Khat in East Africa: taking women into or out of sex work?

The intersection of gender and drug use-related stigma: A mixed methods systematic review and synthesis of the literature

BACKGROUND

Substance use-related stigma is a significant barrier to care among persons who use drugs (PWUD). Less is known regarding how intersectional identities, like gender, shape experiences of substance use-related stigma. We sought to answer the following question: Do men or women PWUD experience more drug use stigma?

METHODS

Data were drawn from a systematic review of the global, peer-reviewed scientific literature on substance use-related stigma conducted through 2017 and guided by the Stigma and Substance Use Process Model and PRISMA guidelines. Articles were included in the present analysis if they either qualitatively illustrated themes related to the gendered nature of drug use-related stigma, or quantitatively tested the moderating effect of gender on drug use-related stigma.

RESULTS

Of the 75 studies included, 40 (53 %) were quantitative and 35 (47 %) were qualitative. Of the quantitative articles, 22 (55 %) found no association between gender and drug use-related stigma, 4 (10 %) identified women who use drugs (WWUD) were more stigmatized, and 2 (5 %) determined men who use drugs (MWUD) were more stigmatized. In contrast, nearly all (34; 97 %) of the qualitative articles demonstrated WWUD experienced greater levels of drug use-related stigma.

CONCLUSION

The quantitative literature is equivocal regarding the influence of gender on drug use-related stigma, but the qualitative literature more clearly demonstrates WWUD experience greater levels of stigma. The use of validated drug use-related stigma measures and the tailoring of stigma scales to WWUD are needed to understand the role of stigma in heightening the disproportionate harms experienced by WWUD.

Development of the Khat Knowledge, Attitudes and Perception Scale

INTRODUCTION AND AIMS

Khat (Catha edulis) is a stimulant plant widely used in East Africa and the Arabian Peninsula. Tobacco is often co-used with khat and its use has expanded to other parts of the world. Chronic khat use is associated with negative health consequences. There is a lack of research to develop a tool to assess attitudes toward khat use. This study aimed to develop a brief tool to assess attitude and perception related to khat (i.e. the Khat Knowledge, Attitudes and Perception Scale).

DESIGN AND METHODS

Four-hundred and three participants in Yemen (151 concurrent users of khat and tobacco, 141 khat-only users and 92 non-users of khat and tobacco) were asked about knowledge and attitudes related to khat. A principle component analysis with Promax rotation, Scree-plot and Cronbach's α coefficients was performed to examine psychometric properties of the Khat Knowledge, Attitudes and Perception Scale.

RESULTS

Principle component analysis revealed five factors: negative beliefs, positive beliefs, idleness, weight control and family issues. Internal consistency of items in negative beliefs, positive beliefs, idleness, weight control and family issues were 0.88, 0.62, 0.62, 0.72 and 0.53, respectively. Greater negative beliefs was inversely correlated with positive beliefs but positively associated with idleness, weight control and family issues. Concurrent users and khat-only users had lower scores on negative beliefs than non-users. Concurrent users had higher scores on positive beliefs than khat-only and non-users.

DISCUSSION AND CONCLUSIONS

These results provide initial support of the usefulness of the Khat Knowledge, Attitudes and Perception Scale.

Immunohistochemical localization of anterior pituitary cell types of vervet monkey (Chlorocebus aethiops) following sub-chronic cathinone exposure

ETHNOPHARMACOLOGICAL RELEVANCE

Khat (Catha edulis) contains cathinone, an active principal that is customarily used as a psychostimulant that wards off fatigue and to some extent used as an aphrodisiac.

AIM OF STUDY

To investigate effects of escalating doses of cathinone on hormone expression by different anterior pituitary cell types using specific antibodies.

MATERIAL AND METHODS

Eleven vervet monkeys (6 males and 5 females) divided into tests (n=9) and controls (n=2) were used. Animals were allocated as group I (saline controls), group II (0.8 mg/kg), group III (3.2 mg/kg) and group IV (6.4 mg/kg) of cathinone. All treatments were via oral route at alternate days of each week. At the end of 4-month treatment phase, GnRH agonist (ZOLADEX) was administered to group II (low dose) and group IV (high dose) alongside cathinone for 2 additional weeks.

RESULTS

High cathinone dose at long-term exposure caused proliferation of gonadotrophs but decrease in lactotrophs and corticotrophs in anterior pituitary sections of animals while effect of low dose on these cells was insignificant. Subsequent GnRH agonist co-treatment with low and high cathinone doses enhanced gonadotroph proliferation but no change on decline of lactotrophs and corticotrophs.

CONCLUSION

We believe that there was a possible potentiation of cathinone on pituitary hormone synthesis thereby influencing reproductive function. Suppression of corticotrophic and lactotrophic functions suggest lowering of stress levels and modulation of reproductive function based on dose level and chronicity of exposure. The findings are consistent with the hypothesis that cathinone interferes with pituitary cell integrity and consequently target organs, but further studies are required to address the precise mechanism underlying this phenomenon.

Why would khat chewers quit? An in-depth, qualitative study on Saudi Khat quitters

Background: Khat chewing, which has many adverse health and social consequences, is highly prevalent and socially accepted in the Jazan region of the Kingdom of Saudi Arabia. Methods: A qualitative study was conducted with 47 adult male former khat users regarding their khat initiation, continuance, and cessation, the amounts of khat they had used, and the health and social consequences of their use and cessation of use. Results: Participants noted a desire to show maturity, ease of availability of khat, and peer pressure as reasons for initiating khat chewing. Many noted long leisure times with little to do as a reason for continuing use. Negative consequences of khat use were seen in economic, health, familial, and sexual areas of their lives. After quitting khat use, participants saw improvements in all of these areas. Conclusions: A comprehensive community development program (CCDP) tackling, among other issues, the normalization of khat use, substantial leisure times with few positive activities, and misinformation about the “benefits” of khat use, as well as developing peer and family training programs to help prevent or stop khat use, would be useful to reduce khat chewing in this community.

The ambiguity of khat in Somaliland

AIM OF THE STUDY

This article presents an analysis of the economic, political and socio-cultural significance of khat in Somaliland, highlighting both its positive and negative effects.

MATERIALS AND METHODS

Thirteen months of anthropological fieldwork in Somaliland, two months of anthropological fieldwork among Somalis in London, four months experience from the Somalia Joint Needs Assessment working as a development specialist on khat, as well as available and relevant literature.

RESULTS

The recent growth in khat consumption in Somaliland is linked to dispersal, unemployment, socio-cultural changes caused by the civil war, and the massive inflow of remittances. Consumption takes place because of an encouraging socio-cultural environment, few opportunities for education and employment, lack of care and support from parents, as well as widespread availability. Khat represents a significant economic drain on the Somaliland economy, but is also an important source of income for the state and an employment opportunity for thousands. The consumption of khat among government employees challenges the efficiency of state institutions, but also provides a participatory and peaceful political environment that is vital to the democratic transformation of Somaliland. Khat causes the breakdown of families and seriously challenges Somali socio-cultural identities, values and practices. However, khat also strengthens male networks, communities and senses of belonging to Somaliland.

CONCLUSION

The article argues that khat has both negative and positive effects on Somaliland society. Comparing the role of khat in Somaliland with khat in Puntland and South-central Somalia it is clear that khat in itself does not determine if it contributes to state building and peace, or state failure and violence. Rather, it is the socio-cultural, political and historical context in which it is consumed that determines its larger societal effects. A nuanced analysis of the positive and negative aspects of khat that builds on local perceptions and practices is necessary in order to work with khat from a regulatory and developmental perspective.

East African discourses on khat and sex

AIM OF THE STUDY

The study aims to review and analyse the varied East African discourses on the effects of khat use on libido, fertility, transmission of HIV, prostitution and rape.

MATERIALS AND METHODS

The data were gathered between 2004 and 2009 in Kenya and Uganda. Between 2004 and 2005 across Kenya and Uganda a broad survey approach was adopted, involving identification of and travel to production areas, interviews with producers and consumers in rural and urban settings. In addition, a survey of 300 Ugandan consumers was carried out in late 2004. Between 2007 and 2009, an in-depth study of khat production, trade and consumption was conducted in Uganda. This study also employed a mixture of methods, including key informant interviews participant-observation and a questionnaire survey administered to 210 khat consumers.

RESULTS

Khat is associated, by consumers and its detractors alike, with changes in libido and sexual performance. Although there is no evidence to support their claims, detractors of khat use argue that khat causes sexual violence, causes women to enter sex work, and that chewing causes the spread of sexually transmitted diseases, including the HIV virus.

CONCLUSIONS

In East Africa the discourse on khat and sex has led to consumption of the substances being associated by many people with uncontrolled sexual behaviour. There is no evidence that khat use fuels promiscuity, commercial sex, sexually transmitted diseases or rape. The current discourse on khat and sex touches on all these topics. Local religious and political leaders invoke khat use as a cause of what they argue is a breakdown of morals and social order. In Kenya and Uganda it is women khat consumers who are seen as sexually uncontrolled. In Uganda, the argument is extended even to men: with male khat chewers labelled as prone to commit rape.

Khat - a controversial plant

Khat (Catha edulis) is a shrub or tree whose leaves have been chewed for centuries by people who live in the Eastern part of Africa and the Arabian Peninsula. It has recently turned up in North America and Europe, particularly among emigrants and refugees from countries such as Somalia, Ethiopia and Yemen. Khat contains a number of chemicals, among which are two controlled substances, cathinone (Schedule I) and cathine (Schedule IV). Both chemicals are stimulant drugs with effects similar to amphetamine. Chewing the leaves makes people feel more alert and talkative, and suppresses appetite. Chewing khat leaves releases cathinone, a stimulant that produces the feeling of euphoria. When cathinone is broken down in the body, it produces chemicals including cathine and norephedrine, which have a similar structure to amphetamine and adrenaline (epinephrine). Regular khat use is associated with a rise in arterial blood pressure and pulse rate, corresponding with levels of cathinone in the plasma. Moreover, regular khat chewers have gingivitis and loose teeth, but there appears to be no convincing unusual incidence of oral cancer. Among khat users in Yemen there is, however, a higher incidence of esophageal cancer compared with gastric cancer. Long term use or abuse can cause insomnia, anorexia, gastric disorders, depression, liver damage and cardiac complications, including myocardial infarction. Manic and delusional behavior, violence, suicidal depression, hallucinations, paranoia and khat-induced psychosis have also been reported. On the basis of the scientific data it seems clear that khat use has negative consequences on the economic development of a country and on the health of the society.