Characterizing Social Connectedness and Associated Mental Health Symptoms among Sexual Minority Men Enrolled in a Substance Use Recovery Support Program

Abstract

Background:

Sexual minority men (SMM; gay, bisexual, and other men who have sex with men) report higher rates of substance use compared to other populations. Social connectedness is a critical component for promoting and maintaining recovery from substance use disorders. However, the degree of social connectedness among SMM who report substance use is largely unknown.

Objectives:

We examined substance use, social connectedness (past 30-d participation in formal recovery support, past 30-d interaction with supportive family/friends, relationship satisfaction, and types of support) and mental health among SMM at the time of their enrollment in a behavioral substance use program from September 2019 to October 2021.

Results:

Of the107 SMM, 80% of the sample reported past 30-d illicit substance use, with methamphetamine representing the most commonly reported drug used (53%). Participants used a variety of social connections for support, including self-help groups (44% voluntary; 5% religious-affiliated; 20% other) and family/friends (81%). Importantly, 15% reported they had no one to turn to when having trouble and 36% were either dissatisfied or very dissatisfied with their relationships. Participants who endorsed significant depressive (58%) and anxiety (70%) symptoms were more likely to endorse relationship dissatisfaction than participants who did not endorse symptoms (p < 0.01).

Conclusions:

One-third of SMM enrolled in a substance use recovery program expressed relationship dissatisfaction, particularly those struggling with depression or anxiety. Future research and programming should examine ways of leveraging existing social connectedness or forging new social supports to enhance mental health and substance use recovery for SMM using substances.

Introduction

Sexual minority individuals report higher rates of substance use and more severe forms of substance use disorder compared to heterosexual individuals (Rosner et al., 2021). Additionally, sexual minorities with unmet mental health needs are more likely to use substances (Rosner et al., 2021), which places individuals at increased risk for overdose, suicide, and HIV transmission through unsafe sexual behaviors (Bourne & Weatherburn, 2017; Mullens et al., 2009). The minority stress model suggests that sexual minorities suffer hostile, chronic, and unique stressors which consequently impact coping methods, emotion regulation, and interpersonal connections (Bourne & Weatherburn, 2017; Hatzenbuehler, 2009; Meyer, 1995). Sexual minority men (SMM) (i.e., gay, bisexual, and other men who have sex with men) are particularly at-risk for negative mental and physical health consequences due to societal portrayals of masculinity as anti-gay; these portrayals create a gender role strain between men and their sexual minority identity (Fields et al., 2015).

Social connectedness, defined as the psychological bond an individual experiences with other individuals, groups, and communities (Hare Duke et al., 2019), has been examined as a protective factor against minority stressors (Ceatha et al., 2019; Garcia et al., 2020). Research has reflected a positive correlation between social connectedness, rates of substance use treatment completion, and recovery (Daly & Gargano, 2021; Pettersen et al., 2019). However, less is known about the types (e.g., family, friends, and peer support groups) and quality of social connectedness among SMM who use substances, or how other forms of marginalization (e.g., HIV status, sex work engagement, race/ethnicity, and mental illness) may impact the degree to which SMM feel satisfied within relationships. The goals of the current investigation were to examine types of social connectedness utilized by SMM seeking substance use recovery support and the level of satisfaction within these relationships. We hypothesized that there would be low levels of social connectedness among SMM reporting substance use and that living with HIV, sex work engagement, marginalized race-ethnicity, and emotional symptoms (e.g., depression and anxiety) would be associated with lower relationship satisfaction.

Methods

Participants and procedures

This investigation examined data collected from 129 clients at the time of their entry into an active substance use recovery program known as “Project BREAK.” Funded by the Substance Abuse and Mental Health Services Administration (SAMHSA), Project BREAK offers behavioral and supportive services for sexual minority and gender-diverse individuals who endorse substance use. Three sites in Rhode Island (i.e., a community-based primary care clinic, a community-based harm reduction organization, and a hospital-based ambulatory clinic) that provide care and supportive services for individuals from the LGBTQ + and sex work communities serve as referral sources for Project BREAK. Individuals who present to these organizations and who identify as SMM actively using substances (i.e., past three months) are offered referrals and connections to the program. Staff and providers of this program began enrolling and offering care in September 2019 and enrollment continues at present.

The present investigation evaluated baseline data collected from a sample of SMM who were enrolled into Project BREAK between September 2019 and October 2021. We use the term “sexual minority men” (SMM) as an umbrella term to capture men whose sexual identities, orientations, or behaviors differ from the heterosexual majority (including men who endorse a heterosexual orientation and engage in same-sex or same-gender sexual encounters)(Timmins & Duncan, 2020). Regardless of sexual orientation, men in our sample are more likely to internalize enacted and anticipated stigma associated with deviating from heterosexual norms. We chose the term SMM to focus on person-centered characteristics rather than behavior-centered characteristics. Ethical approval to review the retrospective program data was obtained from The Miriam Hospital Institutional Review Board (IRB #202021).

Measures

The baseline assessment included self-report measures from SAMHSA’s Core Client Outcome Measures in the Government Performance and Results Act (GPRA)(Harris, 2015) and a supplemental questionnaire.

Demographic data

Demographics included age, race, ethnicity, gender identity, sexual orientation, and highest level of education.

Sexual health

Participants were asked (yes/no) about HIV status and recent history of sex work (past three months).

Mental health

The Patient Health Questionnaire-2 (PHQ-2) is a two-item measure that captures low mood and anhedonia within the past 2 weeks (Kroenke et al., 2003). The Generalized Anxiety Disorder-2 (GAD-2) questionnaire is a two-item measure that captures the experience of anxiety and inability to control worry within the past 2 weeks (Kroenke et al., 2007). Scores for the PHQ-2 and GAD-2 range from 0 to 6 with a cutoff score of 3 suggesting the presence of a depressive (PHQ-2) or anxiety disorder (GAD-2).

Substance use

The Addiction Severity Index-Lite measures substance use in the previous 30 days, lifetime use, and method of use (McLellan et al., 1980).

Social connectedness

Social connectedness, as included in the GPRA tool (Harris, 2015), is a six-item measure in the following domains:

• Participation in formal recovery support. Participants indicated (yes/no) attendance in three types of recovery groups within the past 30 days: voluntary groups, religious groups, and “other” meetings to support recovery.

• Supportive family/friends. Participants reported (yes/no) interaction with family or friends who are supportive of their recovery within the past 30 days.

• Relationship satisfaction. On a Likert scale from 1 (very dissatisfied) to 5 (very satisfied), participants rated “How satisfied are you with your personal relationships?”

• Types of support. Participants were asked “To whom do you turn to when you are having trouble?” with response options: No One, Clergy Member, Family Member, Friends, or Other.

Data analysis

Descriptive statistics including frequencies and measures of central tendency and dispersion were calculated for demographic, sexual health, mental health, substance use, and social connectedness variables. Analyses of variance were used to examine associations between relationship satisfaction and living with HIV, sex work past 3 months, race-ethnicity (person of color vs. non-Hispanic/Latino white), positive depression score, and positive anxiety score. Analyses were performed using SPSS version 27.0 (IBM SPSS Statistics, Armonk, NY) (IBM, 2020).

Results

In total, we reviewed data of 129 individuals (N = 107 SMM, N = 14 transgender, N = 5 cisgender women, N = 3 other gender identity) who completed baseline assessments as part of Project BREAK. We analyzed data of N = 107 SMM for this study (Table 1). In the sample, 49% reported their sexual orientation as gay (28% heterosexual; 21% bisexual, queer, or other sexual minority identity), 65% identified as white (14% Black; 5% American Indian), and 23% as Hispanic/Latino. More than half (55%) of participants reported engaging in sex work within the past three months and 26% reported living with HIV. At program enrollment, 58% screened positive for depression while 70% screened positive for anxiety.

Table 1.

Demographic characteristics of the sample (N = 107).

Variable	N	%
Gender
Male	107	100
Sexual orientation
Gay	52	49
Heterosexual	30	28
Bi +	22	21
Bisexual	17	16
Pansexual	3	3
Queer	1	1
Asexual	0	0
Lesbian	0	0
Other	1	1
Refused	1	1
Race
White	70	65
Black	15	14
American Indian	5	5
Asian	0	0
Native Hawaiian	0	0
Alaska native	0	0
Other	0	0
Refused	2	2
Ethnicity
Hispanic/Latino	25	23
Non-Hispanic/Latino	80	75
Sex work past 3 months	59	55
Living with HIV	28	26
PHQ-2 positive screen	62	58
GAD-2 positive screen	75	70
	M	SD
Age	35.39	9.01 years
Education	12.79	1.93 years

More than 80% of the sample reported using at least one type of illicit drug within the past 30 days at baseline (Table 2). Participants most commonly reported using methamphetamine (53%), cannabis (47%), and cocaine (36%). Frequency of use ranged from 0 to 30 days for each drug category.

Table 2.

Frequencies of past 30-d substance use at baseline (N = 107).

Substance	Past 30-d use (N, %)	M (SD) days
Any illicit drug	89 (83%)	14.32 (11.76)
Cocaine/crack	38 (36%)	3.97 (8.35)
Methamphetamine	56 (52%)	5.13 (8.21)
Cannabis/hashish	50 (47%)	6.79 (10.91)
Opioid drugs	15 (14%)	1.51 (5.48)
Other drugs (fentanyl)	16 (15%)	1.92 (6.43)
Heroin	18 (17%)	2.43 (7.09)
Hallucinogens/psychedelics	8 (8%)	0.21 (1.03)
Benzodiazepines	9 (8%)	0.99 (5.0)
Barbiturates	2 (2%)	0.41 (3.19)
Non-prescription GHB	12 (11%)	0.28 (0.98)
Ketamine	3 (3%)	0.03 (0.17)
Tranquilizers	1 (1%)	0.07 (0.68)
Inhalants	23 (22%)	2.14 (5.69)

Participants utilized a variety of social connections for recovery (Table 3), including self-help groups (44% voluntary; 5% religious-affiliated; and 20% other) and family/friends (81%). Participants also reported turning to romantic partners, healthcare providers, 12 step fellowship sponsors, and community organizations when having trouble. Notably, 15% said they had no one to turn to when having trouble and 36% were either dissatisfied or very dissatisfied with their relationship satisfaction.

Table 3.

Descriptive statistics for social connectedness variables.

Variable	N (%)	M (SD) days
Past 30-d attendance at a voluntary self-help recovery group	47 (44%)	4.39 (8.06)
Past 30-d attendance at a religious self-help recovery group	5 (5%)	0.25 (1.57)
Past 30-d attendance at an other self-help recovery group	21 (20%)	2.10 (5.98)
Past 30-d interaction with family/friends supportive of recovery	87 (81%)	−
Relationship satisfaction		−
Very dissatisfied	9 (8%)
Dissatisfied	30 (28%)
Neither satisfied nor dissatisfied	22 (21%)
Satisfied	35 (33%)
Very satisfied	11 (10%)
To whom do you turn to when you are having trouble?
Type of support	N (%)
No one	16 (15%)
Clergy member	1 (1%)
Family member	36 (34%)
Friends	41 (38%)
Other	13 (12%)

As hypothesized, participants with depression reported significantly lower relationship satisfaction (M = 2.77, SD = 1.12) compared to those without depression (M = 3.56, SD = 1.11; F(1,101) = 12.16, p < 0.01). As hypothesized, participants with anxiety reported significantly lower relationship satisfaction (M = 2.84, SD = 1.15) compared to those without anxiety (M = 3.65, SD = 1.02; F(1,104) = 11.45, p < 0.01). However, living with HIV, sex work engagement, and race-ethnicity were not significantly associated with relationship satisfaction.

Discussion

This is among the first investigations to characterize social connectedness in a sample of SMM enrolled in a substance use recovery support program. At baseline, participants were engaged in a variety of social connectedness activities, including self-help recovery groups and interaction with supportive family/friends. However, 15% stated they had no one to turn to when in trouble, signifying the need to facilitate stronger connectedness in this population. It is also important to highlight that several participants reported turning to healthcare providers, community-based organizations, and peer sponsors for support. Healthcare services are and continue to be crucial to helping people feel connected during their recovery journey.

As expected, anxiety and depression were related to greater relationship dissatisfaction. This is consistent with minority stress theory and prior research documenting how experiences of discrimination, internalized homophobia, sexual orientation concealment, and expectations of rejection are linked to negative psychological outcomes among sexual minorities (Hatzenbuehler, 2009; Pachankis et al., 2021). It is possible that SMM with higher anxiety and depression may perceive relationships as less satisfying due to expectations of rejection—individuals are less likely to feel satisfied in relationships if they think others will reject them. It is also possible (and probable) that SMM have experienced discrimination within relationships, leading to increased anxiety and depression. Evidence shows that individuals are at risk for loneliness when the quality of social interactions is invalidating or discriminating (Brandt et al., 2022). In turn, social isolation due to discrimination can lead to mental health-related problems (Brandt et al., 2022). It is also noteworthy that SMM within this sample may be experiencing additive discrimination due to intersectional forms of stigma such as racism and classism, which might then manifest as reduced relationship satisfaction and increased mental health burden.

As SMM are known to experience elevated rates of loneliness and mental health problems (Gorczynski & Fasoli, 2021), it is essential that SMM feel connected and satisfied within their relationships. Indeed, some studies have reported increased substance use among SMM as a means to feel included among subcultures where drug use is normative, to decrease inhibition and increase intimacy, or to self-medicate to reduce negative affect in social situations (Bourne & Weatherburn, 2017; Carpiano et al., 2011; Hawkins et al., 2019; Power et al., 2018). Qualitative research among SMM living with HIV has shown that substance use may facilitate access to community, especially among individuals coping with intersecting stigmas (Stanton et al., 2022). Social disconnection alone is problematic and even more worrisome as a driver of substance use; it is essential that interventions target social connectedness to improve both mental and physical health outcomes among SMM.

Living with HIV, sex work engagement, and race-ethnicity were not associated with relationship satisfaction. Prior research has shown that the intersection of marginalized identities—not each identity itself—confers greater vulnerability to negative health consequences, which may explain why we did not see significant relationships between each unique identifier and relationship satisfaction (Homan et al., 2021). It may be that participants within our sample experienced emotional symptoms and relationship dissatisfaction concurrently due to systemic oppression resulting from intersecting identities. Given that these were participants newly enrolled in a substance use recovery program, it may also be that substance use was the most salient part of their presenting identity.

The findings of this investigation must be interpreted considering its limitations. Data were collected as part of a baseline program assessment, so we cannot draw any conclusions on the temporality or directionality of findings. Future research should focus on studying these relationships longitudinally to better understand how social connectedness is associated with mental health functioning and substance use over time. In addition, we chose to concentrate our analyses on SMM to maintain a focused approach to our research question regarding social connectedness, which can vary greatly across gender identities. As enrollment and sample sizes for Project BREAK continues, exploring these associations across sexual and gender identities will be a critical next step. Among SMM, research and programming should examine ways of leveraging existing social connectedness or forging new social supports to enhance mental health and substance use recovery for SMM using substances.