasm.
• Videotaping and other recording of sexual interaction should be permitted if all participants are given a fair notice. In cases of sexual abuse, recording without notice should be permitted. Such recordings are, among other things, useful to secure a criminal conviction.
• Although explanation of psychological risks and of cultural perception of the conduct should not be required, it is a nice thing to do anyway.
• An affirmative 'yes' to sex should not ordinarily be required since much of clearly consensual sex is done without it. In addition, if one person is unsure of whether to have sex, a common practice is to introduce sexual touching/behavior gradually, letting the person decide on the limits as the interaction proceeds.
• A person can be indirectly deceived about the benefits of sex from claims (even such as "everyone your age has had sex") that imply a special benefit without explicitly stating it. Moreover, even in the absence of a specific claim, deception can occur through the presence of a special trust to act only in beneficial (or otherwise special) ways. Doctors, parents, teachers, and police officers are commonly entrusted in this way. Religious deception should be handled carefully so as to protect both the right to persuade a person to a religion, and the right not to be deceived into sex. Deception about things other than the benefits of sex should not invalidate the consent to sex (provided the other conditions of consent are met). However, such deception (for example, slander about the person's other sexual partners) can in certain cases be treated as a separate offense.
• The penalty for sex without legal consent should be determined on a case-by-case basis, some violations are much more serious than others. People should not be punished for activity that they non-negligently and in good-faith believed to be safe consensual sex.
• The eight proposed conditions are sufficient but not always necessary for consent. However, since sexual feelings may be unbearably strong, the right not to have sex (including the right to terminate an ongoing sex) is fundamental, and as such must be honored. Forced sex is unacceptable even in the rare cases when it is enjoyable and beneficial to the victim (even if such enjoyment and benefit was the intended and likely result). Consent refers to choice and will and is different from desire (which refers to feelings). Thus sex may be consensual but unwanted (legal) or wanted but nonconsensual (unlikely, but still illegal and unacceptable). Also, consent cannot be given retroactively. Sexual stimulation may be a permissible side-effect of a necessary treatment for a physical illness. However, forced sex may not be used as a treatment for mental illness, even if it is "medically" necessary and the person is a danger to self or others.
• Bondage role-playing should be permitted as long as the consent conditions are met. In such role-play, it is not necessary for word "No" to count as an objection provided that both of the following are met (a) given the totality of circumstances, the person does not appear to object, and (b) the person is clearly capable of giving a genuine objection.
• Deprivation of sex should not ordinarily be used as punishment. However, some punishment, such as incarceration, properly involves physical segregation and the corresponding deprivation of sex.
• Intoxicated persons should not be prohibited from having safe consensual sex. A later regret of sex is not very different from regret of a number of other choices the person may have made while being intoxicated.
• A person should be allowed to make directions about possible sex in case the person becomes unconscious. The legal default should be no sex, except perhaps in narrow circumstances (such as some cases waking up one's sexual partner through sexual contact).
• Laws about sex should ideally be written in age neutral terms.
• Infant circumcision that is not medically necessary should be criminalized, without religious exceptions. Circumcision amounts to a permanent body mutilation. One's religion is not a legal excuse to harm other people.
• Although infants cannot be meaningfully give consent, they can still give a positive or a negative response. Genital stimulation of infants by parents and other authorized caretakers should be permitted provided that the immediate response is positive and the stimulation is harmless or beneficial to the infant.
• Corporal punishment (by parents, educators, and other people) must not be permitted. This is a matter of fundamental rights. The fundamental freedom from physical restraint includes the right to engage in safe consensual physical interaction (excluding commerce). This right applies to people of limited intelligence and experience (such as children) and to conduct that is traditionally regarded as immoral (such as sex). However, there is more to consent than lack of objection. In addition to the eight conditions, it is probably constitutional to require provision (but not understanding) of reasonable additional information clearly specified by the law. Parents must not be permitted to violate the children's fundamental rights, including the right to engage in safe consensual sex. Distribution of all information (including pornography) to all people is protected by the fundamental right of freedom of expression.

Sex for Money

Because sex for money is commercial, and because of the inherent risk of coercion, such sex is not (in my opinion) constitutionally protected. However, a ban on prostitution would be unwise. Instead, laws may require (using more specific phrasing than here) that (1) sex is consensual, (2) sex is physically safe, (3) the payment is fair, and (4) all involved parties receive appropriate information, and know what the compensation is. Part of the fairness involves the right to terminate the sexual conduct at any time without undue penalty. Non-monetary compensation may be used provided that it is not based on special authority of one person. Use of special authority as compensation should ordinarily be prohibited. For example, the government may not shorten someone's jail term in exchange for sex.

A contract to abstain from sex should not ordinarily be enforceable, as such contract is in tension with the fundamental freedom to physical interaction.

When both people and rational and informed, their relationship is (usually) mutually beneficial even if it involves monetary exchange. Informal use of sex in exchange for something is very common, and cannot, consistent with fundamental rights, be entirely prohibited. For example, a person may terminate a friendship (and its benefits) in part because of a lack of sexual satisfaction. Much of pornography production involves paying actors to have sex. Also, many people, including children, rely on money from sex to buy food and other necessities; these people cannot reasonably be expected to stop having sex for money.

Sex Education

Public nudity and indecent exposure.

In deciding to what extent to prohibit nudity, indecent exposure, and outdoor sex, the enjoyment of the participants should be weighted against the offense to the observers. In evaluating offensiveness, one should consider the offense from ugliness of the appearance, rather than the moral offense from violating cultural norms. Considerations of offensives should be significantly discounted because the viewer can avert his or her eyes, and because there is no right not be offended. Moreover, because the sole reason for prohibition is visual offensives, indecent exposure should be treated as pure speech, thus magnifying the value of the perpetrator's interests.

Nudity should be legal in most outdoor areas, including inside cities. Nudity is a natural state of the human body, and is comfortable for sunbathing and swimming. Nudity can be very beautiful, and is frequently used in art. The right to be without clothing is an important freedom that should be respected. The right to nudity should include the right to have an erection (erections can arise spontaneously and prohibiting them would cause anxiety and limit freedom).

Outdoor sex should be legal when it is done discreetly, "not in your face". While there are substantial offensiveness considerations, they are ordinarily outweighed by the liberty of the participants, as the right to have sex is part of the freedom from physical restraint and sex can be one of the most meaningful activities humans engage in. Current (as of 2012) laws may effectively require postponement of sex for hours (or worse) and otherwise impair sex.

Morality and Sex

Introduction.

In the section "Morality and Sex", I list various recommendations relating to sex. These recommendations are directed to the present society rather than a hypothetical society with correct views about sex. The reader should keep in mind that I am not perfect and can make mistakes.

The essay does not advise you whether to have sex. The decision whether to have sex is a personal manner, and it is ordinarily wrong to pressure people to have sex. Moreover, to the extent that sex is enjoyable and without impediments, people usually end up having sex, so it is unnecessary to advise here for people to have sex.

The main reason to have non-reproductive sex is that sex can be a source of happiness. In addition to directly causing happiness, sex can enrich one's experience and promote human bonds. (This essay does not discuss whether and when to have children.) I subscribe to utilitarian theory of morality. The good is to maximize happiness, with equal consideration of everyone's interests.

However, in receiving pleasure, there is a risk of other activities becoming less enjoyable, which decreases (and can even reverse) the net effect of the pleasure. The key is to have sexual pleasure in a meaningful and enriching way.

Sexual conduct has no moral significance beyond the feelings that it causes. (Here, the feelings include long-term feelings as well, such as suffering from a disease.) Sexual feelings have no moral significance beyond the significance attached to them by the mind. For example, when sexual feelings are perceived as pleasurable and without negative connotations, their presence (all other things being equal) is good.

Different societies have attached various moral and religious significance to sex. Examples include "sex is wife's sacred duty to the husband", "boys should be masculine and girls feminine", and "homosexuality is wrong". These beliefs are wrong, and ultimately, irrational. However, there are sufficient historical reasons for their prevalence.

Morality and Law

In ordinary cases, you should respect the law. In choosing to break the law, you should evaluate its effect on you and (with equal consideration of interests) on other people, and then apply a strong weighting towards compliance with the law. The weighting towards compliance is decreased if the law is routinely ignored and unenforced, or if the law is profoundly unjust or irrational or inconsistent with important freedoms.

A List of Suggestions

• It is important to learn about sex.
• Sexual relationships with love and commitment are likely to be more fulfilling than anonymous purely sexual encounters.
• It is very difficult to learn how sex feels without trying it. It is difficult to know whether one would enjoy sex without trying it. A reasonable suggestion is to try sexual conduct to gain understanding and to see whether sex is something that you like.
• Sexual relationships should ordinarily be non-exclusive. Do not pressure your partner to not have sexual relationships with other people.
• Try to be open about your feelings and relationships. It is especially important to be open with your partner about your feelings. However, to the extent that you may be discriminated against because of erroneous beliefs other people have about sex, you should balance this factor against the natural benefits of openness.
• You should ordinarily respect your commitments to keep someone's sexual interactions and preferences private. This is not an absolute rule, particularly in cases of sexual abuse. You can also discuss the relationships anonymously. Ordinarily, you have a right not to disclose you sexual preferences and activities, and ordinary you should not pressure other people to reveal their sexual preferences and conduct. It may be best to be assertive about your right to sexual privacy.
• Relationships where one party does not like sexual conduct but accepts it as a debt of friendship are likely to be unfulfilling and problematic. Consider making such a relationship non-sexual. If you and your partner choose to continue the sexual relationship, then make sure you both understand the role of sex in the relationship, and consider whether using explicit compensation for sex is better.
• Following your sexual orientation--even if it is considered unacceptable in your society--can lead to great joy and emotional fulfillment. If seeking counseling about sex, it is important that the counselor accepts your sexual orientation.
• If you have strong deeply held beliefs against sex, then consider them as an important argument against sex since your enjoyment of sex may be marred by guilt and anxiety. You may want to delay sex until you resolve these (erroneous) beliefs. However, it is important to learn about sex, even if such learning is expressly contrary to your religion. If objecting to sex for moral reasons, then state your objection early. By waiting until the latest possible moment, you may find your morals compromised.
• Sexual intercourse need not be the best way to achieve sexual satisfaction. Other possibilities include solo and mutual masturbation, which can be done in a variety of ways. (Masturbation tends to have much lower physical risks then sexual intercourse. In this essay, masturbation is treated as a type of sex.)
• Sex is sometimes wrong. Here are some valid reasons against sex - you may not enjoy sex, especially if it is done in a wrong way or with a wrong person - a longer interval between instances of sex can make sex more enjoyable - sex may involve physical risks (direct injury, pregnancy, sexual transmitted diseases) - guilt and shame you may have about sex (however, it is important for you to resolve these feelings) - the society may discriminate against you (or your partner) for having sex - your partner does not consent, has valid reasons against sex, or believes that the particular instance of sex is wrong. A person's moral opposition to sexual conduct should be given due respect and not ignored. - your partner expects sex to imply commitment of a kind that you do not wish to make
• Spiritual relationships can be stronger than even very strong (physical) sexual feelings. It is wrong to explicitly limit your relationships to (for example) people of a particular sex. While sexual attractiveness is frequently an important factor in one's relationships, other factors can be more important.

Morality of Adult-Child Sex

• As the more powerful and knowledgeable person, you have a duty to ensure morality of the relationship.
• Ensure that the relationship is consensual.
• Chronological age of the child is not relevant per se. What is relevant are the child's understanding, the societal views of sex with children, and the child's sexual preferences and anatomy.
• Avoid conduct with unacceptable physical risks. It may be best to avoid conduct with significant physical risks.
• You may have to keep your conduct secret (even from the child's parents and counselors), and instruct the child to do the same. Even in the absence of criminal prosecution, both you and the child may be discriminated against if the relationship becomes known.
• Since the relationship is secret, you will have to provide any necessary counseling to the child. Provide appropriate counseling before, during, and after the sexual conduct.
• If you are in a position of authority over the child, some counseling may even be necessary to ensure that the relationship is truly consensual.
• Do not have the relationship if you believe it to be wrong.
• Convince the child that the conduct is morally right before doing it. Do not have sex with the child if you fail to convince the child that the conduct is right. If child later feels guilty and betrayed, serious psychological harm may follow, even if he or she enjoyed the sexual experience. Also, make sure that the child wants the sexual relationship. It make take time for a child to overcome his or her irrational opposition to sex.
• Explain the nature of the child's sexual feelings to the best of your ability. Also, if appropriate, explain that other people are wrong in their condemnation of adult-child sex. A partial explanation may sound like "Genital massage is like ordinary massage. However, your feelings will be much stronger. It will feel very good. If it feels weird, just relax and enjoy it, or ask me to slow down. Contrary to what others may have told you, there is nothing wrong with these feelings or with such massage. It is harmless. If you don't like it, just tell me to stop. Do you want to do it?"
• Do not deceive the child. Do not make false statements like [as of 2012] "Genital fondling is a standard component of therapeutic massage."
• The risks of such a relationship include legal punishment and social discrimination, and for the child, harm from his or her erroneous beliefs related to the relationship. However, the existence of such relationships adds to the richness of the human experience, and such relationships are a source of joy for millions of children and adults worldwide.
• If you pay a child to have sex, then - ensure that the payment is fair and that the transaction (sex plus payment) is in the child's best interests - ensure that the child understands what the payment is - ensure that the payment is concrete and is not part of any special authority you may have over the child - if necessary, explain to the child that getting paid to have sex is OK, and is consistent with human dignity, and is not like selling one's body, etc. - If you act as the child's parent, then paying the child to have sex with you is probably a bad idea. - Even if the above conditions are met, this does not necessarily mean that the conduct is right.
• The above need not fully apply if the child is the one initiating sexual conduct, or if the child has sufficient experience.
• Verify that your participation is consensual. If not, then it is child sexual abuse. For victims of sexual abuse, a good coping strategy is to try to make the best of the experience. Also, counseling with a qualified person is important (however, unfortunately, current reporting regulations may deny you the option of keeping the sexual relationship confidential).
• In choosing whether to have sex, you are exercising your fundamental right to privacy, which is a part of your fundamental right to be free from arbitrary physical restraint. Your privacy is yours to keep or share. You have a right not to have sex, and if you do have sex, to set your limits, and to decide whether to allow recording of the sex for others to enjoy.
• Be careful if the adult only appears to care about you sexually. Trust and emotional connection are important.
• Do not accept alcohol, tobacco, or other recreational drugs from the adult. An adult offering you recreational drugs is probably disregarding your well-being; beware of such adults.
• Verify that the interaction is physically safe; some adults are reckless about this.
• Do not consent to sexual conduct that you do not want.
• If you feel overwhelmed with feelings, then consider asking the other person to stop. Ponder and contemplate your feelings and then decide whether to proceed.
• Do not tell other people (including parents and counselors) about your sexual relationship unless it amounts to sexual abuse, with the exception of those people who are likely to accept your relationship.
• On the other hand, do not hesitate to discuss your feelings with the adult, and with other people whom you can trust to keep your secret.
• Take time to think about what happened, but do not become obsessed with it. Sexual feelings are a healthy part of life, but should not be the dominant part.
• If you like the experience and choose it continue, then take a positive exploratory attitude toward your new feelings. Societies are often irrational about sex. Sex is not a guilty pleasure, and it does not make you impure.
• Be cautious and discreet about initiating sexual conduct with other people. Many people do not like it or have moral objections to it.
• Legal issues aside, getting paid to have sex is OK. However, do not let what may be a sudden access to money by a corrupting influence over you; moral corruption hurts not only other people but yourself as well.

Cultural Beliefs about Sex

The belief that sex is evil.

• Given the central role of sex plays in reproduction (and hence in societal survival), and given the intense feelings accompanying sex, sexual intercourse (whether or not it can lead to reproduction) is viewed as a special class of conduct, with its own moral rules and restrictions.
• Human nature--and romantic love, in particular--has a tendency towards monogamy. This may cause sexual monogamy to be viewed as the best state. Moreover, human nature (for evolutionary reasons) has a tendency towards disapproval of sex between a marriage partner and a third person. This may cause the society to consider such relationships immoral. Treating sex outside marriage as evil may help to channel sexual energy towards raising families. The evolutionary tendency is to disapprove of extramarital sex by your spouse (especially if you are heterosexual male) but not yourself: Extramarital sex by your spouse may cause you or your spouse to spend resources to raise a child who does not have your DNA. However, with contraception and paternity testing, this reason is less valid today.
• Sexual feelings are (in many cases) so exceptionally strong and pleasant that they impair the judgment and cause people to discount other moral considerations when seeking sex. Treating sex as immoral acts as a counterweight against the bias towards having sex. (Sex-related impairment of judgment may also be considered evil in itself.) Because of the strength of sexual feelings, people continue to have sex in the face of social opposition. Such defiance can increase the harshness of the societal intolerance as the society tries to take stronger measures.
• Because genitals are concealed in many cultures, and because genitals look different from the rest of the body, genitals may appear very ugly (as if they are abnormal) to many people. This causes a visceral aversion to most forms of sexual conduct, especially towards "unnatural" sex. Homosexual sex may be seen as contrary to the traditional gender norms.

Opposition to Adult-child Sex

• The primary mechanism of harm is moral conflict. The children involved often believe that they have done something wrong and therefore feel guilt or shame. This is reinforced by the society having a negative attitude toward sex (and by the need to keep sex secret). Moreover, if the child believes that the adult was wrong in choosing to have sex, the child may feel betrayed by the adult, and suffer from this feeling. Such harm is particularly strong if, for example, the adult is a priest who is otherwise preaching abstinence until marriage, or if the adult is a parent or a caretaker. The strength of both sexual feelings and sexual taboos magnifies the moral conflict.
• Given the current legal and social climate, adult-child sexual relationships are usually secret, which denies the child of opportunity to discuss and resolve the issues with the relationship.
• If the relationship becomes known, then the child may suffer from discrimination, as well as from the likely termination of the emotional relationship with the adult.
• Additionally, some types of sexual interaction involve substantial physical risks.
• On an individual level, people tend to follow the society in their beliefs, and are pressured by the society not to say that adult-child sex is often good for children.
• Adult-child sex is viscerally viewed as horrible and immoral, and therefore harmful.
• For children, having consensual sex with adults is correlated with being physically, emotionally, and sexually abused. Statistically, adults who like sex with children are more likely to select children who have been abused: Protecting children from abuse often includes "protecting" them from sex, so children protected from abuse are less likely to have sex with adults. Since the predominant moral view is that adult-child sex is wrong, adults who have sex with children are more likely to do what they or the society think is wrong, and hence are more likely to harm the children. Also, sexual abuse can break a child's moral opposition to sex and can cause the child to learn that sex feels good, which makes the child more likely to have consensual sex.
• When the relationship becomes known, the children involved are expected to behave like victims, and therefore they may behave that way, which leads to the appearance of harm (and can lead to actual harm as well).
• The media often fails to separate consensual from non-consensual adult-child sex, causing the public to conflate the two. Non-consensual sex is often very harmful.
• Most importantly, in the present society, notifying the public about the relationship would mean that the relationship will be terminated and the adult (and quite often, the child) punished or otherwise harmed. Consequently, the children are only likely to report the relationship if they view it as harmful or immoral, creating a strong sampling bias toward harmful cases.
• Adults are supposed to supervise children, and therefore be in control of children. A child will not (or should not) say "No" to an adult. Children (especially victims of sexual abuse) may fail to object to non-consensual sex because they are not aware of their right to object. Correspondingly, adult-child sex is viewed as much more objectionable than sexual play between children. For example, many people believe that it is normal and morally fine for a 10-year old boy to masturbate, and at the same time support mandatory prison terms for adults who massage genitals of 10-year old boys.
• Children do not really understand the meaning and moral implications of sex and therefore their consent is invalid. The view is that the children do not understand that sex is a poison for the soul, and thus adult-child sex is no more consensual than unknowing ingestion of poison.
• Sexual desires can cloud children's judgment. A sexual urge can short-circuit their consideration of the moral elements of sex and of the physical risks.
• Some sexual interaction involves physical risks which many children are ill-equipped to evaluate.
• The typical limitations of children's judgment are (it is argued) universally applicable to all children. Alternatively, because sex with children is so wrong, rational and informed children will always say 'no', so all children who say 'yes' are deceived, seduced, or coerced into sex.

Sex versus Drugs

Sex and drugs are often grouped together because both of them are considered by many to be immoral, both involve aspects that many find disgusting, both can be very harmful, both can involve strong pleasure, and both can cause an altered state of consciousness where normal concerns are suppressed. Such grouping leads some people to believe that since sex is moral, so are drugs. This belief is wrong.

• drugs are harmful
• drugs are addictive
• drugs impair judgment to the point of making their users temporarily less human. Once the drug is taken, this impairment is not consensual, that is it continues regardless of whether the user wants it.
• sex is not harmful
• sex is not physically addictive (but all good things can be psychologically addictive)
• sex is consensual
• sexual desire tends to be self-limiting in that a person will want to spend only a small portion of his or her time having sex.

Sex and Fundamental Rights

This section is not a general essay on fundamental rights. Instead, it is a detailed explanation of fundamental rights related to sex. Fundamental rights are a difficult topic, and parts of this section are more abstract than other sections.

Fundamental rights are the indispensable rights of the people in the civilized society. Fundamental rights exist independently of the government or popular will, and laws that contradict them are illegitimate. Protection of fundamental rights should be written in the Constitution so that the rights can be enforced through judicial review, and whenever possible, existing Constitutions should be construed to protect all fundamental rights. The United States Constitution protects all fundamental rights through the guarantee of due process, "no person shall be ... deprived of life, liberty, or property, without due process of law" (with the exception of proportional representation for the Senate and for the presidential election).

A collection of rights

• prohibitions on distribution of certain information and ideas (such as child pornography) to certain people (such as children) (excluding reasonable non-disclosure agreements).
• prohibitions on safe consensual sex (excluding commerce)
• prohibitions on recording of sex when all participants give consent
• blanket prohibitions on nudity and sex in forests and other such public places, excluding cases with reckless disregard for the offensiveness of the conduct.
• laws requiring reporting of the above activities
• laws requiring parental notification or permission for exercise of children's fundamental rights
• general prohibitions on condoms or sex toys

The first right is the core of the freedom of speech. Freedom of speech includes the right to communicate arbitrary information to an arbitrary person. (Note: Reasonable penalties for breaking reasonable non-disclosure agreements may often be imposed since the person has agreed to the penalty through signing the agreement, provided that appropriate safeguards are met.) Freedom of speech is a necessary component of any democratic society. Information is equivalent to an integer or a binary sequence that encodes information. Thus, information is logically separate from claims about information. False claims are not (at least not always) constitutionally protected.

The right to receive information includes the right to view the information in visual form. For the blind, an analogue of visual image is high-resolution tactile stimulation. This right is necessary due to the limitation of typical human cognitive skills. It is very difficult to fully appreciate a painting just by reading its verbal description or by viewing a binary sequence that encodes the full picture. Some argue that conceivably, some visual pattern will directly cause fatal brain hemorrhage or some other such severe harm. However, the right to view information in visual form should still be construed categorically since

• It is very unlikely such harmful pictures actually exist.
• Given the nature of the human brain, it is difficult to separate harm of understanding of the picture from harm that occurs independent of the understanding. In both cases, feelings can cause physical distress, and the government must not be permitted to censor visual display of a picture based on harm from its understanding. Thus, misery (and even suicide or physical illness) from falling in love based on a picture cannot be grounds to prohibit its visual display.
• Categorical protection gives security and freedom that a partial protection lacks.

The third prohibition is invalid since the videotaping does no harm except through recording of information. To protect freedom of speech, the government is prohibited from arbitrarily suppressing information gathering. Thus, videotaping may not be prohibited unless an information source is privileged. However, a person is entitled to ownership of his or her body, and that right includes allowing collection of information about the body. This is particularly true for videotaping since it records only those pieces of information that are available anyway--the benefit of videotaping over remembering and telling is rather the easiness, reliability, and completeness of the recording.

The fourth prohibition is invalid since it serves no legitimate governmental purpose. The fact that the activity takes publicly is irrelevant if there is no overriding danger of unwilling persons being offended in a visceral way. Some amount and risk of visual offensiveness must be tolerated to protect fundamental rights. The government's sole interest is visual expressiveness of the act, and therefore the act receives substantial protection from the freedom of speech.

The fifth prohibition violates the right to privacy. The right to privacy is necessary to protect against discrimination by private people or misguided governmental officials. For example, by keeping sex private, a person may be protected from being fired from his or her job.

The sixth prohibition is invalid since fundamental rights may not be violated by any authority. Parental consent cannot be required for having safe consensual sex.

The right to manufacture, sell, and use condoms (consistent with general laws about business, safety, and manufacturing) is fundamental since a ban on condoms would be arbitrary but for the impermissible governmental interest in suppressing sex. A general ban on sex toys is similarly invalid.

The second prohibition is a particularly difficult one to analyze, and is the subject of the next section.

Freedom from Physical Restraint

The nature and scope of freedom from physical restraint.

Although freedom of communication is at the center of liberty, biological humans are more than just communicating entities. They have bodies, which are essential for survival, and thus protected through fundamental rights. Even if the issues of health are set aside, governmental control of human bodies would amount to a power too great and potential for coercion too strong to be acceptable. Thus, freedom to control one's body is (subject to certain restrictions) fundamental. This control implies freedom from arbitrary physical restraint, such as the right (again, with restrictions) not to have one's hands tied behind the back. The core scope of freedom from physical restraint is the right to choose the location and position of the body and its parts, both the location in itself, and the location relative to other people. This right (as explained below) in turn implies a right to engage in private physically safe consensual physical interaction.

However, while fundamental, physical freedom of the body is by itself too broad to be granted as an absolute right. The resolution to this dilemma is to analyze potential government interests and their effect on the liberty to determine the permissible legal grounds for restraint. Then, within the scope of these grounds, but not outside of them, governmental interests are balanced against the liberty of the person. The resolution is discussed below.

One legitimate interest is to prevent harm to other people. The harm need not be physical harm; for example (in some cases) unwanted sensory input can be prohibited. However, the relationship to harm must be sufficiently direct. For example, the government may not restrain person A because B threatens to kill C (or B) if A is not restrained.

The government also has an interest in protecting a person from causing physical harm to himself or herself, and it may (in some cases) restrain the person accordingly. This power is necessary to prevent victims from being coerced or deceived into committing suicide. However, the restrictions must be narrowly tailored. For example, when an activity is unsafe but for acceptable safety equipment (such as condoms), the government may not overreact and prohibit both the activity (on safety grounds) and the equipment since a more narrowly tailored regulation would be to require the equipment to be used. Moreover, if activity is protected, the government may not indirectly deter it by prohibiting the safety equipment (that would have been clearly legal but for the deterrence interest). If the danger is from a (human) third party, the government may (sometimes) restrict the person's location with respect to the third party (ex. prevent a meeting if the person is likely to be killed) and require other safety measures, but the government may not prohibit conduct merely because the third party is opposed to it, even in cases of clear and present danger (for example, A may not be prohibited from having sex with B even if C is likely to kill A because of the sex provided that the sex does not make it physically easier for C to kill A).

Especially with regard to children, the government -- in combination with parents/guardians -- has an interest that much (but not all) of the person's time is spent valuably (for example, for education). In pursuit of this interest, a reasonable limitation may sometimes be imposed on the timing and duration of interactions so as not to displace other valuable activities.

A restriction of interactions with other people as a natural consequence of incarceration or analogous punishment may also be imposed. However, the consequence must be a natural one. For example, in the absence of a physical danger, the government may not prohibit back massage as a condition of probation. Restraint to a certain body position (such as having hands tied) may not be used as punishment (as opposed to a reasonable restraint) because of unacceptable danger of cruelty and coercion.

The physical freedom includes a liberty interest in tools that enable the freedom. For example, the government may not prohibit walking canes to discourage the weak from walking, nor may the government prohibit sex toys to discourage sex.

Also, the government interests must be balanced against the significance of the restraint imposed. Safety regulations on sexual activity (ordinarily) must not be arbitrarily severe compared to generally applicable regulations (such as safety regulations in sports).

Human interactions are within the literal scope of freedom from physical restraint. Human interaction that goes beyond communication is central to the lives of biological humans. In consensual interactions, in so far as a certain movement of person B is intended by A, then with respect to harm to A, it is qualitatively similar to that movement being done by A. Thus, the government may not ordinarily prohibit the movement of B on the ground of harm to A beyond the government's capacity to prohibit A's movement on the ground of self-harm. (However, at least with respect to the policy, there are exceptions. For example prohibiting killing on request while permitting suicide is reasonable because it helps to ensure that the intent to kill/die comes from the victim.)

While physical harm provides a legal limitation on the freedom from physical restraint, consensual mental harm does not. The notion of mental harm is too amorphous and its scope too broad for the freedom from physical restraint to receive needed protection if there is a psychological harm exception to the freedom. While physical harm is clear, even profound mental changes can easily be morally unclear. While following certain rules prevents physical harm, the sources of mental harm are endless. Finally, mental harm comes essentially from thoughts, which are protected by the freedom of thought and thus outside of government regulation.

Appraisal of psychological consequences may not be required

Nor may the government require here an appraisal of the psychological consequences. Freedom generally implies freedom to act irrationally. The power to require an appraisal of certain consequences implies a power to suppress based on those consequences. It is one thing to require that certain (easily available) information be provided, but appraisal requires more. The requirement of appraisal implies a possible prohibition on the conduct if (1) the person does not understand the consequences stated, or (2) the person unreasonably disbelieves the stated consequences, or (3) the person is unreasonable in producing a decision based on these consequences.

These requirements are so flexible and open-ended that a hypothetical society of hyperintelligent beings could easily construe them so strictly as to effectively prohibit ordinary humans on Earth from giving informed consent to anything serious. For example, understanding the consequences may require an ability to research foreseeable consequences, as well as sufficient intelligence, linguistic ability, and background knowledge to understand the text. Properly reaching a decision may require integrating the moral value function over the space of possible consequences--something that few ordinary humans actually do.

In addition, the notion of being unreasonable is sufficiently ephemeral so as to permit the judges (even judges in advanced societies) to classify many true beliefs as unreasonable. For example, in a purely atheist society, evangelical Christianity may be misdiagnosed as schizophrenia (in particular, as bizarre delusions that cause significant mental distress).

Moreover, if the government could prohibit an action because of inability to understand the consequences, then presumably the government could prohibit the action when the consequences are unknown since in both cases, the person makes the decision without understanding the likely consequences.

Finally, psychological consequences are exceptionally difficult to predict, understand, and appraise, thus magnifying the danger of requiring informed consent to psychological harm. Informed consent is best described not in binary terms but as a matter of degree. The above is not intended to disparage the ordinary use of informed consent to balance interests, but merely its use as a qualification on a categorical right. The degree to which the consent is informed is important, for example, with regard to elective surgery.

Mental harm and physical harm

Finally, we address attempts to characterize psychological consequences as physical ones, thereby obviating the right to be touched in a psychologically harmful way. It is argued that all mental processes are physical processes in the brain and that therefore all psychological harm is brain damage. However, there is a qualitative difference between affecting brain through a physical injury, and affecting the brain through consensual sensory input. The government has a broad authority to regulate the former, but only a narrow authority to regulate the later. The difference is the mechanism by which the brain is affected. Moreover, while brain trauma can easily be characterized as harmful, the effect of sensory input is much more subtle and whether it is harmful or beneficial is usually a value judgment, not a medical one.

I do not believe that the right to choose sensory input is categorical. For example, the government may prohibit intentional self-inducement of brain seizures through flashing lights. However, such authority must be construed in a very narrow way. First the harm must be an inherent neurological harm and not a consequence of the person's or society's appraisal of the feelings or behaviors. Second, the government bears the burden of proving that the harm is inherent neurological harm. Third, even if the above conditions are met, the governmental action is subject to strict scrutiny review with respect to this harm. (Note: If technology creates new and qualitatively different types of sensory input, the government may have a broader authority with respect to these new types of input.) These conditions are necessary to deny governmental authority to prohibit on the basis of psychological harm. The burden of proof requirement is somewhat analogous to the requirement that a person must be proved guilty before being punished for a crime.

I am not aware of any case of consensual touching (with no direct physical harm) with normal persons where these conditions are met. Certainly, daily sexual stimulation to orgasm does not constitute such harm even if the orgasm is unusually powerful and even if the subject is a young child. (A conceivable exception is the presence of certain rare brain conditions; however, having a level of sexual desire comparable to that of a normal adolescent does not constitute such a condition.) Psychologists generally agree that masturbation in children is not inherently harmful to the brain (an exception is psychologists with a religious agenda). Millions of years of evolution have ensured that affectionate touch has a nurturing value, and that masturbation is not harmful. Moreover, the difference between self-massage of genitals and such massage (including oral stimulation) by an adult is primarily a mental one. (At the least, there is no proof of inherent neurological harm arising from the physical differences in the mechanism of touching.) Thus, guilt, anger, shame, powerlessness, and other such alleged dangers of consensual adult-child sex arise because of thoughts about the feelings rather than through involuntary low-level reactions to the signals emitted by the sensory neurons. Therefore, these consequences do not deprive the act of its constitutional protection.

An example of protected action

To illustrate the extent of the fundamental rights, here is an example of a protected action. A man performs oral sex on an ordinary seven year old boy about once a day. Sometimes, the boy performs oral sex on the man. Sometimes the man massages and penetrates the boy's anus with a lubricated finger. There is no unacceptable physical risk. The boy agrees to the sex because it feels good and recklessly disregards (or just does not understand) the usual warnings about possible psychological harm from adult-child sex. The parents of the boy object to the sex, but the boy chooses to do it anyway.

• The example is deliberately sexual and involves a child since the conflict between fundamental rights and current practice is greatest in sexual behavior, particularly with respect to children.
• Penetration is included in the right of relative positioning of one body relative to another.
• The interaction would be protected even if the adult is the child's parent or caretaker.
• The interaction would be protected even if there are additional (consenting) persons involved.
• The interaction would be protected even if the boy had orgasms.
• Videotaping of the activity would be protected if the boy agrees to it and understands the general nature of videotaping. An ordinary 7 year old is clearly capable of that. Specific understanding of the likely consequences of videotaping cannot be required.
• Fundamental rights are (predominantly) rights to make choices. Full exercise of the freedom from arbitrary physical restraint requires a (conscious) choice to act in that way. There is a wide disagreement between people on the point at which the human organism (or its soul) becomes sentient, or starts to make choices, or even about the nature of human choices. I will not address the disagreement here other than to state the following: Most children are fully conscious and are capable of making genuine choices before their seventh birthday. While 7-year old children may understand less than adults, they are not living in a non-sentient or in a dreamlike state. Also, one's consistent inclination to choose in a certain way merely indicates a preference and does not make the choice less genuine. In the example, the choice of the boy to have sex can be inferred from the clear appearance of such choice.

Consent to orgasm

We conclude this essay on a more immediately entertaining topic. So positive is the experience of orgasm, that the issue of consent to orgasm is often overlooked. A ban on orgasm would be silly for practical reasons, but here we are concerned with orgasm as a fundamental right.

Orgasm presents special issues of consent because

• Orgasm is involuntary, and thus it will continue regardless of the will of the person.
• The feelings during the orgasm may be extremely intense, and conscious thought may be suppressed during orgasm.
• For the first orgasm, the person may not know how it will feel.

However, the presence of a significant consequence does not automatically negate the fundamental right. Instead, a balancing of the interests must be performed. For the combination of the following reasons, an ordinary orgasm (including the first orgasm) is constitutionally protected:

• Although orgasm is involuntary, the physical stimulation as an act is voluntary. Orgasm is not under control of another person and is thus different from forced sex. Moreover, withdrawal of consent during the orgasm will dramatically diminish the usual mental impact of the orgasm. Suppression of conscious thought during orgasm is to a large extent a voluntary consequence as the person concentrates on the feelings. Additionally, since orgasm often takes place in a relaxed environment (such as in bed), a person's reduced responsiveness to the environment is fine. After all, most people spend hours sleeping in bed.
• Orgasm is a biologically natural and ordinarily a psychologically harmless event.
• The intensity of the feelings is compensated for by the short duration of the orgasm.
• For a majority of people, orgasm is an overwhelmingly positive experience.
• The naturalness and usefulness of the orgasm as the sexual climax, and the pleasure and intensity of the feelings magnifies the person's interests in having an orgasm.
• A person who previously had an orgasm can ordinarily appraise the feelings to decide whether to have an orgasm. This appraisal overrides the governmental interests against the orgasm.
• For the first orgasm, the issue of consent is exacerbated because the person may not know how it will feel. However, the person has a special interest in having the first orgasm because (1) by having an orgasm, the person will learn how it will feel, (2) the first orgasm is necessary for any subsequent orgasms. Also, there is no unacceptable risk of unbearable pain.
• The above analysis of orgasm is confirmed by the practically complete lack of legislation that ban orgasm in particular (as opposed to sexual stimulation in general).

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What is chemsex and why does it matter?

• Related content
• Peer review
• Hannah McCall , senior nurse, genitourinary medicine/sexual and reproductive health 1 ,
• Naomi Adams , head of sexual health psychology 1 ,
• David Mason , specialist substance misuse practitioner 2 ,
• Jamie Willis , outreach and training manager 3
• 1 Central and Northwest London NHS Foundation Trust, London WC1E 6JB, UK
• 2 Camden and Islington NHS Foundation Trust, London, UK
• 3 Antidote Service, London Friend, London, UK
• Correspondence to: H McCall hmccall{at}nhs.net

It needs to become a public health priority

“Chemsex” is used in the United Kingdom to describe intentional sex under the influence of psychoactive drugs, mostly among men who have sex with men. It refers particularly to the use of mephedrone, γ-hydroxybutyrate (GHB), γ-butyrolactone (GBL), and crystallised methamphetamine. These drugs are often used in combination to facilitate sexual sessions lasting several hours or days with multiple sexual partners. 1 2

Mephedrone and crystal meth are physiological stimulants, increasing heart rate and blood pressure, as well as triggering euphoria and sexual arousal. GHB (and its precursor GBL) is a powerful psychological disinhibitor and also a mild anaesthetic. Anecdotal reports and some small qualitative studies in the UK find that people engaging in chemsex report better sex, with these drugs reducing inhibitions and increasing pleasure. They facilitate sustained arousal and induce a feeling of instant rapport with sexual partners. Some users report using them to manage negative feelings, such as a lack of confidence and self esteem, internalised homophobia, and stigma about their HIV status. 3 4 5

Quantitative data on drug use in a sexual context in the UK are lacking, with recent Home Office statistics reporting only on the use of any illicit drug in the past year. 6 The Chemsex Study, 5 the first British research project of its kind, used data from the European Men-who-have-sex-with-men Internet Survey (EMIS) 7 to give a “quantitative context.” Of 1142 respondents in Lambeth, Southwark, and Lewisham, around a fifth reported chemsex within the past five years and a 10th within the past four weeks, suggesting that it is practised by a minority of men who have sex with men.

Many barriers exist to chemsex drug users accessing services, including the shame and stigma often associated with drug use and ignorance of available drug services. 2 In the UK, funding for drugs services is focused on tackling heroin, crack cocaine, and alcohol dependency, and both chemsex drug users and health professionals may believe referral to traditional services is inappropriate. 2 Some services are now developing specific chemsex and party drug clinics. At Antidote, a specialist drugs service for the lesbian, gay, bisexual, transgender community in London, around 64% of attendees seeking support for drug use reported using chemsex drugs in 2013-14. 3 Of crystal meth and GHB/GBL users, most reported using them to facilitate sex, with around three quarters reporting injecting drug use. 3

Harms to health

Mental health services are seeing a small but important uptake in services by chemsex drug users. 3 8 Mephedrone and crystal meth can create a powerful psychological dependence, with GHB/GBL creating a dangerous physiological dependence. Mental health effects may require treatment and can become permanent. 5 Some users will need drug treatment to support detoxification, particularly from GHB/GBL. 5

Chemsex drug users often describe “losing days”—not sleeping or eating for up to 72 hours 4 5 —and this may harm their general health. Users may present too late to be eligible for post-exposure prophylaxis for HIV transmission. An increased number of sexual partners 1 2 may also increase the risk of acquiring other sexually transmitted infections. Data from service users suggest an average of five sexual partners per session and that unprotected sex is the norm. 3 However, Bourne and colleagues found that not all chemsex was unprotected. 6

Kirby has described some chemsex practices, particularly injecting drug use, as a “perfect storm” for transmission of both HIV and hepatitis C virus, 9 although strong evidence exists for sero-sorting among chemsex partners. 6 Public Health England has reported an increase in sexually transmitted infections and hepatitis C among men who have sex with men 10 as well as an increase in the injecting of amphetamines and amphetamine-like substances such as mephedrone and crystal meth. 11 Nevertheless, the explanation for these findings is unlikely to be solely, or even predominantly, the minority of men who participate in chemsex.

The lack of data limits the advice that clinicians can give. The National Institute for Health and Care Excellence has provided only limited advice on psychoactive drug use and no specific recommendations relating to chemsex drugs. 12 However, the Novel Psychoactive Treatment UK Network (Neptune), supported by the independent charity the Health Foundation, has published a guidance document for clinicians managing the “harms resulting from the use of club drugs and novel psychoactive substances.” 5

Addressing chemsex related morbidities should be a public health priority. 13 However, in England funding for specialist sexual health and drugs services is waning and commissioning for these services is complex. English sexual health services tend to be open access, with costs charged back to local authorities. Drug services tend to be authority specific with users having to attend a service within their borough of residence. Despite the different funding streams, creating centres of excellence for sexual health and drug services could be a cost effective solution to diminished resources in both sectors. It could also be a source of data for further research into chemsex that would help commissioners in their decision making.

Cite this as: BMJ 2015;351:h5790

Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

Provenance and peer review: Not commissioned; externally peer reviewed.

• ↵ Bourne A, Reid D, Hickson F, Torres-Rueda S, Weatherburn P. Illicit drug use in sexual settings (‘chemsex’) and HIV/STI transmission risk behaviour among gay men in south London: findings from a qualitative study. Sex Transm Infect 2015 Jul 9. [Epub ahead of print.]
• ↵ Bourne A, Reid D, Hickson F, Torres-Rueda S, Weatherburn P. “Chemsex” and harm reduction need among gay men in south London. Int J Drug Policy 2015 Jul 26. [Epub ahead of print.]
• ↵ London Friend, Antidote. Out of your mind. 2014. http://londonfriend.org.uk/wp-content/uploads/2014/06/Out-of-your-mind.pdf .
• ↵ Bourne A, Reid D, Hickson F, Torres-Rueda S, Weatherburn P. The Chemsex study: drug use in sexual settings among gay & bisexual men in Lambeth, Southwark & Lewisham. 2014. www.sigmaresearch.org.uk/chemsex .
• ↵ Novel Psychoactive Treatment UK Network. Guidance on the clinical management of acute and chronic harms of club drugs and novel psychoactive substances. 2015 http://neptune-clinical-guidance.co.uk/wp-content/uploads/2015/03/NEPTUNE-Guidance-March-2015.pdf .
• ↵ Home Office. Drug misuse: findings from the 2013 to 2014 CSEW. 2014. www.gov.uk/government/statistics/drug-misuse-findings-from-the-2013-to-2014-csew .
• ↵ EMIS Network. The European Men-Who-Have-Sex-With-Men Internet Survey. Findings from 38 countries. European Centre for Disease Prevention and Control, 2013.
• ↵ Stuart D. Sexualised drug use by MSM: background, current status and response. HIV Nurs 2013 Spring:6-10.
• ↵ Kirby T, Thornber-Dunwell M. High-risk drug practices tighten grip on London gay scene. Lancet 2013 ; 381 : 101 -2. OpenUrl CrossRef PubMed Web of Science
• ↵ Public Health England. Sexually-transmitted infections. 2014. www.gov.uk/government/uploads/system/uploads/attachment_data/file/437433/hpr2215_STI_NCSP_v6.pdf .
• ↵ Public Health England, Health Protection Scotland, Public Health Wales, Public Health Agency Northern Ireland (2014) Shooting up: infections among people who inject drugs in the United Kingdom 2013. www.gov.uk/government/publications/shooting-up-infections-among-people-who-inject-drugs-in-the-uk .
• ↵ National Institute for Health and Care Excellence. Tackling drug use. 2014. www.nice.org.uk/guidance/lgb18 .
• ↵ Public Health England. PHE Framework 2013-16. www.gov.uk/government/publications/healthy-lives-healthy-people-improving-outcomes-and-supporting-transparency .

Introduction     This book is written from the perspective of a teacher of law in the areas of constitutional and criminal law and of a moral and legal philosopher concerned with the investigation of concepts of law, justice, and human rights. Accordingly, the approach here taken is interdisciplinary: the adequate analysis of these, as of many other, legal problems requires that one be a philosopher in doing law, or, alternatively, that one do law philosophically. Indeed, the approach here is even more ambitiously interdisciplinary than a training in law and philosophy would warrant. For, in the investigation and criticism of the gross and unjust overcriminalization typical of American criminal justice, I have found it necessary not only to draw on forms of legal and philosophical argument, but to trace the links of the subjects under investigation to history, psychology, social science, and even literature. The deeper criticism of overcriminalization requires a form of empirical inquiry into the background assumptions that often uncritically underlie the common American sense of proper criminalization. Accordingly, as the argument evolves, we will explore such assumptions and other often detailed empirical arguments establishing factual premises fundamental to the rational discussion of these issues.     My intent here is to develop a new form of moral, legal, and political argument that connects the moral criticism of overcriminalization not to utilitarianism but to antiutilitarian conceptions of human rights (Chapter 1). This argument of general political theory is used to delineate deep commitments of American constitutionalism and thus to explain and justify specific forms of judicially enforceable constitutional argument, grounded on the constitutional right to privacy, and more general forms of liberal argument, which urge legislatures to replace the improper use of the criminal sanction with reasonable forms of regulation more consistent with basic respect for the rights of the person. The implications of this general argument are explored in detail in three general areas of proposed decriminalization: consensual adult sexual relations (in particular, homosexuality in Chapter 2 and commercial sex in Chapter 3), drug use in Chapter 4, and decisions on the right to die in Chapter 5. The resulting argument connects the limits of the criminal sanction to a general conception of personal responsibility for the meaning of individual human life (Chapters 5 and 6).   1. Human Rights and Public Morality under Constitutional Democracy     As an initial matter, it is important to put the moral criticism of overcriminalization in some historical context. Any coherent account of the ethical foundations of the substantive criminal law and its connections to constitutional principles must take seriously the radical vision of the rights of the person that underlies the United States Constitution and its precepts of criminal law. The idea of human rights was a major departure in civilized moral thought. When Locke, Rousseau, and Kant progressively gave that idea its most articulate and profound theoretical statement, [1] they defined a way of thinking about the moral implications of human personality that was radically new. One central critical focus of this new perspective was the criminal law. The Constitution and Bill of Rights of the United States, in implementing these ideas, not only required just forms of criminal procedure, [2] but also placed limits on the substantive scope of the criminal law. These limits included not only mens rea, actus reus, legality, and proportionality requirements, [3] but also the limitations imposed by the religion and free speech clauses of the first amendment on federal and (after incorporation) state power to criminalize certain kinds of conduct. [4]     Several provisions of the French Declaration of the Rights of Man and of Citizens, adopted by the French National Assembly in 1789, went beyond the United States Constitution in placing express constraints on the scope of the substantive criminal law. [5] Specifically, persons were to have "the power of doing whatever does not injure another," free of the threat of criminal penalties. [6] The Napoleonic Code, whose conception of the proper scope of the substantive criminal law appears to have been inspired by the provisions, accordingly imposed no criminal sanctions on consensual adult sexual acts, such as homosexuality and prostitution. [7]     No comparable general principle then existed in the Anglo-American political and legal tradition. In the United States, the largely unexamined governing assumption, which continues to have vitality, was that the public morality, which the criminal law enforces, is simply the set of moral values at the core of the Calvinist religious conception and its derivatives. America is, after all, a nation founded by religious extremists who conceived their task as building a New Jerusalem in express contrast to European decadence. [8] The American invention of prisons and the extravagant hopes for moral reform that they embodied for groups like the Quakers [9] were of the same spirit as the later American commitment to the "noble" experiment, Prohibition. The criminalization of alcohol was one manifestation of the power of the Calvinistic purity reformers of the nineteenth and early twentieth centuries. It was their tradition that decisively shaped America's common sense of morality and created the expectation that criminal justice could and should radically reform corrupt human nature. [10] Many Americans today, responding to felt injustices in our criminal justice system at every stage of its operation, question the assumptions underlying this conception of criminal justice. A natural means of examining the conception is to conduct a philosophical analysis of its assumptions. One available theory for such an analysis is utilitarianism, which radically questions the whole perspective on human rights implicit in American constitutionalism; another is an antiutilitarian natural rights theory, which takes seriously ideas of human rights implicit in American constitutional practice but affords a critical organon for reinterpreting their implications for criminal justice.   I. THE UTILITARIAN CRITIQUE OF OVERCRIMINALIZATION     The utilitarian argument against the Anglo-American conception of criminal justice began with the publication in 1859 of John Stuart Mill's On Liberty. [11] Mill proposed a general doctrine that may be termed the "harm principle." This principle limits the scope of the criminal law in the following ways:     1. Acts may properly be made criminal only if they inflict concrete harms on assignable persons. [12]     2. Except to protect children, incompetents, and "backward" peoples, [13] it is never proper to criminalize an act solely on the ground of preventing harm to the agent. [14]     3. It is never proper to criminalize conduct solely because the mere thought of it gives offense to others. [15]     Although Mill's harm principle places a constraint on the criminal law comparable to the one embodied in the French Declaration of Rights, Mill did not justify the constraint on the basis of the human rights paradigm, as did the French Declaration. Rather, Mill appealed to a general utilitarian argument, derived from Jeremy Bentham, [16] that failing to follow the harm principle reduces the aggregate surplus of pleasure over pain. Mill was less doctrinaire in his opposition to the language and thought of rights than Bentham, [17] and some find in On Liberty rights-based arguments of personal autonomy. [18] But although Mill did give great weight to preserving the capacity of persons to frame their own life plans independently, he appears—in accordance with his argument in Utilitarianism [19] — to have incorporated this factor into the utilitarian framework of preferring "higher" to "lower" pleasures. Thus, the argument of On Liberty is utilitarian: the greatest aggregate sum by which pleasure exceeds pain, taking into account the greater weight accorded by utilitarianism to higher pleasures, is secured by granting free speech and observing the harm principle.     The Anglo-American tradition of opposition to overcriminalization, initiated by Mill, has—following Mill—conceived of the issue in utilitarian terms. This tradition relies, when seeking the decriminalization of "victimless crimes," [20] on efficiency-based arguments deploring the pointless or counterproductive use of valuable and scarce police resources in the enforcement of these laws. The pattern of argument and litany of evils are familiar. H. L. A. Hart, for example, in his defense of the recommendation of Great Britain's Wolfenden Committee to decriminalize consensual adult homosexuality and prostitution, [21] conceded that some "victimless crimes" are immoral, and then discussed in detail the countervailing and excessive costs of preventing them. [22] In the United States, commentators have emphasized pragmatic arguments that are implicitly utilitarian, identifying tangible evils that enforcement of intangible moralism appears quixotically to cause. [23] Victimless crimes typically are consensual and private, and as a result, there is rarely either a complaining victim or a witness. In such cases, police must resort to enforcement techniques, such as entrapment, that are often unconstitutional or unethical and that tend to corrupt police morals. [24] Enforcement costs also include the cost of forgoing opportunities to enforce more "serious" crimes. [25] When the special difficulty of securing sufficient evidence for conviction and the ineffectiveness of punishment in deterring these acts are considered, the utilitarian balance sheet condemns criminalization as simply too costly.     The utilitarian cast of these arguments is understandable in a nation like Great Britain, where they must be made to a parliament that enjoys constitutional supremacy. In the United States, however, arguments of this kind are made not only to legislatures but also to countermajoritarian courts empowered with judicial supremacy in the elaboration of a charter of human rights. Since 1965, the United States Supreme Court has invoked a constitutional right of privacy to invalidate the use of criminal sanctions against the purchase or use of contraceptives by adults, married [26] and unmarried, [27] and, more recently, minors; [28] the use of pornography in the home; [29] and the use of abortion services by adults [30] and, more recently, minors. [31] In addition, state courts have elaborated a similar right under state constitutions to permit the withdrawal of life support systems from irreversibly comatose, terminally ill patients. [32] One state court has interpreted the privacy right in its state constitution to permit the use of marijuana in the home, [33] and another court has held that the use of peyote by Native Americans in religious ceremonies is a constitutionally protected form of free exercise of religion. [34]     It is difficult, if not impossible, to reconcile the notion of privacy rights that these cases embody with the utilitarian policy arguments that decriminalization proponents generally use. Indeed, the status and rationale of the constitutional right of privacy are at the center of contemporary controversy over constitutional theory and practice. It is argued that the right of privacy is policy-based, legislative in character, and unneutral, and therefore may not properly be adopted by courts, whose decisions must be governed by neutral principles of justification. [35] If the deployment in these cases of the constitutional privacy right or other rights must be construed in utilitarian terms such objections may be conclusive, and decriminalization arguments would be properly directed only to legislatures, not to courts.     It is quite natural to interpret the harm principle as derivative from some more general utilitarian argument. Harm appears to be a quasiutilitarian concept at least insofar as utilitarianism seeks to avoid pain. There are several powerful objections to this interpretation, however.     First, utilitarian arguments for decriminalization proselytize the already converted and do not seriously challenge the justifications that defenders of criminalization traditionally offer. For these defenders, the consensual and private character of prohibited acts, even when coupled with the consequent higher enforcement costs, is not sufficient to justify decriminalization. They point out that many consensual acts, such as dueling, are properly made criminal and that many nonconsensual acts are also properly criminal despite comparably high enforcement costs. The prosecution of intrafamilial homicide, for example, requires intrusion into intimate family relations, and yet intrafamilial homicide is not therefore legalized. [36] Certainly, if there is a good moral reason for criminalizing certain conduct, quite extraordinary enforcement costs will justly be borne. Accordingly, efficiency-based arguments for decriminalization appear to beg the question. They have weight only if the conduct in question is not independently shown to be immoral. But the decriminalization literature concedes the immorality of such conduct, and then elaborates arguments, based on efficiency and costs, that can have no decisive weight. [37]     The absence of critical discussion of the focal issues that divide proponents and opponents of criminalization has made decriminalization arguments much less powerful than they can and should be. In practice, efficiency-based arguments have not been very successful in reducing the scope of "victimless crimes," whether by legislative penal code revision or by judicial invocation of the constitutional right to privacy. The wholesale or gradual decriminalization of contraception, abortion, consensual noncommercial sexual relations between or among adults, and decisions by the terminally ill to decline further treatment [38] has resulted from a shift in moral judgments: these acts are no longer believed to be morally wrong. [39] In contrast, where existing moral judgments have remained unchallenged—as, for example, with commercial sex [40] and many forms of drug use [41] — movement toward decriminalization has been either negligible [42] or haphazard. [43] Yet the decriminalization literature has failed to address these moral questions, perhaps because utilitarianism is presumed to be the only enlightened critical morality. [44] In order to give decriminalization arguments the full force they should have, it is necessary to supply the missing moral analysis. The absence of such analysis has prevented us from seeing the moral needs and interests that decriminalization in fact serves. To this extent, legal theory has not responsibly brought to critical self-consciousness the nature of an important and humane legal development.     A second objection may be made to the utilitarian interpretation of the harm principle. The harm principle is not a necessary corollary of utilitarian tenets. The basic desideratum of utilitarianism is to maximize the surplus of pleasure over pain. If certain plausible assumptions about human nature are made, however, utilitarianism would require the criminalization of certain conduct in violation of the harm principle. Assume, for example, that an overwhelming majority of people in a community take personal satisfaction in their way of life and that their pleasure is appreciably increased by the knowledge that conflicting ways of life are forbidden by the criminal law. Suppose, indeed, that hatred of the nonconforming minority, legitimated by the application of criminal penalties, reinforces the pleasurable feelings of social solidarity, peace of mind, self-worth, and achievement in a way that tolerance, with its invitation to self-doubt, ambivalence, and insecurity, could not. In such circumstances, the greater pleasure thus secured to the majority may not only outweigh the pain to the minority but, as compared to the toleration required by the harm principle, may result in a greater aggregate of pleasure; accordingly, utilitarianism would call for criminalization in violation of the harm principle.     Utilitarians defend the harm principle against such a plausible interpretation of utilitarianism by excluding the offense taken at the mere thought of certain conduct as a ground for criminalization. [45] Yet, how, on utilitarian grounds, can any form of pleasure or pain be thus disavowed as morally irrelevant? Mill appears to have argued that this exclusion follows from the greater weight accorded to autonomy by utilitarianism, both in and of itself (as a higher pleasure) and instrumentally as a means of encouraging innovations and experiments that may enable people to realize more pleasure in their lives. Mill did not, however, explain why autonomy should be given such decisive weight, either as a pleasure in and of itself or as an instrument whose value is so great that other pleasures should be wholly excluded from the utilitarian calculus in order to preserve it. Certainly, the exercise of the competences that accompany rational autonomy often gives pleasure, but it also yields the pain of self-doubt, ambivalence, and insecurity. In any event, why should these pleasures and pains be considered more important within the utilitarian scheme than the pleasures of security, peace of mind, and solidarity, which Mill appears to have disavowed? Although the claims for autonomy on instrumental grounds introduce consequentialist arguments to which utilitarians must give weight, it is difficult to see how these arguments can be regarded as decisive. As an empirical matter, autonomy may lead to creative innovation and experiment, but it also may lead to empty distractions, idle fantasies, and wasted lives. The potential effects weigh on both sides of the utilitarian scales, with perhaps some tilt toward protecting autonomy, but not to the degree that Mill's argument requires.     In order to place the principle of not criminalizing conduct that does not harm others on sound foundations, its moral basis must be interpreted in a non-utilitarian way. [46] Such an interpretation would be more consistent with the historical origins of the principle in the rights-based conception of the French Declaration of the Rights of Man and of Citizens, with the American constitutional tradition, which has based decriminalization arguments on the constitutional right to privacy, and with the texture and resonance of Mill's own intuitive spirit in On Liberty.     This alternative approach entirely abandons Mill's strategy of interpreting the role of autonomy in the defense of the harm principle as an aspect of the ultimate utilitarian good of maximizing the surplus of pleasure over pain. Instead, this chapter will show the harm principle to be a natural consequence of an ethical conception of human rights, in which autonomy is an ultimate good.   II. HUMAN RIGHTS AND THE MORAL FOUNDATIONS OF THE CRIMINAL LAW     In order to present an alternative conception of proper criminalization of acts in a constitutional democracy fundamentally committed to human rights, this chapter will first introduce an explanation of the concept of human rights. It will then show that recent deontological moral theory expresses this concept in a sharply antiutilitarian fashion, and will analyze the implications of this theory for the proper limits of the criminal law. Finally, it will show how this conception elucidates the harm principle in a way that utilitarianism cannot.   A. The Concept of Human Rights     As suggested above, when Locke, Rousseau, and Kant progressively gave the idea of human rights its most articulate and profound theoretical statement, they defined a way of thinking about the moral implications of human personality that was radically new. [47] Recent deontological moral theory, particularly as articulated by John Rawls [48] and Alan Gewirth, [49] enables us to understand and explicate these conceptions in a forceful way, as a plausible alternative to utilitarianism. It also provides us with an effective tool for rebutting familiar Benthamite criticisms of the idea of human rights. [50] Specifically, these neo-Kantian moral theorists have explicated the concept of human rights in terms of an autonomy-based interpretation of treating persons as equals.     1. AUTONOMY. Autonomy, in the sense fundamental to the idea of human rights, begins with the conception that persons have a range of capacities that enables them to develop, to want to act on, and in fact to act on higher-order plans of action that take as their object their lives and the way they are lived, and to evaluate and order their lives according to principles of conduct and canons of ethics to which they have given their rational assent. [51] The philosopher Harry Frankfurt made this point when he argued that an "essential difference between persons and other creatures is to be found in the structure of a person's will." [52] The difference between human beings and animals is not, Frankfurt argued, that the former have desires and motives, or that they make decisions based on prior thought; certain lower animals may have these characteristics as well. Rather, besides wanting, choosing, and being moved to do this or that, persons may want to have or not to have certain desires. As Frankfurt put it, persons are capable of wanting to be different, in their preferences and purposes, from what they are. Many animals appear to have the capacity for... "first-order desires" or "desires of the first order," which are simply desires to do or not to do one thing or another. No animal other than man, however, appears to have the capacity for reflective self-evaluation that is manifested in the formation of second-order desires. [53]

B. Recent Neo-Kantian Theory and Human Rights

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Photo essay: Sex and drugs in an HIV-infected paradise

Malindi, Kenya: A vacation destination with something for everyone. Sitting on the crystal coast of east Africa, the resort town offers glass-bottomed boat cruises, authentic Italian pasta, sex-for-hire and dirt-cheap heroin.

When the sun’s hot and vacation packages from Europe to Kenya run cheap, Italian tourists pour into town. Both women and men come for “sex holidays,” seeking out local “beach boys” for a night or an entire weekend’s worth of activity.

But during the low season — the four months of the year when rain is more frequent and the hotels empty out — things turn darker here. When the crowds die down, it’s hard to ignore that this is a town struggling with drugs and disease.

Buska Ismail waits for the clinical officer at the Watamu Drop-In Center. Photo by Mia Collis/PBS NewsHour

Like many “beach boys,” Buska Ismail works exclusively to get high. He’s learned Italian, French, German and English to grow a customer base for his personal safari tours. When times are good, the business gives him enough cash to shoot heroin five or six times per day.

When they aren’t — when tourism dollars dry up between mid-April and mid-July each year — so does his drug habit. The effect: Unintentional detoxification.

Buska Ismail fights the pain as a clinical officer applies antiseptic to a severe wound on his back. Photo by Mia Collis/PBS NewsHour

Sometimes, Buska can only afford to shoot once per day, triggering withdrawal symptoms like abdominal pain, nausea and dizziness. The combined effect caused him to fall hard on the pavement recently, ripping the top two layers of skin off most of his back.

Buska is 32 years old — about the same age as the booming hard drug business in Malindi. Back when it first started, dealers sold a form of heroin known as “brown sugar,” mostly to European tourists and businessmen. But they soon realized that hooking the locals would be much more profitable in the long-run.

Shooting for a High

Shee Omar shoots up while Ahmed Mohamed smokes a joint filled with heroin and marijuana in a back alley of Malindi. Photo by Mia Collis/PBS NewsHour

For reasons that remain a mystery to most long-time drug users in Malindi, the “brown sugar” began disappearing from the market in the 1990s, replaced with a crystalline powder they call “white crest.”

The shift marked a turning point for the HIV epidemic in Malindi. Brown sugar was most easily consumed by placing it in a piece of foil, heating from underneath and inhaling the vapors — a technique called “chasing the dragon.” But “white crest” burned too quickly for that. So the addicts began rolling it with marijuana and smoking it as a “cocktail.” Or, for a faster, cheaper and longer-lasting fix, injecting it straight into their veins.

Shee Omar readies himself for injection as his friend, Ahmed Mohamed, prepares the dose of heroin. Photo by Mia Collis/PBS NewsHour

Shee Omar, 29, decided to make the switch from smoking to injection about six months ago, because “the quality of heroin in Malindi is very low,” he said. “You have to spend too much to smoke and get high. So this is better.”

In the back alley of a neighborhood called Sea Breeze — with the Islamic call to prayer echoing over the tin-roof houses — Omar sat on a heap of dried coral and listened to his friend, Ahmed Mohamed, explain the best way to shoot.

Ahmed Mohamed, right, known as ‘the doctor’ in this neighborhood, teaches Shee Omar how to shoot heroin safely. Photo by Mia Collis/PBS NewsHour

Ahmed describes himself as a “fisher, carpenter and thief” — he’ll do just about anything for the next fix. But he’s developed a set of habits that have earned him the nickname, “doctor.” For one thing, he’s among the best people in town to help find difficult veins, so he’ll often lend a hand to people like Omar who are still learning to inject. But while he’s helping them get high, Ahmed will also talk with them about the health risks.

Sharing used needles — and the blood that comes with it — is one of the fastest ways to spread HIV. The Kenyan government estimates that along the coast, people who inject drugs account for 17 percent of new infections. And while the HIV prevalence rate in the general population stands at 5.6 percent, roughly a quarter of injection drug users are infected with the virus.

Public health officials warn that ignoring such startling figures will come at a price. After shooting up, many of these drug users return home for unprotected sex with their spouses — or they sell sex for drug money. The higher HIV rates then spill into the general population.

Ahmed knows the cycle all too well. He’s been injecting since he was 14, uses a condom only when he’s sober enough remember it, and recently tested positive for HIV. But one thing he does without fail these days is use clean needles for every new injection.

“I make myself a role model,” he said. “I don’t want anybody else to get in this trap. If my brothers and sisters are going to inject,” he said, “I want to teach them how to do it safely.”

Harm Reduction

The recently opened Watamu Drop-In Center helps addicts in Watamu and Malindi with basic health care, as well as services to make their drug habits safer. Photo by Mia Collis/PBS NewsHour

At the Watamu Drop-In Center, one female addict, a regular, cuts straight to the point: “Welcome to Junky House — the big house for drug addicts,” she says. The Kenya Red Cross started funding the Watamu drop-in center in 2012 to reduce HIV rates among one of the country’s “most-at-risk” groups.

Before it opened, most of the 1,065 people who come here had nowhere to go for even basic medical care. “Because wherever they go, they will be turned away and labeled as thieves,” said Salim Mwakidzuga, the staff clinical officer. “If they are not turned away, they will never be given the first priority to be attended to. And these people are very impatient.”

Here, addicts receive fast and friendly treatment for just about any illness, as well as counseling for their addiction and evidence-based education on how to make their drug use safer.

Lessons Learned

Hajji Fadhil Mohammed, right, listens to Ludovick Tengia, describe the steps of safe injection. Photo by Mia Collis/PBS NewsHour

Addictions counselor Ludovick “Lion” Tengia makes a point of sitting down with all of the users who come into the center for treatment. Though he rarely shares his own history with clients, Tengia speaks to them from a place of experience.

He spent more than a decade shooting and smoking heroin. His family watched as his circle of friends dwindled — many to drug overdoses, some to HIV. They were convinced he would follow them to the grave.

“I remember my mom telling me, ‘I have your coffin ready, you just tell me when it is. I can’t even grieve. I’ve grieved already.’ And that was so painful for me. So I just decided that me and the needles, that’s it,” he said.

In 2003, he made his way to a rehabilitation center in Malindi. But when administrators there met him at the gate, they discovered he was carrying some leftover drugs and they refused to let him in.

So Tengia waited outside the facility long enough to convince them that he was serious — that they should change their minds. Three days later, they finally did.

As a former addict himself, Ludovick Tengia, the addictions counselor at Watamu Drop-In Center, tries to mitigate some of the harm the drug users cause themselves. Photo by Mia Collis/PBS NewsHour

That’s why, as a counselor, Tengia has resolved to meet patients where they are. He knows they won’t listen unless they’ve made up their minds to change.

“If you are trying to quit, I’ll work with you on that. If you want to switch from injection to smoking, I’ll work with you on that. If you come to me and say, ‘I think I need to start injecting,’ I’ll tell you the facts about injecting, the risks which you are exposing yourself to. And then I’ll tell you how to do it safely.”

Injection drug user Hajji Fadhil Mohammed listens carefully to addictions counselor Ludovick Tengia at the Watamu Drop-In Center. Photo by Mia Collis/PBS NewsHour

In a recent counseling session, Tengia asked Hajji Fadhil Mohammed to take him through “the steps of a typical injecting session.” Whenever Mohammed forgot one, Tengia interjected, explaining why it’s necessary to have a clean surface area and sufficient light.

But the No. 1 rule Tengia drills into his patients: Use a clean needle with each injection. Don’t share. No excuses.

Evidence-Based and Forbidden

Clinical officer Sailm Mwakidzuga inspects a needle and syringe kit at the Watamu Drop-In Center. Photo by Mia Collis.

Before they leave, drug users like Mohammed pick up free needles and syringes directly from the Watamu Drop-In Center. The packets come by the boxful from the Kenya Red Cross, which fully endorses the idea of “harm reduction.”

The theory goes that drug users will find a way to shoot regardless, so they should at least do it safely and without spreading HIV in the process — either to each other or to their sexual partners.

Lenora Lippmann, program development officer for the Kenya Red Cross – Coast Region, delivers the syringe kits given to injecting drug users at the Watamu Drop In Center. Photo by Mia Collis/PBS NewsHour

The world’s largest public health groups support the concept of “harm reduction” — from the World Health Organization to the Global Fund to Fight AIDS, Tuberculosis and Malaria, which has funneled nearly $600 million toward “harm reduction” programming and other services for people who inject drugs in the past 11 years.

But many conservatives cringe at the idea of handing drug users a tool for getting high. The U.S. government bans the use of federal dollars on needle and syringe programs — including any flowing through the massive President’s Emergency Plan for AIDS Relief, or PEPFAR. President George W. Bush, who created PEPFAR in 2003, said he didn’t believe in “so-called harm reduction strategies to combat drug use,” and that needle exchange programs signal “nothing but abdication, that these dangers are here to stay. Children deserve a clear, unmixed message that there are right choices in life and wrong choices in life, that we are responsible for our actions, and that using drugs will destroy your life.” Rather, he supported a mix of prevention, education, treatment and law enforcement activities to help drug users recover from addiction and to discourage others from trying in the first place. President Obama signed a bill ending the ‘Needle Exchange Ban’ in 2009, but a group of conservatives in Congress reinstated it as part of a spending bill passed two years later.

Similarly, when the government of Kenya launched a series of pilot needle and syringe programs along its coast in 2012, Muslim clerics demanded they end immediately. “The Quran strongly forbids such harm,” said Sheikh Yusuf Omar on behalf of the clerics at a community meeting in the coastal city of Mombasa. “This program seeks to use harm to stop another harm. This goes against the Islamic teachings. It is forbidden.”

Scattered Needles

Mohamed Ali Issa, a recovering heroin addict, says Needle and Syringe Programs don’t work. Photo by Mia Collis/PBS NewsHour

Among the Malindi area’s most outspoken critics is Mohamed Ali Issa, a once-powerful international businessman who lost everything — his Swiss wife, his children, his job — when he got hooked on heroin. “It was like a poison to me,” he said. “It took everything I had.”

So nine years ago, Issa checked himself into a rehabilitation program, where he quit cold-turkey. He’s been working to repair his relationships and shattered career ever since, and he now calls himself a model for the recovery approach.

“It’s much better to give them treatment or to bring them to a rehabilitation center rather than handing them needles for free. Because if they do that, they will just use more. More and more,” he said.

Used needles are collected from the ground by the Omari Project’s outreach workers at a heroin den in Malindi. Photo by Mia Collis/PBS NewsHour

Issa says the drug addicts don’t remember to return their used needles to the drop-in centers for proper disposal — they simply throw them on the ground, where children can play with them. Recently, one of his friends stepped on one while walking through town and was rushed to the hospital for tests and treatment.

He says that if volunteers and clinic staff are picking up the discarded needles — as they promised they would — they’re not doing it fast enough.

“Before this, we didn’t have many drug users who were using an injection,” he said. “But now, after this center started giving these things for free, many young boys are now trying it.”

Shosi Mohamed, the Omari Project drug rehabilitation and outreach program coordinator, was among leaders responsible for bringing the needle and syringe programs to the coast. Photo by Mia Collis/PBS NewsHour

Shosi Mohamed, program coordinator for the nonprofit “Omari Project” in Malindi, says that’s blatantly not true — that there’s no proof beyond anecdotal stories that the new needle and syringe programs are causing new harm. In fact, a recent study by the Omari Project and the London School of Hygiene and Tropical Medicine “proves that the NSP program has not contributed to an increase of drug use in Malindi or the coast, in general,” he said. Elsewhere in the world — in cities from Amsterdam to New York — long-term studies show that implementation of needle and syringe programming has led to dramatically lower HIV rates without any uptick in drug use.

It’s why the Omari Project — a group named after the first injection drug user in Malindi to die after using a contaminated needle — now sends dozens of volunteers directly into the back alleys and drug dens of this city daily to hand-deliver the syringe packets. Rather than encouraging drug use, Mohamed said it can often be the first step to helping them connect with Omari Project’s other programming, including life-saving treatment and counseling services.

The Omari Project Drop In-Center in Malindi takes its name from the first injection drug user in Malindi to die of AIDS after sharing a contaminated needle. Photo by Mia Collis/PBS NewsHour

“Handing them that needle is sometimes the only way we can engage them and talk seriously about their drug use,” Shosi Mohamed said. “Do they really want to keep on using drugs? Do they really need to keep on injecting? Are they injecting properly? Because we can give you new needles and syringes, but who’s going to give you new veins? It makes people think more about their best options. And the best options for most people is not sharing needles, or stopping injection altogether.”

Hassan Abdul receives medical care for an infected hand at the Omari Project Drop-In Center in Malindi. Photo by Mia Collis/PBS NewsHour

Hasan Abdul’s hand became severely inflamed after he missed a vein and shot heroin directly into the tissue. Photos by Mia Collis/PBS NewsHour

Take, for example, Hassan Abdul, who knows about the Omari Project through its needle and syringe services. When he missed a vein the other day and shot heroin directly into the tissue of his hand, he knew to come here for emergency treatment. Later, he’ll receive follow-up counseling to help him change his lifestyle, if he wishes to do so — or learn how to inject more safely in the future.

Roughly 40 percent of injection drug users in Malindi have developed wounds from poor injection practices. One of them is Mbarak Salim. Photo by Mia Collis/PBS NewsHour

Before the Omari Project launched the needle and syringe program in 2012, 32-year-old Mbarak Salim used the same dirty needles so often they became dull. A bloody wound opened at his regular injection site, eventually spreading and becoming infected.

He uses clean needles now, which reduces the risk that the abscess will grow. And while doctors at the local hospital once told him that his leg would probably need to be amputated, consistent treatment at the Omari Project means he’s now headed for recovery instead.

Mbarak Salim receives counseling from Monica Wanja at the Omari Project Drop-In Center in Malindi. Photo by Mia Collis

Omari Project paralegal Monica Wanja also meets with clients like Salim when they stop in for treatment. She tells them about their civil rights and advises that they can find legal support at the center should they get into trouble.

Now sober for seven years, Wanja wants them to understand that full recovery is possible.

She tells them that she was once so overcome by addiction that she resorted to injecting in her breasts and genitals because the veins everywhere else were too damaged. When she gave birth to a daughter, she breastfed with one-hand and injected with the other. She rummaged through hospital trash cans for used needles. She had sex with Italian tourists at night for drug money. And eventually, she contracted HIV.

Monica Wanja, a recovering addict and a paralegal at the Omari Project, wipes away tears while describing her former life of drug abuse. Photo by Mia Collis/PBS NewsHour

Like most of Malindi’s addicts, Wanja remembers vaguely talking about wanting to quit. She even checked herself into the Omari Project’s rehabilitation center nine times without ever taking it very seriously.

But before Wanja’s tenth stint at the facility, her grandmother — her only real source of support — sat her down to announce she was dying and had some tough words to leave behind: “This is your last chance. When I am gone, you will have no one. It is you now that has to make the decision.’”

Seven years have passed and temptation visits her daily, but Wanja says she hasn’t touched heroin since.

Relapse and Rehabilitation

The Omari Project Drug Rehabilitation Center sits several miles outside of the town of Malindi, far removed from many of the temptations the recovering addicts face in normal life. Photo by Mia Collis/PBS NewsHour

The gate is always open at the Omari Project Drug Rehabilitation Center, several miles outside of town. Those who check themselves in can leave at any time.

But most find this a peaceful spot to heal — or at least try. They cook meals together and garden between counseling sessions and meditation. They care for baby goats and chickens. Mostly, they sit and think about where they’ve been and where they want to go.

Fatima Lali Athman was once employed by the Omari Project as an outreach worker. She is now, once again, a patient. Photo by Mia Collis/PBS NewsHour

Fatima Lali Athman knows this piece of land well. She checked in here for treatment in 2010, sobered up and became such a success story for the Omari Project that the rehabilitation center hired her as staff.

But her husband — a recovering drug user himself — started into heroin again shortly after Fatima returned home. She tried to resist the urge but said the easy access and constant temptation became too much. When she started smoking again, she quickly lost control.

Athman checked herself back in as a patient several months ago — a deep embarrassment for her and testament to the fragility of the recovery process. But it’s what needed to happen, she says.

“I didn’t look after my children. I didn’t do anything for myself. I stopped caring about everything. I knew it wasn’t healthy for anyone,” she said. “So I’m taking this chance again and hoping for the best.”

Traditional Swahili dhows sail in the Indian Ocean off the coast of Malindi. Photo by Mia Collis/PBS NewsHour

Even the most desperate drug users in Malindi haven’t lost that feeling of hope — that a brighter future is somehow possible for themselves and their city.

Drug use continues to thrive here. But disease rates seem to have leveled off, health officials say. And that in itself, most agree, is a reason to keep hoping for more.

This photo essay was produced with the support of the International Center for Journalists .

Jason Kane is a PBS NewsHour producer, focusing on health care and national affairs.

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Cannabis for Better Sex? Here’s What the Science Says.

The research is thin, but anecdotal experience suggests that the right dose and delivery method can make a positive difference for some people.

By Christina Caron

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A few weeks ago, the Ask Well column highlighted treatments for low libido in women. Afterward, several readers wanted to know if cannabis could be added to the list of potential remedies.

It’s a question that is especially relevant now that the U.S. House of Representatives has passed a bill decriminalizing marijuana at the federal level.

Marijuana, the most commonly used drug that is federally illegal, is currently allowed for medical use in 37 states , and in 18 states for adult recreational use. According to a 2020 survey, nearly 18 percent of Americans age 12 or older had used it within the past year, and more than two-thirds of Americans support legalizing it, according to various polls .

To learn more about cannabis and sex we turned to several experts, including a gynecologist who has surveyed women about their marijuana use.

The bottom line: It’s hard to say with certainty that cannabis will increase desire or improve your sex life, but anecdotal evidence suggests that the right dose of cannabis can make a woman’s orgasms more satisfying and increase sex drive. This is in part because cannabis can enhance the senses and also alleviate some of the symptoms that inhibit desire, like anxiety, sleeplessness or pain. It can have positive effects for men, as well, but also several negative ones, and women should be aware of its potential downsides, too.

What does the research say?

Both men and women have long reported that cannabis alters their sexual experience. In an essay published in 1971, the astronomer Carl Sagan, a longtime marijuana user, wrote that cannabis “enhances the enjoyment of sex” and “gives an exquisite sensitivity.”

There is very little research on cannabis and libido, however, in part because cannabis research has been notoriously difficult to fund and it remains a federally illegal drug in the United States. Most of the research that does exist relies on data from questionnaires, which are heavily skewed toward people who already use cannabis and are not representative of the general population, making it difficult to draw firm conclusions. In addition, the surveys do not provide reliable and precise information about dosage, delivery method or timing.

But based on the limited evidence, the drug does seem to enhance the sexual experience among many women who already use it.

“I’ve had several patients come to me and say, ‘I have low libido. Can you help me? And, oh, by the way, if I use marijuana, I can orgasm, no problem,’” said Dr. Becky K. Lynn, a sexual medicine and menopause expert and the founder of Evora Women’s Health in St. Louis. “They also tell me that low libido improves with marijuana.”

Dr. Lynn, who also teaches at the Saint Louis University School of Medicine, is the lead author of a study published in 2019 that surveyed 373 women about cannabis at an obstetrics and gynecology clinic in Missouri. Of those, 34 percent reported having used marijuana before sexual activity and most of them said it resulted in an increased sex drive, improved orgasm and decreased pain.

Studies have also found that some women use cannabis to help manage menopause symptoms like hot flashes, night sweats, insomnia and vaginal changes, such as dryness, all of which may contribute to lower libido when untreated.

In addition, an online survey of more than 200 women and men who use cannabis found that nearly 60 percent said cannabis increased their desire for sex; almost 74 percent reported increased sexual satisfaction. But the study, which was conducted by researchers in Canada and published in The Journal of Sexual Medicine, also said that 16 percent reported sex was better in some ways and worse in others, and a little under 5 percent said it was worse.

Research on cannabis use and sexual function among men is likewise sparse and can be contradictory. According to the International Society for Sexual Medicine , some men report that their sexual performance improves when they use marijuana, while others may experience problems such as less motivation for sex, erectile dysfunction, trouble reaching orgasm or premature ejaculation. Cannabis use has also been associated with reductions in sperm count, concentration, motility and viability .

‘Start low and go slow’

All drugs have risks and potential side effects, cannabis included.

If your doctor has cleared you to try cannabis in a state where it is legal, Dr. Peter Grinspoon, a primary-care doctor at Massachusetts General Hospital Chelsea HealthCare Center and a medical-cannabis consultant, advised taking a “teeny bit” in a tincture if you’re new to it — in some cases as little as 1 milligram of THC, the main psychoactive ingredient in weed — before slowly working your way up.

“At low doses, cannabis helps libido, but at high doses, it often isn’t as effective,” he said, adding that the wrong amount will lead some people to become paranoid and anxious. The drug could also inhibit orgasm, creating the opposite effect of what was intended.

Dr. Lynn agreed. “Start low and go slow,” she said.

How much is too much marijuana? That will vary from person to person.

And because cannabis is known to impair judgment, coordination and reaction time, those who use psychoactive drugs before or during sex “must take into consideration whether people using the product and their partners can have safe and consensual sex,” said Dr. Stacy Tessler Lindau, a gynecologist at the University of Chicago Medicine and the creator of WomanLab , a website about sexual health.

Given that cannabis can compromise judgment about contraception or the ability to consent, she added, women can either look to avoid products with psychoactive components or, if they wish to use them, increase safety by having sex with a trusted partner.

“Sex with a stranger ideally would not involve any intoxication of anyone involved,” she said.

Dr. Jordan Tishler, a former emergency medicine doctor and president of the Association of Cannabinoid Specialists , recommended trying cannabis alone for the first few times and masturbating, in order “to understand what it does to the body and sensations.”

What is the best cannabis delivery method?

Smoking marijuana or using oil vape pens should be avoided, because they can harm the lungs, the experts said.

Dr. Lynn typically recommends tinctures, which are concentrated cannabis extracts that are taken by mouth. It is easy to measure the number of milligrams you want to use, she said.

Dr. Tishler usually advises his clients to start with 5 mg of THC. Taking one puff on a cannabis flower vaporizer before having a sexual experience can work faster and more predictably than edibles or lubricants infused with THC, he said.

“I teach patients to take a puff in a particular manner,” Dr. Tishler added: “a very deep, slow inhalation that allows us to estimate how much dose they are getting.”

Remember that libido is complicated

There are multiple factors that can affect someone’s sex drive and sexual function, some of which could be addressed by seeing a physician or a mental health provider.

If a woman had pain with intercourse, for example, she would need to be referred to a gynecologist for a full evaluation, Dr. Grinspoon said. Cannabis could potentially help, but there would be more to investigate and consider in anyone who is experiencing uncomfortable physical symptoms.

“You can be treating the symptom while looking at the underlying cause,” he said. “It’s not mutually exclusive.”

Audio produced by Kate Winslett .

Christina Caron is a reporter for the Well section, covering mental health and the intersection of culture and health care. Previously, she was a parenting reporter, general assignment reporter and copy editor at The Times. More about Christina Caron

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Nearly One-Third of U.S. Adults Know Someone Who’s Died of Drug Overdose

Survey also finds ‘overdose loss’ bolsters recognition of addiction as an important policy issue that spans party lines

Losing a loved one to drug overdose has been a common experience for many Americans in recent years, crossing political and socioeconomic divides and boosting the perceived importance of the overdose crisis as a policy issue, according to a new survey led by researchers at the Johns Hopkins Bloomberg School of Public Health.

A nationally representative survey of more than 2,300 Americans, fielded in spring 2023, suggests that 32 percent of the U.S. adult population, or an estimated 82.7 million individuals, has lost someone they know to a fatal drug overdose. For nearly one-fifth of survey respondents—18.9 percent, representing an estimated 48.9 million adults—the person they knew who died of overdose was a family member or close friend.

The rates of reported loss due to overdose did not differ significantly by political party affiliation, but those who experienced overdose loss were more likely to view addiction as an extremely or very important policy issue.

The study was published online May 31 in JAMA Health Forum .

“The drug overdose crisis is a national tragedy,” says Alene Kennedy-Hendricks, PhD, assistant professor in the Department of Health Policy and Management at the Bloomberg School, who led the analysis. “Although large numbers of U.S. adults are bereaved due to overdose, they may not be as visible as other groups who have lost loved ones to less stigmatized health issues. Movements to build support for policy change to overcome the devastating toll of the overdose crisis should consider the role of this community.”

Over one million Americans have died from drug overdoses since the late 1990s, including more than 100,000 per year in the last few years, according to the Centers for Disease Control and Prevention. Last year, overdose deaths declined slightly for the first time in five years, decreasing three percent from 2022, according to preliminary data from the CDC’s National Center for Health Statistics. At about 108,000 estimated deaths, the CDC 2023 preliminary numbers remain near historic highs. 

The overdose crisis has evolved over several phases, beginning with prescription opioids such as oxycodone playing a key role, followed by heroin and, more recently, powerful synthetic opioids like illicitly manufactured fentanyl and polysubstance use. Opioids can suppress breathing as a side effect, and the unpredictability of the illicit drug supply and the potency of fentanyl have dramatically increased the risk of overdose.

While the survey questions did not specifically identify opioids, the majority of overdose deaths over the last two decades have been opioid-related.

The overdose crisis has not only impacted its direct victims but also their relatives, friends, and acquaintances. Kennedy-Hendricks and her colleagues at the Bloomberg School’s Center for Mental Health and Addiction Policy set up the study to help illuminate this wider impact, which otherwise has been little studied.

The paper was co-written with colleagues from Boston University School of Public Health, the University of Minnesota, and the de Beaumont Foundation. The study’s senior author is Sandro Galea, MD, DrPH, MPH, dean of Boston University School of Public Health. 

The survey is part of the CLIMB (COVID-19 and Life Stressors Impact on Mental Health and Well-being) study. Led by Catherine Ettman, PhD, an assistant professor in the Bloomberg School’s Department of Health Policy and Management, the CLIMB study has surveyed a nationally representative sample of adult Americans annually since 2020. For this overdose loss study, questions to participants from March 28 to April 17, 2023—CLIMB Wave 4—included “Do you personally know anyone who has died from a drug overdose?” A total of 2,326 participants responded to the question. Participants answering “yes” were then asked “Who do you know that has died from a drug overdose?”  

Overdose losses were reported across all income groups. Forty percent of lower-income respondents (defined as annual household incomes less than $30,000) reported overdose loss. Over one-quarter—26 percent—of respondents in the $100,000 and higher annual household income category reported an overdose loss.

The rate of reported overdose loss was not significantly different across self-described Republicans, Democrats, and Independents, adding to the picture of a far-reaching phenomenon.

The data suggested a high level of endorsement across all groups—greater than 60 percent, even among those reporting no overdose loss—that addiction is an extremely or very important policy issue. Respondents who reported overdose loss had 37 percent greater odds of viewing addiction as a very or extremely important policy priority. 

“This study contributes new evidence that the addiction crisis and the losses that come with it are common across Americans, but the burden is greater among those who are more economically precarious,” says Ettman. “Addressing addiction can be a unifying theme in increasingly divided times.”

The researchers plan to follow up with further studies in future CLIMB survey waves, looking at associations between overdose loss and other social variables such as trust in institutions.

“ Experience of Personal Loss Due to Drug Overdose Among U.S. Adults ” was co-authored by Alene Kennedy-Hendricks, Catherine Ettman, Sarah Gollust, Sachini Bandara, Salma Abdalla, Brian Castrucci, and Sandro Galea.

CLIMB Study Wave 4 was funded by a grant from the de Beaumont Foundation.

Media contacts: Kate Sam [email protected] or Kris Henry [email protected]

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LGBTQI+ People and Substance Use

• Research has found that sexual and gender minorities, including lesbian, gay, bisexual, transgender, queer, and intersex people (LGBTQI+), have higher rates of substance misuse and substance use disorders than people who identify as heterosexual. People from these groups are also more likely to enter treatment with more severe disorders.
• People in LGBTQI+ communities can face stressful situations and environments like stigma and discrimination , harassment, and traumatic experiences . Coping with these issues may raise the likelihood of a person having substance use problems.
• NIDA supports research to help identify the particular challenges that sexual and gender minority people face, to prevent or reduce substance use disorders among these groups, and to promote treatment access and better health outcomes.

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• See the Stigma and Discrimination Research Toolkit from the National Institute of Mental Health.

June 4, 2024

Winning papers announced for 2024 Population Health Library Research Awards

This award was created in 2017 in partnership with the University of Washington Libraries and is open to undergraduates from all three UW campuses. The projects submitted were completed for either UW course credit or for the Undergraduate Research Program.

The key factors for choosing awardees included the innovativeness of their research hypothesis, the quality of their writing and how well they connected their work to the theme of population health. The following section describes the four awardees, their majors, the titles of their projects and summaries of their projects.

Lindsay Lucenko (Law, Societies, and Justice), "Gender Dynamics in King County Drug Diversion Court: Exploring Experiences and Perspectives"

This research explores the experiences of men and women in the King County Drug Diversion Court, a rehabilitative program for drug-related offenses. Participants undergo a five-phase program with the potential for charge dismissal, but concerns about coercion persist. Participants must maintain sobriety, undergo frequent tests, attend support meetings, communicate with case managers, find employment, and fulfill familial duties.

The study investigates how gender influences these obligations’ fulfillment, especially considering the court’s predominantly male population. Through nine semi-structured interviews, I examined participants’ experiences with the criminal justice system, focusing on gender impacts. Findings reveal nuanced gendered experiences, informing justice system reform. By combining qualitative interviews and existing research, this study sheds light on gender dynamics within the court, contributing to policy and practice for a fairer criminal justice system.

Evelyn Erickson (Chemical Engineering), "Tandem dechlorination and hydrogenolysis of waste PVC plastic into value added chemicals "

Plastic waste is a serious problem with detrimental environmental impacts, within this mixed plastics pose a significant challenge in depolymerization. My project focuses on polyvinyl chloride (PVC), a particularly difficult plastic to break down due to the chlorine atom. Chlorine can poison catalysts and release harmful by products like hydrochloric acid or chlorine gas.

I have been working to dechlorinate PVC and then further break down this waste plastic to form value added products. Once dechlorinated PVC becomes a hydrocarbon and can be treated similar to other waste plastics like polyethylene and polypropylene. This tandem dechlorination and depolymerization occur in a single step through a strong amine base and ruthenium catalyst helping to activate the reaction.

Nede Ovbiebo (Pre-science - Biochemistry), "What are the health outcomes of phytochemical supplements versus fruits and vegetables?"

This research stems from concerns about the efficiency of modern diets, which increasingly rely on supplements rather than natural food sources. I analyzed data and reviewed information to compare the effectiveness of phytochemical supplements and whole fruits and vegetables. The study emphasized that while phytochemicals are used in various therapies, their individual effects cannot be compared to the combined benefits of whole foods based on current scientific developments. I have placed the results in a booklet to be printed and disseminated in the future to enable more people to plan their diets wisely and incorporate phytochemicals flexibly into their daily routines.

Hayden Goldberg (Public Health-Global Health, Biochemistry), "An Evaluation of Agricultural Safety and Health in Pesticide Application Technology"

The use of pesticides in the Pacific Northwest is essential in the process of safeguarding public health, most notably by mitigating pests, protecting our food supply, and aiding in produce distribution. However, long-term exposure to pesticides can result in illness for those handling the substances as well as their families. Newer methods, such as aerial drone spraying involve the use of emerging technologies that are poised to change the landscape of the agricultural industry and health outcomes of farmworkers.

This project will be assessing thoughts regarding adoption of these technologies. Through the creation of an electronic survey, I will be obtaining a variety of responses from individuals involved in the application of pesticides on farms. I will then analyze responses both quantitatively and qualitatively. The main objective of my research project is to capture the attitudes of the pesticide application technologies to inform policy, regulations, and decision-making regarding their uses.

Please visit our funding page to learn more about these awards.

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Population health is a broad concept encompassing not only the elimination of diseases and injuries, but also the intersecting and overlapping factors that influence health.

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