Transgender-related discrimination and substance use, substance use disorder diagnosis and treatment history among transgender adults

BACKGROUND

Substantial research gaps exist regarding the relationship between transgender-related discrimination and substance use outcomes for transgender adults, with few studies accounting for other experiences of victimization.

METHODS

Transgender adults (N = 600) from Massachusetts and Rhode Island completed a survey online or in-person. Multivariable linear and logistic regression models examined the association between lifetime experiences of transgender-related discrimination using the validated 11-item Everyday Discrimination Scale (theoretical range = 0-44) and substance use outcomes: past 12-month substance use frequency, lifetime substance use disorder (SUD) diagnosis, and substance use treatment (SUTx) history. All models were adjusted for age, gender identity, race, survey modality, childhood physical/sexual abuse, intimate partner violence, and discrimination attributable to other reasons than being transgender.

RESULTS

The mean transgender-related discrimination score was 20.8 (SD = 9.6, range = 0-44). Overall, 11.8 % of the sample had a SUD diagnosis and 11.0 % had received SUTx. In separate multivariable models adjusted for sociodemographic and victimization experiences, the highest quartile of transgender-related discrimination was significantly associated with higher past 12-month substance use (B = 1.44; aR² = 0.13; p = .009), SUD diagnosis (aOR = 3.64; 95 % CI = 1.46-9.07; p = .006), and lifetime treatment history (aOR = 3.93; 95 % CI = 1.50-10.21; p = .005).

CONCLUSIONS

There was a significant positive association between experiencing high levels of transgender-related discrimination and substance use outcomes among the transgender adults sampled. Longitudinal research is needed to understand the specific mediators driving these relationships and to address the implications of transgender-related discrimination on SUD treatment utilization.

Differential Patterns of Risk and Vulnerability Suggest the Need for Novel Prevention Strategies for Black Bisexual Men in the HPTN 061 Study

BACKGROUND

Black men who have sex with men (BMSM) and some who also have sex with women (BMSMW) account for over 70% of new HIV infections in the United States representing an elevated HIV risk in this group, also informing risks of HIV transmission to other BMSM and female sexual partners.

SETTINGS

We examined trajectories of self-reported substance use, HIV-related sexual risk behaviors, and psychosocial vulnerabilities among BMSMW versus BMSM over a 1-year study period.

METHODS

We analyzed baseline, 6-, and 12-month follow-up data from the HIV Prevention Trials Network "BROTHERS" Study (HPTN 061; n = 1126). Categorizing participants by sexual partner type across 3 time points: (1) BMSMO: having male and no female partners across assessments and (2) BMSMW: having sex with male and one or more female partners at least at 1 time point. Using generalized estimating equations, we estimated associations between being BMSMW (versus BMSMO) and changes in psychosocial vulnerability, substance use, and HIV-related sexual risk behaviors.

RESULTS

Generalized estimating equation models controlling for sociodemographics, time-varying effects, and intervention status showed that BMSMW versus BMSMO had 50% increased odds of crack use, 71% increased odds of alcohol use during condomless anal intercourse (CAI), 51% greater odds of using drugs at last CAI, and twice the odds of receiving goods at last CAI.

CONCLUSIONS

Findings show stable and comparatively elevated illicit drugs, alcohol, and exchange sex during last CAI among BMSMW. Future intervention research should focus on ways to address changes in substance-related HIV-transmission behaviors over time in this population of men.

The Role of Gay-Related Stigma in HIV-Risk Behavior Among Sexual Minority Men in Europe

Sexual orientation stigma stems from discriminatory social contexts and may ultimately impact the behavioral health of stigmatized individuals through stress-related pathways. Sexual minority stigma is of particular concern in Europe given the diversity of social contexts on the continent and sexual minority men's rapidly increasing risk of HIV infection, especially in Central and Eastern Europe, potentially rooted in stigma. This study assesses whether stigma in the ubiquitous social contexts surrounding sexual minority men (e.g., family, workplace, government) may place them at higher risk for HIV contraction across six countries. We utilized a large cross-sectional survey sample of HIV-negative sexual minority men (N = 2087; mean age = 31.6, SD = 9.7) from six European countries to test whether those who reported sexual orientation stigma also engaged in more HIV risk-related behaviors, including condomless sex with casual partners (in the absence of PrEP) and substance use before and during sex. Regression analyses were performed in Mplus. We found that a one standard deviation increase in reported sexual orientation stigma was significantly associated with the following during the last sexual encounter: a 19% increase in odds of sex under the influence of alcohol, 27% increase in odds of sex under the influence of cannabis, 49% increase in odds of sex under the influence of illicit drugs, an 11% increase in odds of condomless sex with casual partners in the past 6 months, and a 26% increase in odds of knowing where to receive an HIV test. Sexual minority men who reported perceiving greater sexual orientation-related stigma within their ubiquitous social contexts were significantly more likely to report sexual risk and alcohol and drug use during their last sexual encounter, yet reported more knowledge of preventive services. Contextual stigma might serve as a precursor to behavioral risks of HIV infection, generating maladaptive stress responses capable of being modified through individually-focused interventions. Structural interventions are also needed to ultimately reduce stigma at its source.

Intersecting burdens: Homophobic victimization, unstable housing, and methamphetamine use in a cohort of men of color who have sex with men

BACKGROUND

Men who have sex with men with histories of homophobic victimization bear heightened risk of unstable housing and methamphetamine use. However, it is unclear whether unstable housing explains the link between homophobic victimization and methamphetamine use in this group. The present study aims to test associations between homophobic victimization, unstable housing, and recent methamphetamine use across 24 months in a cohort of men of color who have sex with men (MoCSM).

METHODS

Our analysis stems from data of 1342 person-visits from 401 MoCSM participating in an ongoing cohort study. We performed a lagged multilevel negative binominal regression to test the association between past homophobic victimization and recent unstable housing, and a lagged multilevel ordered logistic regression to test the association between past homophobic victimization recent methamphetamine use. We then performed a path analysis to test whether recent unstable housing mediates the association between past homophobic victimization and recent methamphetamine use.

RESULTS

Findings showed homophobic victimization associated significantly with increased odds of unstable housing (IRR = 1.70, 95% CI [1.35, 2.14], p < 0.001) and recent methamphetamine use (OR = 1.40, 95% CI [1.15, 1.71], p = 0.001). Mediation analysis indicated that past homophobic victimization was indirectly associated with recent methamphetamine use via unstable housing (OR = 1.06 (95% CI [1.01, 1.11], p = 0.010).

CONCLUSION

Our findings suggest that homophobic victimization and unstable housing should be addressed alongside treatment and prevention of methamphetamine use in MoCSM.

Examining the Sexual Health Consequences of Alcohol Consumption Among Black Gay and Bisexual Men

BACKGROUND

Black men who have sex with men (MSM) are disproportionately affected by HIV infection. Efforts are needed to understand correlates of HIV risk among this group. Alcohol consumption may have a role in HIV transmission given its association with condomless sex. This study aimed to examine the association between alcohol consumption (i.e., drinking before/during sex and levels of alcohol use problems) and condom use during lifetime, past 6 months, and the event (i.e., a specific sexual episode) level.

METHODS

Black MSM (N = 102) reported sexual behavior and condom use for lifetime, past 6 months, and the most recent condom and condomless sex events. The Alcohol Use Disorders Identification Test (AUDIT) determined alcohol use problems.

RESULTS

Ordinal and binary regression analyses analyzed associations between AUDIT scores and condomless sex (receptive and insertive). AUDIT scores were associated with a greater likelihood of condomless sex (lifetime receptive sex: OR = 1.06, p < 0.05; past 6 months insertive sex: odds ratio [OR] = 1.09, p < 0.01). At the event level, there was no greater likelihood of drinking during last condomless sex as compared to last condom sex, χ2 (1) = 0.18, p = 0.39.

CONCLUSIONS

There was evidence that an increase in alcohol use problems was associated with a greater likelihood of risky sexual behavior. Drinking before/during sex was not related to condom use. These findings contribute to understanding the nuanced relationship between alcohol use and sexual risk.

Perceived Risk of HIV Infection Among Drug-Using African American Male Prisoners: One Year After Community Re-entry

BACKGROUND

African Americans represent 13% of the U.S. population but 46% of people living with HIV and nearly 40% of state and federal prisoners. Disproportionate rates of HIV among African American males involved in the criminal justice system have been associated with risk factors, including: contracting sexually transmitted infections (STIs), substance misuse, and inconsistent condom use. However, many African American males may not perceive an elevated risk of HIV upon re-entering the community.

OBJECTIVE

The current study examines correlates of perceived HIV risk among incarcerated African American drug-using males about one year after release from prison.

METHODS

Derived from a larger Health Services Utilization study, interviewing (N = 661) incarcerated men at baseline with a 92% follow-up rate approximately one year after community re-entry, the current study is a secondary data analyses from self-identified African American men (N = 250). After list-wise deletion, the total N = 221 for the final study results.

RESULTS

An ordered logistic regression model examining perceived risk of HIV as the dependent variable found age, cocaine use before sex, and condom use were significant correlates in the model. Alcohol use before sex mediated the relationship between cocaine use before sex and perceived HIV risk.

CONCLUSIONS

Results suggest men in this study are engaged in HIV risk behaviors and risk perception varies. Implications for individual-level, community-level and policy interventions are discussed.

Portuguese American gay men in southeastern Massachusetts: cultural scripts and risk for HIV

In this study, we examined the lived experiences of an understudied subgroup, Portuguese American gay men, within the context of sexual script theory. We employed a phenomenological study design with eight men to provide a more in-depth analysis of their sociocultural sexual behaviours. Recruitment was conducted through word of mouth and a snowball approach beginning with two well-known HIV education and prevention outreach centres in southeastern Massachusetts. In this study, the sexual scripts of the participants were conceptualised within the three domains of cultural, interpersonal and intrapsychic scripts. Our findings suggest the three scripts are constantly interacting and informing one another. This ongoing negotiation influences the way our participants position their sexuality within the broader context of their everyday life within the US Portuguese community. Participants script their sexuality while they navigate multiple but separate entities within their culture, their religion and their families. Learning from these experiences could have important implications for the development of HIV prevention programmes for specific subgroups of men who have sex with men.

Correlates of Seroadaptation Strategies Among Black Men Who have Sex with Men (MSM) in 4 US Cities

We assessed associations of demographic, psychosocial, and substance use factors with seroadaptation strategies among 835 BMSM in four US cities. Seroadaptation strategies were practiced by 59.8 % of men, with 10.5 % practicing 100 % condom use, 26.5 % serosorting, 7.2 % condom serosorting, and 15.6 % seropositioning. In multivariable analyses, compared to men who used no seroadaptation strategies, serosorters were older, were less likely to be HIV infected, had fewer male sex partners, and had higher levels of social support and sexual self-efficacy. Condom serosorters had less psychological distress, were more likely to use methamphetamine, and had higher levels of sexual self-efficacy. Seropositioners were older, were less likely to be HIV infected, to have a main partner, and report alcohol/drug use with sex, while having higher levels of sexual self-efficacy. Seroadaptation practices among BMSM need to be considered to address perceived safer sex strategies and strengthen access to a broader reach of culturally-relevant prevention efforts.

The Association Between Alcohol Consumption and Condom Use: Considering Correlates of HIV Risk Among Black Men Who Have Sex with Men

Epidemiological data indicate Black men who have sex with men (MSM) are the most at-risk group for HIV infection. However, the factors driving this disparity are not fully understood. Condom use remains a significant point of intervention in mitigating sexually transmitted infections. Alcohol consumption is highly prevalent among Black MSM, has a significant role in the culture of sex, and may significantly interfere with condom use. This review will examine the relationship between alcohol consumption and condom use among Black MSM. In this review we, (a) discuss the prevalence of alcohol use among MSM and its association with condom use; (b) consider the role of alcohol in the culture of MSM; (c) review the literature on the relationship between alcohol and condom use; and (d) discuss the role of several empirically-supported moderating variables in strengthening the relationship between alcohol use and noncondom use. This review places the finding and implications for HIV risk among Black MSM in the context of the broader literature on MSM.

Feasibility, Acceptability, and Preliminary Efficacy of a Live-Chat Social Media Intervention to Reduce HIV Risk Among Young Men Who Have Sex With Men

Given the popularity of social media among young men who have sex with men (YMSM), and in light of YMSM's elevated and increasing HIV rates, we tested the feasibility, acceptability and preliminary efficacy of a live chat intervention delivered on Facebook in reducing condomless anal sex and substance use within a group of high risk YMSM in a pre-post design with no control group. Participants (N = 41; 18-29 years old) completed up to eight one-hour motivational interviewing and cognitive behavioral skills-based online live chat intervention sessions, and reported on demographic, psychosocial, and behavioral characteristics at baseline and immediately post-intervention. Analyses indicated that participation in the intervention (n = 31) was associated with reductions of days of drug and alcohol use in the past month and instances of anal sex without a condom (including under the influence of substances), as well as increases in knowledge of HIV-related risks at 3-month follow-up. This pilot study argues for the potential of this social media-delivered intervention to reduce HIV risk among a most vulnerable group in the United States, in a manner that was highly acceptable to receive and feasible to execute. A future randomized controlled trial could generate an intervention blueprint for providers to support YMSM's wellbeing by reaching them regardless of their geographical location, at a low cost.

The association between alcohol use and engagement in casual sexual relationships and experiences: a meta-analytic review of non-experimental studies

The present study provides a meta-analytic review of the association between alcohol use and engagement in casual sexual relationships and experiences (CSREs). Specifically, the meta-analysis focused on non-experimental studies of community and college samples. Results from the meta-analysis, which included 29 relevant studies (34 effect sizes), indicated that alcohol use was significantly associated with engaging in CSREs, r = .34, 95 % CI [.29-.38], but that this link showed considerable variability. Subsequent analyses examined moderators that may explain this heterogeneity. Results revealed that age and method of assessment significantly moderated the effect of alcohol use on CSRE engagement such that the association was greater for emerging adults (18-24 year olds) than older adults and online assessments produced greater effect sizes than paper-and-pencil assessments. These results have implications for future research and intervention development. In particular, this meta-analysis emphasizes the need for studies that utilize consistent measurements of CSRE engagement, include diverse methodology, and expand upon sampling.

Differences in substance use, psychosocial characteristics and HIV-related sexual risk behavior between Black men who have sex with men only (BMSMO) and Black men who have sex with men and women (BMSMW) in six US cities

We assessed associations in substance use, psychosocial characteristics, and HIV-related sexual risk behaviors, comparing characteristics of Black men who only have sex with other men only (BMSMO; n = 839) to Black men who have sex with men and women (BMSMW; n = 590). The study analyzed baseline data from the HIV Prevention Trials Network Brothers Study (HPTN 061), a feasibility study of a multi-component intervention for Black MSM in six US cities. Bivariate analyses compared BMSMO to BMSMW along demographics, substance use, psychosocial characteristics, and HIV-related sexual risk behaviors. Logistic regression models then assessed multivariable associations between being BMSMW and the odds of engaging in HIV-related sexual risk behaviors. Adjusted analyses revealed that BMSMW remained more likely to have unprotected anal intercourse while under the influence of alcohol (AOR: 1.45; 95 % CI:1.11-1.90) and were more likely to receive money/drugs for sex (AOR: 2.11; 95 % CI:1.48-3.03), compared to BMSMO. Substance use is an important factor to be considered when developing risk-reduction interventions for BMSMW. Structural interventions that address factors that may contribute to exchange sex among these men are also warranted.

Problematic alcohol use and HIV risk among Black men who have sex with men in Massachusetts

This analysis was designed to explore the frequency of problem drinking and its role in potentiating HIV risk among a community-recruited sample of Black men who have sex with men (MSM) in Massachusetts. Black MSM (n=197) recruited via modified respondent-driven sampling between January and July 2008 completed an interviewer-administered survey, including HIV sexual behavior, the Center for Epidemiologic Studies Depression Scale (CES-D), and the CAGE alcohol screener. Bivariate and multivariable logistic regression procedures examined the association of behavioral HIV-risk factors and other psychosocial variables with problematic alcohol use (CAGE score 3 or 4). Overall, 29% of the sample was found to abuse alcohol. In a multivariable model adjusting for demographic and behavioral variables, factors associated with increased odds of problem drinking were: (1) depressive symptoms (CES-D 16); (2) one or more episodes of serodiscordant unprotected anal sex during last sexual encounter with a casual male partner; and (3) one or more episodes of unprotected anal or vaginal sex with a female partner in the past 12 months. Black MSM who engaged in HIV risk behaviors may be more likely to have concurrent problematic alcohol use. HIV prevention interventions with Black MSM may benefit from incorporating screening and/or treatment for alcohol problems, as well as screening for co-morbid depressive symptoms.

Health system and personal barriers resulting in decreased utilization of HIV and STD testing services among at-risk black men who have sex with men in Massachusetts

Testing for HIV and other sexually transmitted diseases (STD) remains a cornerstone of public health prevention interventions. This analysis was designed to explore the frequency of testing, as well as health system and personal barriers to testing, among a community-recruited sample of Black men who have sex with men (MSM) at risk for HIV and STDs. Black MSM (n = 197) recruited via modified respondent-driven sampling between January and July 2008 completed an interviewer-administered assessment, with optional voluntary HIV counseling and testing. Logistic regression procedures examined factors associated with not having tested in the 2 years prior to study enrollment for: (1) HIV (among HIV-uninfected participants, n = 145) and (2) STDs (among the entire mixed serostatus sample, n = 197). The odds ratios and their 95% confidence intervals obtained from this analysis were converted to relative risks. (1) HIV: Overall, 33% of HIV-uninfected Black MSM had not been tested for HIV in the 2 years prior to study enrollment. Factors uniquely associated with not having a recent HIV test included: being less educated; engaging in serodiscordant unprotected sex; and never having been HIV tested at a community health clinic, STD clinic, or jail. (2) STDs: Sixty percent had not been tested for STDs in the 2 years prior to study enrollment, and 24% of the sample had never been tested for STDs. Factors uniquely associated with not having a recent STD test included: older age; having had a prior STD; and never having been tested at an emergency department or urgent care clinic. Overlapping factors associated with both not having had a recent HIV or STD test included: substance use during sex; feeling that using a condom during sex is "very difficult"; less frequent contact with other MSM; not visiting a health care provider (HCP) in the past 12 months; having a HCP not recommend HIV or STD testing at their last visit; not having a primary care provider (PCP); current PCP never recommending they get tested for HIV or STDs. In multivariable models adjusting for relevant demographic and behavioral factors, Black MSM who reported that a HCP recommended getting an HIV test (adjusted relative risk [ARR] = 0.26; p = 0.01) or STD test (ARR = 0.11; p = 0.0004) at their last visit in the past 12 months were significantly less likely to have not been tested for HIV or STDs in the past 2 years. Many sexually active Black MSM do not regularly test for HIV or STDs. HCPs play a pivotal role in encouraging testing for Black MSM. Additional provider training is warranted to educate HCPs about the specific health care needs of Black MSM, in order to facilitate access to timely, culturally competent HIV and STD testing and treatment services for this population.

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.

Sexual orientation, drug use preference during sex, and HIV risk practices and preferences among men who specifically seek unprotected sex partners via the internet

The present study entailed conducting a content analysis of 1,434 ads/profiles posted on one of the most popular “Men who have Sex with Men” (MSM) websites that specifically fosters unprotected sex. Ads/profiles were selected randomly based on the American ZIP code of residence (n = 1,316), with a randomly-drawn oversampling of profiles of men who self-identified as heterosexual or “curious” rather than gay or bisexual (n = 118). Data were collected between September 2006 and September 2007. The purpose of the present paper is to examine the conjoint effects of self-identified sexual orientation and preference for having/not having sex while high, on men’s sought-after sexual risk. Analytical comparisons of the four groups showed that, on most measures, the combination of sexual orientation and drug use preference during sex differentiated the men. Generally speaking, gay/bisexual men who advertised online for partners with whom they could have sex while high expressed the greatest interest in risky sexual behaviors (e.g., felching, unprotected oral sex, unprotected anal sex) and various risk-related preferences (e.g., multiple partner sex, anonymous sex, eroticizing ejaculatory fluids). This is especially true when they are compared to their heterosexual/“curious” counterparts whose online profiles were not as likely to indicate a desire for having sex while high.

Methamphetamine use patterns among urban Black men who have sex with men

The present study investigates patterns of methamphetamine, contexts of use and sources for purchasing methamphetamine in a sample of gay, bisexual and heterosexually identified Black men who have sex with men living in New York City. Participants reported using multiple substances and used, on average, nine days within the last 30 days. They spent an average of US$159 per month on methamphetamine and a median of US$398 on all substances. Frequency of monthly methamphetamine use was related to the use of powdered cocaine and alcohol use, but not to the use of other substances. Black men who have sex with men primarily used in private venues, such as at home or in the homes of friends, and reported obtaining methamphetamine from multiple sources. Men who reported exchanging sex for methamphetamine reported greater use in public venues, such as sex clubs, sex parties and circuit parties. Findings from the present study may be critical in establishing culturally-appropriate treatment modalities for Black men who have sex with men who use methamphetamine.

Stigmatization, Stress, and the Search for Belonging in Black Men Who Have Sex With Men Who Use Methamphetamine

Black men who have sex with men (BMSM) continue to be disproportionately affected by HIV. Methamphetamine use has been identified as a source of HIV risk in gay and bisexually identified men, yet the relationship between methamphetamine use and sexual risk among BMSM specifically remains unclear. The goal of this qualitative study was to investigate psychological, contextual, and developmental factors informing methamphetamine use and HIV risk behavior among a sample of heterosexual, gay, and bisexual BMSM (N = 52) in New York City. Methamphetamine use and sexual risk were associated with stress induced by stigmatization arising from and within larger dominant White gay culture, stigmatization incurred within the community, internalized homophobia, and stress induced by living under the shadow of the perceived inevitability of contracting HIV as BMSM. Methamphetamine use was associated with venues where participants could be sheltered from experiences of racism, homophobia, and dominant hegemonic images of Black masculinity, while exploring and developing same-sex desires, thereby instilling a sense of community belonging. Suggestions for culturally appropriate strategies for treating both methamphetamine use and HIV risk behaviors among BMSM are discussed.