Although this was a small, non-controlled qualitative study without detailed cannabis use characterization, it was suggestive of cannabis’ positive effect on female sexual function and is consistent with the current report. In a similar interview-based study with 37 female cannabis, the authors found that frequent users reported increased sexual pleasure, orgasms, satisfaction, and intimacy compared with less frequent users .20 However, this observation did not reach statistical significance. However, in interviews in 84 graduate students, of which 18 were female students, heavy users of cannabis tended to report more positive sexual experiences compared with lower intensity users.These findings are similar to those by Koff who, in a survey of 128 women, found that users of cannabis tended to enjoy sexual activity more than non-users. Interestingly, unlike most studies, he assessed if method of consumption had any impact on sexual experiences , and similar to the findings reported here, found no impact. However, the issue with these early studies has been that they represent a small, select sample size, and use non-validated questionnaires in an interview format. More recently, researchers have used survey instruments to examine the effect of cannabis on female sexual function. However, many of these studies still do not use validated instruments or use sets of individual questions from them resulting in inconsistent findings. Johnson et al23 surveyed 1,801 women asking specifically about sexual dysfunction and substance use. Although there was no significant increase in sexual dysfunction among cannabis users , inhibited orgasm and dyspareunia were more common among female cannabis users. This is in contrast to the present study that found orgasm to be improved in more frequent users, whereas pain during sexual activity was unaffected. In contrast, Lynn et al10 surveyed 373 women and reported that frequent users had improved orgasms . Other realms of sexual function, such as satisfaction, sex drive, lubrication, and dyspareunia, were not impacted by either use vs not or frequency of use.
An Australian survey of 8,650 men and women, of which 754 reported cannabis use, found no association between cannabis vertical farming use and sexual dysfunction in women when comparing users vs non-users as well as frequency of use.While sexual dysfunction was assessed, a validated questionnaire was not used to obtain composite scores. In contrast to these studies, Johnson et al,who asked questions specifically about female sexual dysfunction, found that cannabis use was associated with inhibited orgasm in a survey of more than 1,500 women. The exact mechanisms by which cannabis may increase sexual function in women is unknown. The endocannabinoid system has been postulated to be involved in female sexual function, and prior studies have demonstrated that increased amounts of endogenous cannabinoids such as arachidonoyl ethanolamide and 2-arachidonoylglycerol are associated with increased sexual arousal.9 Exogenous use may similarly lead to activation of the endocannabinoid system leading to increased sexual function as we found here. As many patients use cannabis to reduce anxiety, it is possible that a reduction in anxiety associated with a sexual encounter could improve experiences and lead to improved satisfaction, orgasm, and desire.Similarly, THC can alter the perception of time which may prolong the feelings of sexual pleasure.Finally, CB1, a cannabinoid receptor, has been found in serotonergic neurons that secretes the neurotransmitter serotonin, which plays a role in female sexual function thus activation of CB1 may lead to increased sexual function.Several limitations of the present study warrant mention. Our cohort of women was derived from a population of cannabis users who made a purchase at a single-partner cannabis dispensary during a specific time period that may represent a unique subset of cannabis users especially as prior reports show lower prevalence of cannabis use in the general population introducing possible selection bias. In addition, while respondents had purchased a product at the partner dispensary, the specific locations from which respondents purchased their product is unknown. However, the population was geographically diverse and was not representative of only 1 region within the United States. Any survey distributed in such a manner is subject to volunteer and recall bias. Although respondents were asked about chemovar, it is possible some respondents did not know the dominant chemovar in the product they purchased thus altering the results. In addition, while frequency was assessed the exact dosage of product , duration of use or chronicity is unknown. The impact of frequency of use on sexual function was compared by dichotomizing less frequent and more frequent users with no comparison to a non-user control group.
It is possible that inclusion of a non-user population may alter the findings. In addition, we cannot exclude the possibility of causation in that more frequent female cannabis users happen to have higher FSFI scores rather than causal relationship. Although the multivariable linear regression was adjusted for available factors, residual confounders may exist that were not examined and therefore alter the results. While the FSFI is the most commonly used female sexual function survey, it is not the only one , and use of another validated survey may yield differing results. Althoough the FSFI cutoff for female sexual dysfunction has been validated and was examined here in associated with frequency of cannabis use, the clinical signifificance in FSFI subdomain scores is unknown. Although other aspects of sexuality were not assessed, such as vaginismus, this would be a potential area for future study.Finally, while the survey assessed cannabis use within the last 4 weeks, it did not differentiate between chronic and new users. Our results demonstrate that increasing frequency of cannabis use is associated with improved sexual function and is associated with increased satisfaction, orgasm, and sexual desire. Neither, the method of consumption nor the type of cannabis consumed impacted sexual function. The mechanism underlying these findings requires clarification as does whether acute or chronic use of cannabis has an impact on sexual function. Whether the endocannabinoid system represents a viable target of therapy through cannabis for female sexual dysfunction requires future prospective studies though any therapy has to be balanced with the potential negative consequences of cannabis use.While the cannabis-associated burden-of-disease is lower than that for licit drugs like alcohol or tobacco, its use is associated with risk for multiple possible acute and chronic adverse outcomes, including psycho-cognitive impairment, cannabis use disorder , mental health problems, and respiratory problems . Most of these outcomes materialize, however, in a sub-group of ‘highrisk’ users sharing a set of common risk factors . While most countries continue to control cannabis through variations of prohibitionist policies, several jurisdictions have recently implemented policy reforms, some including legalization of cannabis use and supply . Among the purported benefits of legalization policy are that it allows both cannabis use and products to be regulated, and targeted interventions can openly be designed and legitimately applied towards reducing cannabis-related risks or harms . Canada has been the second national jurisdiction, after Uruguay, to implement legalization of cannabis use and supply . Canada has long had among the world’s highest cannabis use rates: about one in eight Canadians, and about one in four or more youth/young adults reported cannabis drying racks use around the time of legalization . While several studies have identified cannabisimpaired driving and CUD as main contributors to cannabis-related burden of disease in Canada, other related indicators have shown increases in adverse outcomes in the period leading up to legalization .
In anticipation of cannabis legalization, and specifically of the need for effective interventions to reduce cannabis-related harms towards envisaged public health outcomes, a set of ‘Lower-Risk Cannabis Use Guidelines’ were updated by an international expert group, and widely disseminated . The LRCUG were conceived as an evidence-based population health intervention, built on scientific data identifying user-modifiable, behavioral risk factors associated with adverse outcomes associated with cannabis use . Based on this evidence, the LRCUG present a set of user-oriented recommendations towards informing and adjusting use-related risk behaviors, and consequentially reducing acute or long-term health harm for desired results. As such, the LRCUG serve as a ‘targeted prevention’ tool, as exists in other areas of health behaviors . Crucial for their acceptance and uptake, the LRCUG were endorsed by ten national, leading health and addictions organizations in Canada, and subsequently disseminated through a diverse suite of ‘knowledge translation’ materials and activities . While health-oriented targeted prevention tools like the LRCUG are conceptually timely and topical, their uptake and impact on behavioral choices, and outcomes in the target population, cannot be assumed, and require empirical assessment . In this context, this paper aimed to compile and review available, empirical indicators on LRCUG-related behaviors among cannabis users in Canada at the time around legalization. The legalization of cannabis use and supply has been implemented in Canada and other jurisdictions with the improvement of cannabisrelated public health outcomes as a primary objective . The LRCUG were developed and widely disseminated in Canada as an evidence-based population health and prevention tool to inform and guide active cannabis users towards reducing risk behaviors for adverse health outcomes . While the evidence behind the LRCUG’s recommendations is evolving, little is systematically documented about cannabis users’ actual behaviors vis-à-vis the LRCUG’s recommendations in Canada or elsewhere. Such knowledge, though, is important to inform intervention needs and development . This paper begins to fill this knowledge gap, based on a review and mapping of available relevant indicator data from major Canadian surveys. We found survey indicator data on the majority – but not all – of the LRCUG recommendations, while presumably including those contributing most to cannabis-related disease burden . The development of additional survey items related to other LRCUG recommendations is recommended to close these partial indicator and knowledge gaps. Available indicators from the surveys suggest that adult Canadians, on average, initiate cannabis use around age 19 years. This age makes them eligible for legal cannabis use and procurement under legalization, and thereby should help to reduce risks for key cannabis-related health and social harms as particularly evidenced for young people . However, the initiation ages reported are partly artefactual since the surveys’ sampling frames are limited mainly to adult samples and, overall, sizeable proportions of Canadians are reported to initiate cannabis use at ages below 18 years. For example, in addition to the CCS’ youth sub-sample, the mean age for cannabis use initiation is 14 – 15 years in the large-scale CSTADS and OSDUHS surveys comprising youth samples . These underage users cannot legally purchase or use cannabis, and so place themselves at possibly amplified risk for both cannabis use or illegality-related health and social harms, including brain/cognitive development, CUD, or enforcement .
Based on one survey’s data only , about one third of Canadian users report using high-potency products. High-potency products are known to increase the risk for adverse outcomes from cannabis use . Recent US-based data have shown trends towards increased high-potency product use in legal markets . In Canada, various policy measures aim to reduce high-potency cannabis product use from legal sources, although highpotency products continue to be available from illegal sources and remain difficult to control . In addition, unregulated cannabis products are unlabelled, and potency estimates need to rely on subjective guesses rather than objective information. Data also show that the vast majority of users in Canada consume cannabis via smoking , many in combination with tobacco, as has been the norm in North America . Nevertheless, rates of smoking cannabis seem to be declining, with parallel increases in the use of alternative use modes ; it is unclear, however, whether these are mostly experimental or more regular as, for example, within mixed patterns of multiple use modes . This shift, in part, is facilitated by the recent introduction of legal, non-smoking cannabis products to the Canadian market. While these ‘alternative’ use modes come with their own specific health risks, as exemplified by recent cannabis vapingrelated lung injury cases , as well as concerns of over-ingestion , non-smoking modes of administration appear to provide overall ‘safer’ use options overall, especially for long-term health outcomes .