Club Drug Use, Sexual Behavior, and HIV Seroconversion: A Qualitative Study of Motivations

Abstract

This qualitative study funded by the National Institute on Drug Abuse examines phenomenological meanings surrounding motivations for club drug use in a sample of HIV seroconverted and seronegative gay and bisexual men. Grounded in the cognitive escape model (CEM), this study sought to clarify the synergistic relationship between club drug use, risky sexual behavior, and seroconversion. Sixteen seropositive participants were drawn from a large-scale (n = 450), longitudinal, mixed-method investigation of club drug use among gay and bisexual men in New York City from 2001–2004 and matched with 16 seronegative participants for race/ethnicity, most-frequently used substance, and educational level. Total sample size consisted of 32 participants. Sample size consisted of 13 (41%) Black/African-American, 12 (37.5%) White/Caucasian, 5 (15.5%) Hispanic/Latino, and 2 (6%) mixed/other race/ethnicity participants. Findings suggest behavioral outcomes of club drug use and HIV seroconversion result from complex interactions between physical, emotional, and social motivations.

“Love don’t say no.”

“If you are going to carry E pills with you all night, you might as well carry some condoms.”

Introduction

Epidemiological research on the incidence of HIV-seroconversion indicates that not only do men who have sex with men (MSM) continue to be disproportionately affected by HIV but also HIV transmission through sexual contact remains the primary means for contracting HIV among this group (CDC, 2003; CDC, 2004). In addition, research indicates that not only are gay and bisexual men continuing to use club drugs—specifically, methamphetamine, methylenedioxymethamphetamine (MDMA), ketamine, gamma hydroxy butyrate (GHB), and powdered cocaine—but also gay and bisexual men are still placing themselves at risk for contracting HIV through unsafe sexual behaviors, thus further fueling what researchers have termed the “syndemic” relationship between substance abuse and HIV seroconversion in the gay community (Singer, 1996; Stall et al., 2003). Because of this relationship, club drug use remains an important health concern in the gay community and thus a critical research focus (Colfax et al., 2004; Klitzman, 2006; Mansergh et al., 2006; Stall and Purcell, 2000).

While not all club drug use leads to risky sexual behavior, methamphetamine use in particular has been associated with HIV risk behaviors (Halkitis, Green, and Mourgues, 2005; Semple, Patterson, and Grant, 2002; Semple, Patterson, and Grant, 2004). Recent research on the relationship between methamphetamine and other club drug use and sexual practices has brought to light the complex relationship between motivations to use club drugs and resulting risky sexual behavior (Halkitis and Parsons, 2002; Halkitis, Shrem, and Martin, 2005; Halkitis, Zade, Shrem, and Marmor, 2004; Klitzman, 2006; Parsons, Halkitis, Wolitski, Gomez, and S.U.M.S, 2003; Ross, Mattison, and Franklin, 2003). We believe that the motivations informing club drug use and sexual risk leading to seroconversion may be understood in terms of cognitive disengagement or escapism on the part of gay and bisexual men, and therefore we have grounded our study in the Cognitive Escape Model (CEM) proposed by McKirnan, Ostrow, and Hope (1996).

The CEM proposes that individuals use nonrational and affective coping strategies in order to manage stress associated with the realities of HIV (both the potential for seroconversion in HIV-negative persons and the reality of HIV/AIDS in HIV-positive persons) as well as to cope with the stigma associated with sexual identity/MSM status (Fullilove and Fullilove, 1999; McKirnan et al., 1996). Further, fatigue, fatalism, and negative affect surrounding the potential for HIV seroconversion or the reality of being HIV positive may lead people to “cognitively disengage” and substitute “automatic sexual scripts” as a reaction to these stressors (McKirnan et al., 1996). Finally, using escapism as a coping strategy is a learned behavior, which may be automatically triggered by preexisting psychological states such as anxiety, depression, loneliness, or post-traumatic stress disorder (PTSD), and by symptoms arising from external environmental factors like the direct or indirect experience of violence or stigmatization resulting from racism or homophobia (McKirnan et al., 1996).

The CEM theorizes that vulnerability (in the form of expectancies, high performance standards, negative affect, and experiences) interact with releasing stimuli (in the form of internal states, substance use, settings, and partner characteristics) to induce cognitive disengagement. By vulnerability, McKirnan et al. (1996) are referring to sources of stress that gay and bisexual men face because of the potential for HIV seroconversion or the reality of HIV in their lives. In reaction to these vulnerabilities—which exist in the form of negative cognitions/predictions and affect—individuals will convert information into its opposite. McKirnan et al. (1996) term this as an “optimistic bias,” which distorts reality so that individuals believe they are not placing themselves at risk. Vulnerability and releasing stimuli are the precursors of cognitive disengagement and in turn, sexual risk-taking.

More recently, the CEM has also been applied in mixed methodology studies on the intersection between club drug use and sexual behaviors among MSM (Haubrich, Myers, Calzavara, Ryder, and Medved, 2004; Vicioso, Parsons, Nanin, Purcell, and Woods, 2005; Williams, Elwood, and Bowen, 2000). In order to provide context to existing and emerging quantitative analyses of club drug use and seroconversion among gay and bisexual men, the present qualitative study explores motivations for using club drugs and partaking in risky sexual behavior.

This article reports the findings of qualitative interviews conducted with 16 men who entered our longitudinal study on club drug use and sexual behavior believing they were HIV negative or HIV unknown, yet who were, in fact, tested and confirmed to be HIV positive. These 16 seroconverted participants were subsequently matched with 16 participants who were confirmed as HIV negative for a total sample size of 32 participants. Analyses of 16 seroconverted men’s motivations for drug use and sexual practices vis-à-vis their 16 seronegative counterparts is of particular importance precisely because these 16 seroconverted men engaged in sexual and drug-taking behaviors believing that they were not HIV positive and therefore not placing themselves or their partners at risk for contracting HIV.

Methods

Study Design

Participants for this analysis were drawn from Project BUMPS, a large-scale (n = 450), longitudinal, mixed-method investigations of club drug use among gay and bisexual men in New York City conducted from 2000 to 2004. The purpose of this study, funded by the National Institute on Drug Abuse, was to determine the patterns of club drug use and the relative influence of club drug use on sexual risk-taking, in addition to disentangling psychosocial factors (ex., loneliness, self-esteem, perceived social support, etc.), which may predispose men to use club drugs. We focused on five specific club drugs (methamphetamine, MDMA, ketamine, GHB, and powdered cocaine) and collected data in four waves (baseline, months 4, 8, and 12) using both quantitative measures and qualitative interviews. The baseline qualitative interviews provide the source of data for the following analysis.

We implemented a targeted, convenience-sampling strategy to recruit ethnically diverse samples from the following three different types of community-based venues in which gay and bisexual men were likely to be accessed: Mainstream gay venues, AIDS Service Organizations (ASO), and public sex environments. Mainstream gay venues were defined as locations and events serving the gay community, including gay bars, pride events, street fairs, bookstores, and community centers. AIDS Service Organizations were defined as institutions that provide a variety of programs and assistance to people living with HIV and AIDS, including community-based organizations and health treatment centers. Public sex environments were defined as locations where men have sex with men, including commercial sex clubs, outdoor cruising areas, and pornographic video stores. We also added circuit parties to our recruitment efforts, recruiting at the yearly Black Party and the White Party.

Participants were recruited through both active and passive recruitment strategies (Halkitis, Green, Mourgues, 2005a). In order to be eligible for the study, participants were required to (1) be 18 years of age or older, (2) report six separate incidents of club drug use (any combination of five club drugs) in the last 12 months, (3) report at least one sexual encounter with another male while using a club drug before or during the sexual encounter in the past 3 months, and (4) agree to show documentation of positive HIV status or, if reportedly HIV negative, agree to take a confirmatory HIV test. The baseline assessment included both qualitative, audio taped, face-to-face interviews assessing drug use and sexual histories, as well as quantitative computer-administered surveys assessing frequency and type of drug used and sexual behaviors. At baseline, participants undertook consent, completed both the quantitative surveys via audio-assisted computer self-interview (ACASI), and the qualitative interview under the guidance of a trained research associate. HIV status was also confirmed at this time. Those who self-reported a seropositive status were required to provide proof of this status (i.e., doctor’s letter, prescription bottle with participant’s name). Those who self-reported as seronegative or unknown HIV status underwent mandatory HIV antibody testing via the OraSure^™ system. Participants returned two weeks later for their results.

In addition, demographic and psychosocial variables were considered. Informed consent was obtained from each study participant before beginning the interview. Participants were paid a $30 incentive for their initial interview. In order to ensure cultural sensitivity to MSM communities, recruiters underwent recruitment training conducted by a licensed clinician. Recruitment staff consisted of HIV-negative and HIV-positive members of the gay and bisexual community. All procedures were approved by the Internal Review Board (IRB) of New York University.

Participants

The overall sample consisted of 450 men of whom 60.9% (n = 274) identified their HIV status as HIV negative, 33.3% (n = 150) identified their status as HIV positive, and 5.8% (n = 26) identified their HIV status as unknown. HIV testing at baseline revealed that of the 274 self-reported HIV-negative men, 11 (4%) tested HIV positive, and of the 26 men who indicated they were unaware of their HIV status, 5 (19.2%) tested positive for HIV. These 16 men were diverse in terms of their race/ethnicity. Among the 11 men who reported an HIV-negative status and tested seropositive, four (36.4%) were African-Americans, four (36.4%) were White, two (18.2%) were Latino, and one (9.1%) was of mixed race. Similarly, among the five self-reported unknown-status men, three (60%) of the seroconverted men were African-American, while two (40%) were White. Comparisons of the 16 seroconverted men to those in the overall sample who were confirmed to be HIV negative indicate that these men were not significantly or practically different in terms of age (29-years old vs. 31 years old) or annual income than those who tested negative at baseline (Halkitis, Green, and Carragher, 2006).

Measures

In order to more fully understand contextual and phenomenological meanings associated with club drug use and sexual risk-taking, we conducted semistructured interviews together with a Critical Incident Measure (CIM; Ross, Wodak, Miller, and Gold, 1993). Participants were asked to provide a narrative of their most recent sexual encounter under the influence of club drugs and the one in which club drug use was not involved. Participants were asked to describe how and where they met their partners, the time of day, the characteristics of the venues/contexts in which they met their partners, characteristics of the partner(s), the contexts and environments in which they had sex, the sequence and kinds of sexual behaviors they engaged in, thoughts/emotions during and after sex, drug use, likes/needs satisfied, and HIV status disclosure. In addition, interviewers probed for information regarding perceived positive and negative experiences associated with club drug use as well as for perceived interaction between club drug use and sexual behaviors, and any impact the incidents may have had on future drug use. Thematic areas for this study were drawn from salient qualitative findings from two previous studies conducted with gay and bisexual men who use substances (Halkitis and Parsons, 2002; Purcell, Parsons, Halkitis, Mizuno, and Woods, 2001).

Current Study

For the purposes of this investigation, 16 seroconverted men were matched with 16 HIV-negative men for race/ethnicity, most-frequently used club drug, self-reported HIV status, and age. In one case where we were unable to match a participant according to race/ethnicity together with the other three criteria, we chose to use educational level as a proxy for race/ethnicity. Consequently, one 24-year-old African-American male, with a 4-year college education, who reported using methamphetamine and initially being HIV negative, was matched with a 23-year-old Latino/Hispanic male who was in fact HIV negative.

Because we were interested in phenomenological experiences of club drug use and the role they play in risky sex leading to seroconversion, we employed a two-level thematic approach to data analysis as outlined by Miles and Huberman (1984) and recently employed by Semple, Patterson, and Grant (2002) and Knight et al. (2005). Qualitative audio interviews of both groups were transcribed verbatim and consensus was reached on an operational definition for motivation. Motivation was defined, for the purposes of our study, as a “conscious or unconscious stimulus for action towards a desired goal, especially resulting in psychological or social factors. These factors give purpose or direction to behavior” (Oxford English Dictionary, 2006). Researchers and interns then coded for the general theme of motivation independent of knowledge of the respondent’s serostatus. Where appropriate, coding methodology put forth by Semple et al. (2002) was employed. Segments of the transcripts that met the operational definition were then excerpted using QSR NUD-IST (version 5.0) and sorted independently by the researchers into reoccurring subthemes throughout the interviews (Semple et al., 2002). Subthemes were then reviewed, compared, and a consensus was reached on dominant motivational subthemes. Researchers then recoded the excerpted motivations for subthemes. Where researchers disagreed on motivational subthemes, disagreements were discussed and agreement on categorization of motivational subtheme was reached (Semple et al., 2002). Transcription and coding were conducted by the researchers and three student interns. The researchers and undergraduate interns coded data from the same three transcripts (i.e., check-coding) and discussed coding in order to ensure each shared the same understanding of the codes. Interrater reliability was approximately 85% for thematic information.

Results

Sample Characteristics

The seroconverted and the comparison groups were statistically similar in terms of key demographic characteristics. On average, the seroconverted men were 29 years old (SD = 3.78) and the seronegative matches were 32 years old (SD = 6.7). Similarly, both groups were equivalent in terms of the ages at which they started using club drugs. The seronegative men reported the beginning of club drug use, on average, at the age of 20.5 years (SD = 3.8), while the seroconverted men reported the beginning at the age of 22 years (SD = 3.8). Both groups indicated having used, on average, four of the five club drugs, with 44% (n = 7) of the seroconverted men and 38% (n = 6) of the seronegative men reporting having used all five club drugs of interest to the investigation (i.e., methamphetamine, MDMA, ketamine, GHB, and powdered cocaine). For a more detailed description of the participant characteristics see Table 1.

Table 1.

Participant characteristics (n = 32)

	Seroconverted in % (n = 16)	Seronegative in % (n = 16)
Sexual orientation
Gay	81.0	81.0
Bisexual	19.0	19.0
Education
High school or less	12.5	25.0
Some college	62.5	31.3
Bachelor’s degree	18.8	37.5
Graduate degree	6.3	6.3
Annual income
Less than 10 K	18.8	12.5
Greater than 10 K but less than 40 K	68.8	56.3
Greater than 40 K but less than 75 K	12.5	25.0
75 K or more	0.0	6.3
Employment status
Full-time (40 hr per week or more)	31.3	50.5
Part-time (less than 40 hr per week)	25.0	6.3
Permanently or temporarily disabled and not working	0.0	6.3
Unemployed: Part-time or Full-time student	6.3	6.3
Unemployed, others	37.5	31.3

Motivations for Club Drug Use

Qualitative analysis of the narratives revealed seven recurring, motivational subthemes that were considered central for understanding the role that club drug use plays in gay and bisexual men’s lives. These motivations were enhanced physical sensation, facilitation of sex, emotional enhancement, emotional equivalence, emotional escape, facilitation of social interaction, and ability to overcome social inhibitions.

Descriptions of these seven motivations appeared to fall within three larger domains, namely a physical, an emotional/mental, and a social domain. In the physical domain, participants reported that drug use gave them a physical rush, stamina, made sex more intense and pleasurable, as well as alleviated sexual inhibition, thus allowing them to have gay sex. In the emotional/mental domain, participants recounted that drug use enhanced emotions, helped them to be on the same wavelength as their peers, as well as allowed them to emotionally escape from traumatic experiences and life stresses. In the social domain, participants articulated that drug use enhanced their social interactions with men, that is, it gave them courage to approach and look beautiful to men, feel accepted by them, as well as allowed them to overcome social inhibitions associated with talking to men. Also, in the social domain, the men viewed drug use as a tool for obtaining sex and companionship through the promise of peer drug use.

The physical domain:

Both groups reported being motivated to use club drugs in order to increase physical sensations arising during sex by making them “extremely horny,” “prolonging orgasm,” and “intensifying orgasm,” thus allowing for “cold sex” and “straight-up sex” (see Table 2). Confluences in word choice and tone suggest that little qualitative difference exists in the actual type of sexual sensations experienced by the two groups. Qualitative differences arose, however, in the motivation for overcoming inhibitions occurring during or shortly before sex itself. Of the men who spoke of using club drugs to overcome inhibitions surrounding the physicality of gay sex, the seronegative men indicated they used substances in order to stimulate themselves physically to the point where they were “less inhibited” and had the “courage” to initiate sex. Conversely, the seroconverted men explained they used club drugs in order to facilitate a rougher, more physical sex, which was otherwise described as undesirable during sober sex.

Table 2.

Motivations for drug use

	Common descriptors of motivations for seroconverted narratives	Common descriptors of motivations for seronegative narratives
Physical domain
Physical sensation (nonsexual)	“focus,” “lose weight,” “party more,” “energy”	“physical stamina,”“keeps you awake for days,” “rush,” “stay awake,” “energy”
Sexual sensation (sexual)	“extremely horny,” “prolongs ejaculation,” “longer sex,” “more aggressive during sex,” “intense [sex]”	“sexual,” “cold sex,”“intense [sex]”
Facilitation of sex	“less inhibited,” “group sex,” “nasty sex,” “makes me feel a little more freakier,” “more free”	“less inhibited,”“initiating sex more,”“more courage”
Emotional/mental domain
Emotional enhancement	“insight,” “feel in control,” “makes me feel alive and beautiful,” “I love everyone on crystal,”“self-improvement”	“affectionate,”“considerate,” “in tune,” “care,” “open and smart,” “happiness,” “discover things about myself,” “I’m in heaven,” “peaceful,” “creative”
Emotional equivalence	“I’ll feel what they’re feeling,” “I’m not, you know, apart from the party,” “I wanted to feel in,” “peer pressure,” “makes me feel accepted with them,” “wonderful connections with people,” “I did it to basically be around him”	“I like being on the same wave length,” “It makes me more together with my people”
Emotional escape	“I hate my life,” “feel more comfortable around a lot of gay men at one time,” “feel less guilty about what I’m doing,” “they look at you with hatred,” “coping mechanism,” “get away from reality,” “the anger that I had built inside of me,” “puts me in another world,” “everything just goes away”	“relaxing,” “relief,” “anti-depressant,”“escapism,”“melancholy,” “like I’m normal”
Social domain  Social interaction	“makes me outgoing and very talkative,” “makes me feel accepted”	“makes me cool with the people I’m with,” “I will focus on guys,” “I will notice cute guys on the dance floor,” “it’s a fake confidence”
Overcoming social inhibitions	“security,” “I’m kind of bashful,” “people will come over to you,” “makes us more secure,” “more bold, more brave,” “less afraid,” “I would have waited for him to make the first move”	“relaxes your inhibitions”

These two qualitative divergences suggest that while the seronegative men may use substances in order to physically stimulate themselves to the point where they overcome inhibitions associated with initiating gay sex, the seroconverted men may, in fact, use substances in order to emotionally disconnect to the point where they are able to physically tolerate fantasies of extreme, unsafe sex. Describing the relationship between his use of ketamine and sex, one 29-year-old White seroconverted man recounts: “You can take more longer. You can do the things that you may not want to do or you may not be able to do if you were sober.” In another, even more perceptible statement, a 28-year-old White seroconverted man discusses his use of cocaine for the purpose of having group sex: “I’m more free. I can get into group activity or people watching. I’m more open to other things than just a closed bedroom door.” Both seroconverted men appear to be drawn to club drugs because they already desire rougher, more extreme, and ultimately raw sex. Club drugs become a facilitator for a behavior that preexisted club drug use. Club drugs give men the stamina to have more extreme sex (multiple partners, fisting, etc.) that might not be possible otherwise.

The emotional/mental domain:

The desire to overcome inhibitions occurring shortly before or during sex, that is, to partake in sex that would otherwise have a dystonic element is suggestive of the role that club drug use plays in the emotional/mental lives of both groups. Three motivations for club drug use were determined to evoke a strong emotional/mental component: emotional enhancement, emotional equivalence, and emotional escape. However, strong qualitative disparities emerge in the tone, content, and word choice between the two groups when asked what specific emotional reasons existed for their drug use, suggesting that the seroconverted men are attempting to control greater levels of negative affect associated with daily stressors and negative self-images (see Table 2). Affect-laden expressions like “hate,” “disgust,” “anger,” “fuck it,” and “the stress, the stress, the stress” stand in strong contrast to expressions like “relaxing,” “relief,” “anti-depressant,” “escapism,” “melancholy,” “non-conformity,” and even “like I’m normal,” arising in the descriptions of the seronegative men. The need to emotionally escape from life stresses is made explicit by a 27-year-old White seronegative man’s description of using cocaine during casual sex one night after having been gay bashed.

And we had met up and we ran into each other at _____ right down the street, and I was with my friends and they were taking care of me because it was after I had gotten attacked and um, and then we had some coke and then we drove home and then he came in and him and I had sex. Just oral.

The need to escape the painful experience of being physically assaulted led him to a club that night as well as to drug use and sex. It did not, however, lead to a high-risk sexual encounter. This portrayal is the strongest description of emotional escape by the seronegative men, yet it is still dissimilar to the intensely affect-laden descriptions of motivations to escape that are replete throughout the seroconverted narratives. Here, one 25-year-old White seroconverted man painfully relates his use of methamphetamine to escape depression:

I am so depressed that I hate my life, it’s so disgusting that I like, go and do, I look for drugs, because when I do find that good high, you know sometimes when I get high, that I don’t think about how aggravated I am with my life. I use drugs to kind of like escape. I guess everybody uses drugs to escape something, and that is why I use drugs. I try to get high as much as possible. Because when I am high, I don’t think about how disgusted I am with my life.

The social domain:

Sexual and drug-taking motivations are always embedded within a social context that both informs and is informed by emotional/mental and physical motivations. In order to further comprehend the complex relationship between club drug use, sexual practices, and seroconversion, we sought to understand how participants actively employ interpersonal scripts for their own sexual and drug-taking behavior within gay-specific, cultural scenarios deemed important to the participants. Social venues influence interpersonal scripts and thus will also impinge on patterns of sexual behavior.

Overall, both seroconverted and seronegative men reported being motivated to use club drugs in order to enhance social interactions with men and to overcome social inhibitions associated with approaching men and talking to them (see Table 2). Club drugs allowed participants in both groups to become “outgoing and very talkative and very aware of everything around” them, and to feel “cool with everybody.” Both groups also reported that club drug use enabled them to be less “inhibited,” less “bashful,” and “more socially secure,” while eradicating fear of rejection. However, divergences became apparent between seroconverted and seronegative participants’ descriptions of the actual ways in which they employed club drugs to connect with men. Here, a 34-year-old Black seroconverted man explains how cocaine and the desire for sex work together to determine his interactions with men in clubs: “Now, I’m probably pretty much gonna have sex. But the coke, not everyone uses it, but when I find someone who does, it’s like ‘Ok, let’s have sex,’ ‘cause I’m gonna have coke ‘cause I’m gonna have better sex, greater sex, longer sex.”

Here, the participant offers the other man—and himself—the promise that both will have a sexual experience that he feels is commensurate with his own perceived standards of gay male sex. It is not the seroconverted man himself who offers the promise of “better sex, greater sex, longer sex;” rather the cocaine offers this promise to him and for him. His sole connection to the other man is through the shared use of cocaine. The cocaine is constant in every sexual situation. The other man however, is exchangeable. The participant is, in essence, having sex with the cocaine, while the other man is simply an instrument. The participant has “successfully” negotiated a social interaction, yet in essence has relinquished his own agency to the cocaine. One 39-year-old Black seroconverted man makes it clear that cocaine is used as a type of lure to bring men to him when he states, “doing blow, its like oh, you gotta, do you have you know, okay. . . People will come over to you, they will.”

In addition, not only the man uses the substance as a lure to attract another man that he feels he might not otherwise be able to have, rather the participant himself accepts the offer of club drugs from another man in order to remain connected to him. Here, a 29-year-old mixed-race/ethnicity seroconverted man relates how his last sexual encounter under the influence of Ecstasy began:

When I came out [of jail] I went up to the club. … And this guy that I always wanted to talk to was there too, but I didn’t see him. So when my bar brother told me about him, “Yeah, standing behind you right there, blah blah,” and he came over and he’s like “You don’t know who I am.” And I was like, “I’m hoping you such and such.” You know what I’m saying. But we start talking and all that, we had a couple of drinks, and he asked me do I take E. So I was like, “Yeah,” and he was like, “I have one for you,” and he gave me one. I took it, we drank alcohol, lit up some marijuana, smoked the marijuana, drinking. ... And nobody could see I was touching his leg.

Through the use of club drugs, the participant makes his drug-taking behaviors commensurate with those of the other man in order to entice that other man to continue to pay attention to him. The participant adopts a deferential script in an effort to be seen as attractive to the other man. The participant does so to the point where he agrees to take the man home to the apartment that he still shares with his ex-boyfriend after the man states that he is actually homeless and goes home each night with whoever will have him. They have sex that the participant later describes as “risky.” To adopt a deferential script in order to be “accepted” or “fit in” with other men seems to be a central motivation in the narratives of the seroconverted men. “Well, it does make me feel that I am part of the group when I do it with them, it makes me feel accepted with them and for some stupid reason I think it is cool a bit,” recounts a 31-year-old White seroconverted man.

In a third type of social interaction among the seroconverted men, the participant appears to use the sexual encounter as an opportunity to use club drugs that he is otherwise unable to obtain or afford. Here, the same 31-year-old White seroconverted man mentioned above relates his most recent sexual experience under the influence of multiple drugs:

It was one evening, I was doing a show, shooting at _______, then I wanted to continue, you know, I wanted to dance. So, I wanted to find some place where I could dance, so I went over to ______ and music was going and I was dancing. I had poppers with me, and I was drinking, and I didn’t have any drugs on me ‘sept poppers, and you wanna pull drugs sometimes but don’t have anything, so I would sniff a couple of hits, and you know, and when you cover it with drinking and dancing, and you know, it just heightens everything. And some guy was checking me out from across the room, and I looked over, he smiled, and I liked his smile, so I went right up to him, and I said, “hi” and all this other stuff, and he cut to the chase and said, “Would you like to go hang out?” I said “sure.” So, we got back to his place, we did some coke, and he asked me if I wanted to do some Ecstasy, and I’m like “Sure.” We, you know, did some X. I asked if he knew anybody who had pot or if he had any pot, ‘cause I really like using that with Ecstasy.

These three types of social interactions stand in stark contrast to the seronegative descriptions of using club drugs in order to instill feelings that will allow them to perform in a public venue for men thus becoming the object of their desire. Here, the 31-year-old White seronegative man, who was matched with the above seroconverted participant, relates his experiences of using Ecstasy in a club situation in a fundamentally different way:

Um, it doesn’t necessarily make me horny. It does that for a lot of my friends. Um, it just, I don’t know, it brings me to, um, I just feel completely free of everything, and it just enables me to kinda get lost in the whole, the music, and the dancing, and I will focus on guys, and I’ll notice cute guys on the dance floor, but it’s not necessarily a feeling I’m gonna act on, per se.

Finally, the disparity in the types of motives for social interaction suggests that while the seronegative men may be using club drugs in order to test and learn gay-specific cultural scripts, the seroconverted men are using regimented scripts in order to overcome inhibitions that allow them to experience fantasies of dissolution and merging.

Discussion

We undertook an analysis of qualitative data from a large-scale investigation of club drug use among gay and bisexual men living in all parts of New York City in order to differentiate motivations for club drug use in a cohort of men who were HIV seroconvereted as compared to a subset of men who were confirmed to be HIV negative. Our original sample was diverse in age, socioeconomic status, educational status, as well as their place of permanent residence in New York City. Our analysis included 16 men in each category who were matched on key demographic factors. Data were drawn from the baseline interviews of these men, and these data were subjected to thematic analysis. Differences emerged between the two groups with regard to motivation for the use of club drugs, which fell within three major domains—physical, emotional, and social.

With regard to physical motivators, the data suggested that both groups used club drugs in order to increase sexual feelings and sensations. However, while the seronegative men used club drugs to allow them to function sexually, the seroconverted men used club drugs to facilitate preexisting desires to engage in “extreme” sexual acts, such as “fisting,” “group sex,” and “rimming” (Halkitis, Shrem, and Martin, 2005b). In the emotional/mental domain, responses suggested that the seroconverted men were attempting to control greater levels of negative affect associated with daily stressors and negative self-image, thus suggesting that they were attempting to self-medicate clinically significant levels of depression and anxiety through the use of club drugs and risky sex. Finally, strong qualitative differences emerged in the way that club drugs were used in order to negotiate social situations. While the seronegative men used club drugs in order to test out gay-specific social scripts, the seroconverted men reported using substances in order to attract men. In a similar vein, they also viewed the other person’s offer of club drugs as a demonstration of that person’s desire for them, that is, as an expression of their own sexual self-worth and desirability, and thus were willing to adapt deferential sex scripts with other men who use substances in order to conform to the other person’s desires. Mutchler (2000) suggests similar patterns. The seroconverted men also reported using the opportunity to have sex together with drugs in order to be able to use drugs that they could not otherwise obtain or afford. Findings in all three domains provide support to the theory that men come with preexisting mental states (vulnerabilities) into a sexual and drug-taking event that may cause them to disengage through drug use and engage in unsafe sex. These antecedents form the precipitators for cognitive escape (McKirnan et al., 1996).

Researchers have long examined motivations for behavior, attempting to isolate facilitators leading to substance abuse and risky sexual behavior (Koblin et al., 2000). From a biopsychosocical perspective (Engel, 1977), it is necessary to consider physical, emotional, or social/contextual realities as inextricably connected. Thus, from this perspective, men may desire extreme physical sex, but this desire is inseparable from (1) the underlying emotional states that drive these behaviors and (2) the contexts in which they occur. Findings gathered here support the thesis that physical, emotional, and social elements also act synergistically to produce HIV risk behaviors, and that epidemics such as HIV and drug use occur in synergy (Stall et al., 2003).

Study’s Limitations

While the data presented here indicate the importance of understanding the overlapping realities of club drug use and sexual behavior, some methodological limitations did exist. To begin with, analysis was based on a small subsample of 16 seroconverted men matched with 16 seronegative men. However, our analyses indicated that we had reached saturation with regard to the level-one themes. In addition, data were gathered from a convenience sample of 450 men. Yet, our sample was diverse in terms of race/ethnicity, HIV status, and geographic distribution (Halkitis, Pandey, and Palamar, 2007). Moreover, the inclusion criteria were restrictive in so much as intravenous drug users and men who indicated that crack cocaine or heroin was their most frequently used drug were excluded. It is our hypothesis that the overall study sample was that of a group of men who were binge (rather than chronic) drug users (Halkitis et al., 2005a; Halkitis et al., 2007). Finally, the data presented here were based solely on the qualitative component. However, data gathered here were strengthened by the findings associated with the quantitative analysis conducted with the same 16 seroconverted men and the overall sample (Halkitis, Green, and Carragher, 2006).

Conclusions

Our work indicates the complexity of club drug use in the lives of gay and bisexual men. Findings in the physical domain suggest that the seroconverted men may be physically limited by HIV infection. Because they are unaware that HIV could bring about the physical states they are experiencing, they may use club drugs to “medicate” negative physical symptoms. In addition, they may simultaneously use club drugs in an effort to maintain previous levels of sexual performance that have been affected by their HIV status. Data gathered here provide evidence for the necessity of conducting community-wide, venue-based rapid testing programs aimed at MSM who use club drugs. Our work also suggests that motivations, which often include the desire to escape unpleasant psychological states, may be at the heart of the high rates of use in this population as well as play a significant role in the long history of substance abuse in the gay community. This may be owing to the fact that gay men may suffer as a group from the trauma of HIV, the trauma of being raised in a heterosexist world, and for many, the trauma of child abuse. We know that men who experience abuse, be it sexual or societal, are more likely to engage in maladaptive behaviors. In relation to club drugs, maladaptive behaviors are further compounded by the vital role that sexuality plays in constructing gay identity as well as by the use of club drugs to facilitate sex that may serve to mask feelings of isolation, stigma, or internalized homophobia. Findings like these strongly indicate a need for interventions aimed at diagnosing and treating affective disorders both behaviorally and with psychotropic medication, when necessary.

In conclusion, approaches to treatment for drug addiction among gay and bisexual men must delve into mental health factors in order to disentangle associations between use and undesired psychological states, rather than simply dealing with the drug-using behavior in isolation. Further, motivations informing the use of club drugs and HIV risk-taking by gay and bisexual men cannot be understood from simple cognitive-based models (McKirnan et al., 1996; Halkitis, Wolitski, and Gómez, 2005c). Individuals may be empowered with knowledge but ultimately knowledge is insufficient in explaining behavior. Findings gathered here indicate that behavioral outcomes are complex interactions of physical, emotional, and social motivations. Moreover, these findings speak to the need to clinically address all of the elements within substance-abuse treatment.

Glossary

AIDS (Acquired Immunodeficiency Syndrome)

AIDS refers to a collection of symptoms resulting from specific damage to the immune system caused by HIV. The late stage of the condition leaves individuals prone to opportunistic infections and tumors

Club Drugs

Otherwise known as party drugs, common club drugs include ecstasy, ketamine, GHB, methamphetamine, Rohryponol, and in larger metropolitan areas, powdered cocaine. Club drugs are among the drugs used sometimes by teens, young adults, and more recently, among lesbian, gay, bisexual and transgender (LGBT) groups who are part of a nightclub scene. Individuals may be attracted to the generally low cost, seemingly increased stamina, and intoxicating highs that are said to deepen party experiences. However, club drug use has been associated sometimes with severe physical and psychological effects

HIV (Human Immunodeficiency Virus)

HIV is a retrovirus that can lead to AIDS. Infection with HIV occurs by the transfer of blood, semen, vaginal fluid, pre-ejaculate, or breast milk. HIV primarily infects vital cells in the human immune system such as helper T cells (specifically CD4+ T cells), macrophages, and dendritic cells. HIV infection leads to low levels of CD4⁺ T cells

Methamphetamine

Methamphetamine is a synthetic central nervous system stimulant categorized by the U.S. Food and Drug Administration as a Schedule II amphetamine, because it has a high potential for abuse and psychological or physical dependence. Common names for methamphetamine include meth, crystal meth, crystal, Tina, ice, and glass. Methamphetamine may be smoked, injected, snorted, swallowed, or inserted into the anus; insertion into the anus is often termed a “booty bump.” Long-term use can cause physical symptoms (decayed teeth, weight loss, skin lesions, stroke, and heart attack), mental symptoms (paranoia, hallucinations, anxiety, and irritability), as well as behavioral symptoms (aggressiveness, violence, and isolation

MSM (Men-who-have-sex-with-men)

MSM is a term derived by clinicians, behavioral researchers, and public policy-makers to describe men who engage in sexual relations with men, yet who do not self-identify as being gay

Biographies

Roy Jerome is a Ph.D. candidate in Counseling Psychology at New York University and former Research Associate at the Center for Health, Identity, Behavior & Prevention Studies. He currently holds an American Psychological Association Minority Fellowship in Substance Abuse Research funded by a grant from the National Institute on Drug Abuse (NIDA) and the National Institute on Mental Health (NIMH). He is also a Research Associate at Harlem United Community AIDS Center, Inc., where he conducts research on the effects of the built and social environment on HIV-positive communities in New York City. He also completed a Ph.D. in Germanics, concentrating on the representation of masculinity, trauma, and self-psychology, in postwar German literature. His current areas of research include men’s psychology, trauma theory, methamphetamine use, risky HIV transmission behavior, health disparities, and mental health in men and women in the Black communities of New York City. He is also Coinvestigator and Project Director on Project Hope, a study dedicated to understanding the emerging use of methamphetamine in Black MSM communities of New York City.

Perry N Halkitis, Ph.D., M.S. is Associate Dean for Research and Doctoral Studies, Professor of Applied Psychology, and Director of the Center for Health, Identity, Behavior & Prevention Studies at the Steinhardt School, of Culture, Education, and Human Development at New York University. He is internationally recognized for his work examining the intersection between the HIV, drug abuse, and mental health, and is well-known as one of the nation’s leading experts on methamphetamine addiction and HIV behavioral research. He recently led the following two edited volumes: HIV + Sex: The Psychological and Interpersonal Dynamics of HIV-Seropositive Gay and Bisexual Men’s Relationships. (American Psychological Association, 2005), and Barebacking: Psychosocial and Public Health Perspectives (2006, Haworth Press). Author of over 90 peer-reviewed academic manuscripts, Dr. Halkitis’ research examines how sexual and drug-related risk-taking are influenced by interpersonal, contextual, developmental, and cultural factors in the United Sates. His research has been funded by the National Institutes of Health, Centers for Disease Control and Prevention, New York City Department of Health & Mental Hygiene, New York State AIDS Institute, United Way, the New York Community Trust, and American Psychological Foundation. In addition, Dr. Halkitis is a well-respected applied statistician and psychometrician. Dr. Halkitis is a recipient of numerous awards from both professional and community-based organizations, and was elected a fellow of the New York Academy of Medicine in 2005.

Daniel Siconolfi, B.A., is currently pursuing his Master’s in Public Health (MPH) at New York University (NYU), after receiving his Bachelor’s degree in Gender & Sexuality Studies from NYU in 2006. His research interests include gay men’s health, HIV prevention, and male body image and masculinity. He is a research associate and project director at CHIBPS.