Culture, drugs and unsafe sex: confusion about causation

The future of drugs: recreational drug use and sexual health among gay and other men who have sex with men

There are complex historical connections between sexual minoritisation and desires to chemically alter bodily experience. For gay men, drug and alcohol use can be a creative or experimental response to social marginalisation - and not necessarily a problematic one in every instance. Numerous studies have found that infection with HIV and other sexually transmissible infections (STIs) is more likely among gay and men who have sex with men (MSM) who use recreational drugs than those who do not, but the causal nature of these relations is uncertain. Sexualised drug use is associated with a range of other problems, including dependence, mental health issues, accident and overdose. A growing body of work in the Alcohol and Other Drugs (AOD) field demonstrates the action of drugs and their purported effects to be a product of their relations with various other actors, contexts and practices. Given these contingencies, it is impossible to predict the future of drugs or their effect on the sexual health of gay and MSM with any degree of certainty. This article outlines some of the conditions most likely to mediate such futures in the medium term. Public funding for lesbian, gay, bisexual, transgender and queer drug issues should not remain restricted to questions of HIV prevention and sexual health. It should be expanded to equip sexual health and AOD service providers with the cultural and sexual literacy to mitigate stigma and allow them to respond constructively to drug problems among sexual and gender minorities as a matter of priority.

Gender and social rejection as risk factors for engaging in risky sexual behavior among crack/cocaine users

Crack/cocaine and engagement in risky sexual behavior represent important contributors to the escalation of the HIV infection among women. Several lines of research have emphasized the role of social factors in women's vulnerability for such practices and stressed the importance of understanding such factors to better inform prevention efforts and improve their effectiveness and efficiency. However, few studies have attempted to pinpoint specific social/contextual factors particularly relevant to high-risk populations such as female crack/cocaine users. Extensive previous research has related the experience of social rejection to a variety of negative outcomes including, but not limited to, various forms of psychopathology, self-defeating, and self-harm behavior. Motivated by this research, the current study explored the role of laboratory-induced social rejection in moderating the relationship between gender and risky sexual behavior among a sample of crack/cocaine users (n = 211) at high risk for HIV. The results showed that among women, but not among men, experiencing social rejection was significantly associated with a greater number of sexual partners. Further, experiencing social rejection was not related to the frequency of condom use. Implications for future research, prevention, and treatment are discussed.

Is it really crystal clear that using methamphetamine (or other recreational drugs) causes people to engage in unsafe sex?

Many studies have found associations between unsafe sexual behaviour and use of crystal methamphetamine (and many other recreational drugs). Researchers and authors of relevant articles in popular media have often interpreted these associations as meaning that using ‘crystal’ directly causes people to engage in unsafe sex, and that interventions should aim to reduce crystal use in order to reduce the prevalence of sexually transmissible infections such as HIV. There is consistent evidence that crystal users are a high-risk group in terms of sexual behaviour. However, most relevant studies have provided only circumstantial evidence regarding a causal relationship. Promoting the idea that a particular recreational drug is a major direct cause of unsafe sex may have the unintended adverse effect of creating an excuse for engaging in unsafe sex, thereby increasing its use, and may incur opportunity costs by preventing limited available health promotion resources from being directed more usefully. This paper examines the limitations, in terms of demonstrating causality, of various types of study that have been published on this topic in relation to crystal use in particular. Researchers who investigate relationships between recreational drug use and behaviour, including sexual behaviour, should be careful about the wording of their conclusions and recommendations, and should consider the possibly counterproductive ways in which their findings might be represented in the media.

Social context and perceived effects of drugs on sexual behavior among individuals who use both heroin and cocaine

Researchers have identified the association between the use of cocaine and sexual behavior as an important risk factor for HIV infection and have attempted to elucidate the nature of this association. Several lines of research have suggested that facilitation of sexual behavior during intoxication with cocaine may be because of the direct pharmacological effects of the drug (e.g., increase in sexual desire), whereas others have pointed to the importance of factors related to the context of drug use (e.g., opportunities for sexual behavior, expectations about the effects of the drug, social norms). The present study explored the perceived effects of cocaine and heroin on sexual behavior, as well as the social context of drug use as a function of drug type (cocaine vs. heroin), among 46 inner-city drug users who reported a history of regular use of both crack cocaine and heroin. Results indicated that compared to heroin, cocaine had deleterious effects on participants' perceived sexual desire and performance. Despite such deleterious effects on sexual behavior, cocaine was more frequently used with an intimate partner than heroin. Furthermore, participants did not differ in the extent to which they used the two drugs in other social contexts (e.g., with friends, family, or neighbors). These preliminary results suggest that the relationship between cocaine and sexual behavior, especially among long-term cocaine users, may be facilitated by opportunities for sex that exist in the context of cocaine use, rather than by the pharmacological effects of the drug.

Management of injecting drug users admitted to hospital

General hospital clinicians frequently deal with injecting drug users because substance use has diverse medical and psychiatric complications. Non-specialist clinicians often initiate management when specialist consultation is not available or accepted by the patient. Here, we summarise evidence for the management of hospitalised injecting drug users. The first challenge is to engage a drug user into medical care. A non-judgmental approach towards patients and acceptance of their lifestyle choices facilitates engagement. Pragmatic clinical goals can be negotiated and achieved. We also describe common conditions of injecting drug users. Accurate diagnosis and appropriate management focus on common issues such as intoxication, withdrawal, pain management, drug seeking, psychological comorbidity, behavioural difficulties, and pregnancy. Effective management can reduce the medical and social effect of these conditions and is not difficult.

Accounts of HIV seroconversion among substance-using gay and bisexual men

Statistical associations between substance use and seroconversion among gay and bisexual men abound. However, these associations often ignore men's own interpretations of their seroconversion. Using in-depth interviews with gay and bisexual men who reported using drugs or alcohol at the time of their seroconversion, we identify how these men explain the events that led to HIV transmission. Whereas a small minority of respondents reported substance use to explain their seroconversion, the majority reported three competing explanations. These participants claimed that they lacked sufficient knowledge about the behavioral risks that led to their seroconversion; that their decision to engage in unsafe sex was because of negative personal affect; and that they "trusted the wrong person." We link these findings to prevention and suggest that gay and bisexual men who use substances for recreational purposes will benefit from prevention efforts designed to address issues of gay and bisexual men rather than substance-using men.

The idiographic study of inconsistent condom use behavior of persons living with HIV

A pilot study was conducted to assess the feasibility of using, in a multiply disadvantaged population, an electronic daily diary to test hypotheses linking affective states to variability in psychosocial determinants of condom use. Twenty-one mostly non-Caucasian individuals reporting profound economic disadvantage, heavy alcohol use and HIV infection completed a 5-7 minute interactive voice response (IVR) telephone-based survey daily for three weeks. Potentially affect-related within-person variability was observed in HIV-preventive attitudes, intentions and self-efficacy. Surprisingly, in this sample, HIV-preventive attitudes, intentions and self-efficacy exhibited as much, or greater, variability within persons as compared to between persons. Positive affect was found to significantly co-vary with self-efficacy to practice safer sex B=0.20, t((199))=2.14, p=0.03. For each unit increase in daily positive affect, daily self-efficacy increased by 0.20. Results suggest that a daily diary methodology is both feasible in a high-risk population and may offer new insights into understanding unprotected sexual behavior.

A discursive approach to disinhibition theory: the normalization of unsafe sex among gay men

HIV research and prevention commonly cite disinhibition theory as an explanation for HIV infection among gay men. Analyzing qualitative interview data in which men talk about recreational substance use and their safer sex practices, we interrogate the concept of disinhibition theory from a discursive perspective. From this perspective, we treat talk not as a route or resource to something presumed to lie beyond the talk, but as a form of action designed for its interactional context. We demonstrate how the men normalize unsafe sex through constructions of disinhibition as common and widespread. In doing so, the men manage accountability for their own experiences with foregoing condom use while using substances. Our analysis demonstrates the men's displayed concerns to avoid individualized explanations for having engaged in unprotected sex. This may explain why some gay men may resist HIV prevention campaigns, based on these very individualized explanations.

In the shadows of a prevention campaign: sexual risk behavior in the absence of crystal methamphetamine

Because of its ability to reduce inhibitions and increase sexual drive, an emerging body of research has repeatedly identified crystal methamphetamine as a key variable in explaining new HIV transmissions among men who have sex with men (MSM). The implications of which have included the development of HIV prevention policies and public health campaigns centered on curbing methamphetamine use in urban gay centers throughout the United States. Data collected from a diverse sample of gay and bisexual men attending large-scale gay, lesbian, and bisexual community events in New York City (n=738) indicated that 10.2% of men used methamphetamine recently (i.e., <90 days) and that 29.9% of the sample had experienced a recent episode of unprotected anal intercourse. The majority, 81.1%, of those men reporting unsafe sex had not used methamphetamine recently. This analysis identified a bivariate relationship between methamphetamine use and sexual risk, but also highlights other variables that were significantly related to risky sexual behavior. Logistic regression analyses indicated that recent GHB use, temptation for unsafe sex, being younger in age, and identification as a barebacker were better indicators of risky sexual behavior than methamphetamine use. Policies focused on methamphetamine prevention may help to curb risky sexual behavior among select groups of individuals; however, these will not adequately address the sexual health of the many gay and bisexual men who, in the shadows of anti-methamphetamine policies and prevention programs, continue to engage in unsafe sex but are nonusers of methamphetamine.

Associations between crystal methamphetamine use and potentially unsafe sexual activity among gay men in Australia

It has been suggested that crystal methamphetamine may have disinhibiting or aphrodisiac effects, which may lead to unsafe sexual behavior and increase the risk of HIV transmission. Using data from two Australian studies, the Sydney Gay Community Periodic Survey study and the Positive Health (PH) cohort study, we examined changes over time in use of crystal, other recreational drugs, and Viagra, and in a range of sex-related behaviors. Compared to non-users, crystal users reported having more sex partners, looking for sex in more types of venues, and being more likely to engage in unprotected anal intercourse with casual partners (UAIC) and in esoteric sex. Crystal users were also more likely to be using other recreational drugs and Viagra than non-users. Crystal use remained significantly associated with UAIC after adjustment for other relevant variables in a log-binomial regression analysis (adjusted prevalence rate ratio=1.26; 95% CI: 1.19-1.34). The other variables (HIV status, number of sex partners, number of types of venue where men looked for sex, Viagra use, other drug use) were independently associated with UAIC, and did not show confounding or mediating effects on the crystal-UAIC association. Nevertheless, these data did not allow reliable attribution of higher levels of these sex-related behaviors among crystal users specifically to the effects of crystal. The prevalence of crystal use among Australian men who have sex with men (MSM) increased between 2002 and 2005 (e.g., from 26% to 39% among HIV-+ MSM). However, the prevalence of UAIC remained stable or decreased over time in various study subgroups, as did the prevalence of other sex-related behaviors, suggesting that crystal use does not necessarily drive unsafe sexual behavior. Crystal use and unsafe sexual behavior can, and should, be considered and addressed separately in health promotion and community education campaigns.

Explaining associations between adolescent substance use and condom use

PURPOSE

This study examined different explanations for associations between adolescent substance use and lower condom use, in terms of the event-specific effects of alcohol or drugs, psychosocial factors, and sexual behaviors (intercourse frequency, greater number of partners and pill use).

METHODS

Pupils from 25 schools in Scotland, UK provided data on use of alcohol, tobacco, cannabis and psychosocial factors at ages 14 and 16 years; and sexual behaviors at age 16 years. Logistic regression was used to examine associations between substance use and condom use in those reporting intercourse more than once (n = 1322), adjusting for explanatory variables.

RESULTS

Regular use of any of the three substances at age 14 or 16 was associated with lower condom use at age 16, adjusting for gender and social background. The greatest attenuation of the substance use odds ratios was achieved by adjusting for all behaviors and psychosocial factors. This finding applied to different substance use groups, although cigarette-only and alcohol-only groups at age 16 differed in the relative importance of being "drunk or stoned" to other factors explaining condom use.

CONCLUSIONS

Among adolescent substance users, being "drunk or stoned" at intercourse was only one factor related to not using condoms. Psychosocial factors (including attitudes to sexual risks and peer sexual norms) and having more sexual partners also explained substance users' condom use, with lesser effects due to greater intercourse frequency and pill use. Multiple explanations for substance use/condom use associations may guide counseling and education services.

Unprotected anal intercourse and substance use among men who have sex with men with recent HIV infection

OBJECTIVES

To examine within-subjects and combined between- and within-subjects associations between substance use and unprotected anal intercourse (UAI) among men who have sex with men (MSM) with recent HIV infection.

METHODS

One hundred ninety-four MSM who were recently infected with HIV completed a computer-assisted questionnaire regarding sexual behaviors and substance use with their last 3 partners. Associations between UAI and substance use were assessed using conditional logistic regression (CLR) to assess associations among the 116 MSM reporting UAI with some but not all partners and generalized linear mixed effects models (GLMMs) to examine a combination of within- and between-subjects associations in the entire sample (N = 194).

RESULTS

In multivariate CLR models and GLMMs, UAI was associated with the use of methamphetamine (odds ratio [OR] = 4.9 and OR = 3.5, respectively), marijuana (OR = 4.0 and OR = 2.2, respectively) and erectile dysfunction medications (EDMs) when used with a main partner (OR = 13.8 and OR = 10.1, respectively).

CONCLUSIONS

Results indicate that a direct association may exist between specific substances and UAI and provide evidence that the use of methamphetamine and EDMs may contribute to HIV transmission.

The varieties of ecstatic experience: an exploration of the subjective experiences of ecstasy

Previous investigations of the subjective effects of MDMA (material sold as ecstasy) have conducted interviews and surveys of various groups of ecstasy users within particular sub-populations. This study examined subjective drug effects reported by different sub-populations of ecstasy users and explored whether the function or purpose served by using ecstasy influenced the nature of the drug experience. Drawing on previous measures of alterations in consciousness, psychedelic drugs and cannabis, and informal interviews with ecstasy users and MDMA researchers, a 130-item survey assessing subjective effects of ecstasy/MDMA was developed. Principal components analysis of responses of ecstasy users revealed six components; perceptual alterations, entactogenic effects, prosocial effects, aesthetic effects, negative effects and sexual effects. The derived scale was used to predict ecstasy use behaviours, and functions and experiences of use. A variety of component scores were related to ecstasy use parameters; in particular, heavier users expected fewer negative, perceptual and aesthetic effects from taking the drug. The reasons given for using ecstasy (use function) also influenced reported drug effects. Abstainers expected greater negative, perceptual, aesthetic and sexual effects than users. These data indicate that the subjective ecstasy experience is influenced by a variety of extra-psychopharmacological factors. Drug intervention strategies may be made more effective by targeting particular user groups defined by reasons given for substance use, as it is likely that their experiences of ecstasy effects will differ. Future research into ecstasy may be improved by recognizing user diversity.

Club drugs as causal risk factors for HIV acquisition among men who have sex with men: a review

We reviewed medical and psychology databases for articles published between January 1980 and August 2005 demonstrating associations between HIV/Sexually Transmitted Infection risk and club drug use. Seventy-four articles were reviewed, of which 30 provided adjusted risk ratios for associations between HIV/sexually transmitted infection risk and club drug use among men who have sex with men. Definitions and lists of club drugs were broad and inconsistent. We constructed a conceptual framework of biologically plausible pathways for causation. Using Hill's criteria to examine club drugs as causal risk factors for HIV, we found the most evidence for methamphetamine and volatile nitrites; however, more studies are needed.

Accounting for unprotected sex: stories of agency and acceptability

Based on the idea that risks are knowable, calculable and preventable, dominant social scientific and health promotion discourses foster an image of individual risk control and responsibility. The presentation of the self is a moral enterprise. Accounts of unprotected sex by HIV positive people who have the potential to transmit HIV to their sexual partners can be particularly morally charged. Drawing on 73 depth qualitative interviews with HIV positive people and their sexual partners, this paper explores how the interview accounts of unprotected sex can illuminate the way in which the self is presented within the context of situated norms of risk acceptability and moral responsibility. We identify two forms of account: stories of agency; and stories of acceptability. Stories of agency tend to deny agency and abdicate individual responsibility given the circumstances, and were also a key feature of accounts in which the sexual partners of HIV positive people were placed at risk of HIV transmission. Categories of appeal included the denial of agency as a consequence of: risk calculus and condom accidents; alcohol and drug effects; powerlessness and coercion; and forces of nature. By contrast, stories of acceptability tend to justify unprotected sex as acceptable. Categories of appeal included: HIV positive concordance; and commitment in relationships. Other forms of justification included: alter responsibility; and intentional HIV transmission. We conclude that accounts of risk management are risk managed. We call for greater attention by social scientists to the way in which accounts are constructed, and in particular, to 'anti-rational' forms of explanation within accounts.

Substance use and unsafe sex amongst homosexual men in Edinburgh

A self-reported behaviour survey using an anonymous critical incident based questionnaire was administered by trained interviewers in 1998. Five hundred and thirty-one homosexual and bisexual men were recruited from gay bars, clubs, cafes, a sauna and 'cruising ground' in central Edinburgh. The use of alcohol and recreational drugs and details of sexual activity over the preceding three months and at the last sexual encounter were recorded. Unsafe sex was defined as anal sex without the use of a condom with a partner of unknown or different HIV status. Safer sex was defined as all other types of sex, including anal sex with a condom and anal sex without a condom with a partner whose HIV status was known to be the same. Of the questionnaires completed, 506 were suitable for analysis; 29 men (6.1%) reported anal sex with a partner of unknown or different HIV status without a condom ('unsafe sex') during their last sexual encounter. A total of 53 men (10.5%) could recall an episode of unsafe sex within the last three months. Men who had used marijuana or inhaled nitrites ('poppers') less than two hours before sex, or whose sexual partners had done so, were more likely to have unsafe sex than those who had not. Although alcohol use was more likely before sex with casual partners, the use of alcohol less than 2 hours before sex was not associated with sex being unsafe.

Consistent condom use in the heterosexual relationships of young adults who live in a high-HIV-risk neighbourhood and do not use "hard drugs"

This study was set up to determine the predictors of condom use in the heterosexual non-commercial sexual relationships of young adults who neither inject drugs nor use cocaine, heroin or crack, in a neighbourhood with widespread drug-use-connected HIV. The analytic sample is 279 young adults, aged 18-24, who have never injected drugs and who have not used heroin, cocaine or crack in the last year. They were recruited in the Bushwick neighbourhood of New York City, July 1997 to September 1999. A face-to-face interview included items about their sociodemographic background, substance use and sexual networks. Sexual relationship and self-reported consistent (100%) condom use over the prior year with the partner in a given relationship was examined. Subjects had 337 heterosexual non-commercial relationships. Consistent condom use was reported in 32% of these relationships. In multiple logistic regression, consistent condom use was more likely in relationships that are not 'very close' (odds ratio = 3.92; 95% confidence interval = 2.08, 7.52); in the relationships of subjects whose peer norms support condom use (OR = 1.94; 95% CI = 1.43, 2.69), who are not problem drinkers (OR = 8.70; 95% CI = 2.22, 58.8), and (perhaps as a result of measurement issues) who are men (OR = 1.95; 95% CI = 1.04, 3.68). In conclusion, consistent condom use remains uncommon among youth in this high-risk neighbourhood. It is thus important to keep HIV from entering the sexual networks of youth in communities like this through programmes aimed at drug injectors and their sexual partners. Programmes to increase condom use among young adults should focus on strengthening norms that promote safer sex to protect oneself and others. In addition, assistance should be provided to youth who are problem drinkers.

Patterns of initiation of sex and drug-related activities among urban low-income African-American adolescents

PURPOSE

To examine the pattern of adolescent's involvement in drug-related behaviors and sexual initiation, and its relationship with: (a) age and gender, (b) sensation- seeking, (c) perceptions of peer and family risk involvement, and (d) involvement in high-risk sexual behavior.

SUBJECTS

Two hundred and sixty-one urban African-American youth, aged 9 to 15 years at baseline, who were sexually experienced by the end of the 4-year study interval. The longitudinal assessment (4 years) was focused on: (a) alcohol use, illicit drug use, and drug trafficking; (b) high-risk sex; (c) propensity to sensation seeking; and (d) perceived peer and family risk involvement.

RESULTS

Involvement increased over the 4-year study interval such that over half of the adolescents reported use of alcohol and/or use of marijuana in the final assessment period. For each of the three drug-related activities examined, the largest proportion of youth who engaged in sexual intercourse never engaged in drug-related activity, and the next largest proportion initiated sexual involvement before drug use. Sensation-seeking scores, which were relatively stable across time, were lower among girls, and also were lower among youth who remained uninvolved in drug-related behaviors. For all three drug-related behaviors, rates of high-risk sex were higher among youth who initiated both sex and drugs, and were lower among youth who reported engaging only in sex. Although youth who did eventually initiate drug use had higher perceived levels of family and peer drug use compared to those who remained uninvolved, these perceptions did not contribute directly to high-risk sexual behavior.

CONCLUSIONS

Youth who will become both sexually active and involved with drugs during adolescence are especially vulnerable to involvement in high-risk sexual behavior.

Alcohol use and sexual behavior among "Black" adolescents

This paper reports on findings collected from 1993-1995 from an ethnographic interview study that investigated whether a pattern of HIV-related risk behavior varies across subpopulations of minority adolescents by studying behaviors and perceptions of risk for HIV infection among two ethnic groups of 314 Black adolescents-African-American and Haitian Blacks. Of those who had sex within the past 6 months and were current drinkers, 69% said they did not have sex after drinking. Although many of the adolescents believe that drinking has a disinhibitory effect and may be a factor in nonuse of condoms, alcohol is but one element in a constellation of factors related to sexual intercourse and condom use.