Abstract
Illicit substance use poses a significant public health challenge in the United States. Certain populations are disproportionately impacted by substance use disorders. Men who have sex with men (MSM) have been shown to be three to four times more likely to report substance use compared to the general population. MSM also make up a disproportionate number of new cases of STIs. The impact of substance use disorders on STI and HIV infection risk has been well documented among this vulnerable population. Understanding the intersection of substance use and sexual risk is important to design effective interventions to reduce substance use and risk of STIs. However, little is known about the relationship between venues used to arrange sexual encounters including hook-up apps and substance use. This study describes the demographics and social network characteristics of MSM who presented to an STI clinic in Rhode Island including reported substance use and the primary hook-up venues used for meeting sexual partners. The results show that individuals using online venues to meet sexual partners were more likely to report substance use, indicating the possible utility of interventions using social media to address the unique vulnerability of STI and HIV infection for substance using MSM.
Keywords: Homosexual, men who have sex with men, high risk behaviour, North America
Introduction
Illicit substance use is a major public health issue in the United States (US). Rates of opioid misuse overall are at an all-time high with 11.4 million individuals over the age of 12 reporting opioid misuse in 2017 and 30 million people reporting any illicit substance use during the prior 30day period.1 The challenges presented by substance use have been underscored by a considerable rise in deaths resulting from a drug overdose; an estimated 70,237 individuals died from overdose by any drug in 2017 compared to 36,010 in 2007.2 Importantly, gay, bisexual, and other men who have sex with men (MSM) are disproportionately affected by substance use disorders. MSM have been shown to be three to four times more likely to report substance use compared to the general population.3–5 In particular, previous studies have demonstrated that MSM report increasing rates of methamphetamine use.6 Other studies have highlighted higher rates of the use of substances such as poppers, ecstasy, cocaine and marijuana among MSM compared to the general population.7 Despite these higher rates, little is known about the demographic and social network characteristics of MSM who report substance use.
Understanding substance use patterns among MSM is critical to address not only co-morbidities associated with substance use itself, but also because substance use may also increase the risk of HIV and other sexually transmitted infections (STIs). Although the reasons for high rates of substance use among MSM may be complicated and varied, the literature shows that substance use among MSM is common particularly during sex.8 MSM tend to engage in substance use due to increased sexual arousal, lack of inhibition, and because of initiation by their partner.8 Substance use is also associated with a higher risk of STIs, in addition to sexual practices that may increase risk of STIs.9 MSM who frequently use illicit substances are less likely to consistently wear condoms, may participate in an increased number of sexual encounters, and are more likely to engage in transactional sex,10 compared to MSM who do not engage in illicit substance use. Between 2013 to 2018 in the US, there was a significant increase in STIs with a 19% increase in chlamydia, 63% increase in gonorrhea and a 71% increase in primary and secondary syphilis,11 while HIV remained relatively stable.12 In comparison to the general population, MSM make up a disproportionate number of new cases of STIs in the US, representing up to 70% of new HIV cases and 64% of new primary or secondary syphilis cases.11 Importantly, the presence of a bacterial STI, particularly in the rectum,13,14 places individuals at increased risk for acquiring HIV.15–17
Understanding the social context and intersection of substance use and sexual risk is important to design effective interventions to reduce substance use, as well as reduce risk of HIV and other STIs among MSM.18,19 Importantly, online hook-up applications (apps) and other internet sites may facilitate sexual encounters and have been associated with increased risk of HIV and other STIs.20–23 The internet has become a popular venue for seeking partners among MSM.24 In 2013, one particular app reported that it had six million users in over 100 countries around the world.25 Mobile technology has allowed for quicker and easier methods for MSM to meet potential sexual partners based on proximity, attraction, and sexual behaviors. Prior studies have suggested that compared to men who do not seek partners online, men who do seek partners via the internet tend to have a higher frequency of anal sex, more previously diagnosed sexually transmitted infections, more potential exposure to sex partners, and a greater exposure to sex partners who are living with HIV.24 However, little is known about the relationship between hook-up apps and substance use.26 This study evaluated substance use and the use of hook-up sites among MSM presenting to a publicly-funded STI clinic. We describe demographics and social network characteristics of MSM who reported substance use, identify the primary hook-up sites and other venues used for meeting sexual partners, and discuss implications for intervention development.
Methods
The study was conducted between October 2014 and January 2017 at the Rhode Island STI Clinic, which serves approximately 3,000 patients per year, of which one third of whom identify, based upon sexual behaviors reported upon intake, as MSM. All men who self-reported having sex with other men who presented to the STI Clinic were offered the opportunity to take part in the study. Individuals who were aged 18 and over were enrolled into the study. Research staff administered a one-time, cross-sectional demographic and behavioral assessment in person. Sociodemographic data collected included age, race, ethnicity, education level, income, and insurance (public/private/none). Behavioural data collected included sexual behaviours such as participation in transactional sex and the number of lifetime sexual partners. Other behavioural information collected included substance use in the last 12 months reported on a comprehensive list of illicit substances including: crack/cocaine, synthetic cathinones (bath salts), crystal methamphetamine, gamma-hydroxybutyrate (GHB), 3,4-methylenedioxymethamphetamine (MDMA), lysergic acid diethylamide (LSD), heroin, ketamine and “other” (which allowed participants to provide responses that were otherwise not included in the provided list). This study focused on illicit and/or problematic substance use; thus alcohol, tobacco, marijuana and inhaled nitrites (poppers) were excluded from this study, as these substances are either legal for adult use, or, in the case of marijuana, becoming increasingly decriminalized. Participants were also asked where they had met sex partners in the past 12 months, choosing from an extensive list of local physical venues such as bars and clubs, gay parties or sex parties (social events targeting gay men with our without a sexual theme respectively), gyms, bathhouses, sex venues, and parking/cruising areas, as well as virtual venues including hookup sites. Data were reviewed on clinical outcomes, including the results of testing for syphilis serology and pharyngeal/rectal/urethral chlamydia and gonorrhea. Extragenital tests for chlamydia and gonorrhea were collected by self-performed swabs, which have demonstrated sensitivity and specificity comparable to physician-collected specimens.27,28 Nucleic acid amplification testing (NAAT) was used to detect presence of chlamydia or gonorrhea in urethral and extragenital specimens.29
Chi-square and Fisher’s exact tests were used to assess differences in socio-demographic and substance use differences (i.e., individuals who reported substance vs. individuals who reported no substance use) between groups. A two-sided p-value of less than 0.05 was considered statistically significant. Bivariate regression models identified sociodemographic and venues used for meeting sexual partners including through internet-based sites and reported substance use. Multivariate logistic regression was performed to explore associations between substance use and a number of sociodemographic characteristics, sexual risk behaviors and a history of an STI diagnosis (Table 4). Confounding variables were identified using directed acyclic graphs (DAGs) and a priori. We only observe missing data in one variable: income. As only 0.7% (three participants) had missing data in one variable, a completed case analysis was used. All statistical analyses were completed using Stata 15.0 (StataCorp LP, College Station, Texas). The study was approved by the Miriam Hospital IRB.
Table 4.
Exploratory analysis of substance use using multivariate logistic regression.
| Odds ratio (OR)/95% confidence interval (CI) | |
|---|---|
|
| |
| Age | 0.98 (0.95, 0.99) |
| Race | |
| White | 1.00 |
| Non-White | 0.57 (0.33, 0.97) |
| Ethnicity | |
| Non-Hispanic/Latino | 1.00 |
| Hispanic/Latino | 0.69 (0.36, 1.36) |
| Education+ | |
| High school diploma or less | 1.00 |
| Some college | 1.44 (0.73, 2.83) |
| College degree | 0.48 (0.23, 1.00) |
| Graduate education | 0.60 (0.25, 1.47) |
| Income* | |
| <$12,000 | 1.00 |
| $12,000-$29-999 | 0.70 (0.33, 1.45) |
| $30,000-$59,999 | 0.87 (0.50, 1.73) |
| ≥$60,000 | 0.85 (0.36, 2.17) |
| Health Insurance+ | |
| Yes | 1.00 |
| No | 1.44(0.80, 2.58) |
| Lifetime partners+ | |
| <=10 | 1.00 |
| 11–20 | 4.00 (1.42, 11.29) |
| More than 20 | 6.09 (2.31, 16.06) |
| Diagnosed with STD+ | |
| No | 1.00 |
| Yes | 1.19 (0.72, 1.97) |
| Engagement in transactional sex* | |
| No | 1.00 |
| Yes | 4.63 (2.04, 10.49) |
| Venue met sex partners. . . | |
| Online* | |
| No | 1.00 |
| Yes | 2.21 (1.07, 4.56) |
| Bar/club* | |
| No | 1.00 |
| Yes | 3.16 (1.88, 5.33) |
| Through friends* | |
| No | 1.00 |
| Yes | 2.33 (1.39, 3.91) |
| School* | |
| No | 1.00 |
| Yes | 1.30 (0.65, 2.59) |
| Gay party* | |
| No | 1.00 |
| Yes | 3.56 (1.83, 6.93) |
Adjusted for age, race, ethnicity, and education.
Adjusted for age, race, and ethnicity.
Results
A total of 415 individuals were enrolled in this study with a median age of 37 years (Table 1). Nearly two thirds (63.6%) identified as white and approximately 18.5% identified as Hispanic/Latino. Most reported having a college degree (35.2%) followed by some college (29.5%), a high school diploma or less (19.2%) or some form of graduate education (16.1%). Nearly two thirds reported their relationship status as single and a majority (56.4%) reported more than 20 lifetime sexual partners. Of those surveyed, approximately one quarter (25.1%) tested positive for any STI at their most recent clinic visit, 8% or less reported a history of incarceration, and 8% or less reported a history of transactional sex. Of those surveyed, 20% (83/415) reported a history of substance use. White MSM were more likely than non-white MSM to report substance use as were those reporting at least some college education compared to other levels of education. Additionally, individuals who reported more than 20 lifetime partners compared to those with less than 20 lifetime partners along with individuals reporting transactional sex were all more likely to report substance use (all p < 0.05). However, testing positive for any STI did not have a statistically significant association with substance use among those enrolled (p = 0.93).
Table 1.
Demographic and behavioral characteristics of the study cohort (N = 415).
| Substance use* | ||||
|---|---|---|---|---|
|
|
||||
| Total N = 415 |
Yes N = 83 |
No N = 332 |
p-Value | |
|
| ||||
| Age (median, interquartile range [IQR]) | 37 (23, 35) | 26 (21, 32) | 28 (23, 37) | 0.01 |
| Race | 0.05 | |||
| White | 264 (63.6) | 61 (73.5) | 203 (61.1) | |
| Non-White | 151(36.4) | 22 (26.5) | 129 (38.9) | |
| Ethnicity | 0.36 | |||
| Non-Hispanic/Latino | 338 (81.5) | 71 (85.5) | 267 (80.4 | |
| Hispanic/Latino | 77 (18.5) | 12 (14.5) | 65 (19.6) | |
| Education level | 0.002 | |||
| High school diploma or less | 77 (19.2) | 17 (20.7) | 60 (18.7) | |
| Some college | 119 (29.5) | 37 (45.1) | 82 (25.6) | |
| College degree | 142 (35.2) | 18 (22.0) | 124 (38.6) | |
| Graduate education | 65 (16.1) | 10 (12.2) | 55 (17.1) | |
| Income (N = 412) | 0.14 | |||
| Less than $12,000 | 122 (29.6) | 33 (39.8) | 89 (27.1) | |
| $12,000–$29,999 | 80 (19.4) | 15 (18.1) | 65 (19.8) | |
| $30,000–$59,999 | 137 (33.3) | 24 (28.9) | 113 (34.3) | |
| $60,000 or greater | 73 (17.7) | 11 (13.3) | 62 (18.8) | |
| Relationship Status | 0.3 | |||
| Single | 271 (65.3) | 59 (71.1) | 212 (63.9) | |
| Relationship/married/civil union | 123 (29.6) | 19 (22.9) | 104 (31.3) | |
| Divorced/separated/other | 21 (5.1) | 5 (6.0) | 16 (4.8) | |
| Health insurance | 0.53 | |||
| None | 82 (19.7) | 20 (24.1) | 62 (18.7) | |
| Private | 241 (58.l) | 45 (54.2) | 196 (59.0) | |
| Public | 92 (22.2) | 18 (21.7) | 74 (22.3) | |
| Tested positive for any STD† | 0.93 | |||
| No | 311 (74.9) | 63 (75.9) | 248 (74.7) | |
| Yes | 104 (25.1) | 20 (24.1) | 84 (25.3) | |
| Lifetime partners | 0.001 | |||
| <10 | 82 (19.8) | 5 (6.0) | 77 (23.2) | |
| 11–20 | 99 (23.9) | 20 (24.1) | 79 (23.8) | |
| More than 20 | 234 (56.4) | 58 (69.9) | 176 (53.0) | |
| Transactional sex‡ | <0.001 | |||
| No | 384 (92.5) | 68 (81.9) | 316 (95.2) | |
| Yes | 31 (7.5) | 15 (18.1) | 16 (4.8) | |
| Ever incarcerated | 0.19 | |||
| No | 382 (92.0) | 73 (88.0) | 309 (93.1) | |
| Yes | 33 (8.0) | 10 (12.0) | 23 (6.9) | |
| Frequency of alcohol consumption | 0.14 | |||
| Once a month or less | 95 (22.9) | 13 (15.7) | 82 (24.7) | |
| 2–4 times a month | 162 (39.0) | 32 (38.6) | 130 (39.2) | |
| 2 or more times a week | 158 (38.1) | 38 (45.8) | 120 (36.1) | |
Non-popper, non-marijuana, non-alcohol use in the last 12 months (bath salts, crystal methamphetamine, GHB, MDMA, LSD, heroin, ketamine, crack/cocaine, other).
Includes results of syphilis, gonorrhea (urine, oral, rectal), and chlamydia (urine, oral, rectal) testing.
Given or received money, drugs, housing, or other for sex.
Venues where individuals met their sexual partners are reported in Table 2 and Figure 1. The most common venue was through the internet (77.6%), at a bar or club (41.2%) or through friends (38.8%). There was a statistically significant relationship between substance use and meeting sexual partners online, through friends, at a bar or club, bath house or sex venue, a gay party or sex party (however the survey respondent chose to interpret these terms) and in public bathrooms (all p < 0.05). The most common internet hook-up sites were Grindr (60.7%), Scruff (27.5%) and Tinder (17.1%). Of the online sites or apps used for sexual networking, use of Grindr, Tinder and Facebook were found to have a statistically significant association with reported substance use.
Table 2.
Venue where met partners in Rhode Island, last 12 months (N = 415).
| Substance use* | ||||
|---|---|---|---|---|
|
|
||||
| Total N (%) |
Yes n (%) |
No n (%) |
p-Value | |
|
| ||||
| Did not meet any partners | 23 (5.5) | 2 (2.4) | 21 (6.3) | 0.280 |
| At work | 41 (9.9) | 10 (12.0) | 31 (9.3) | 0.593 |
| In school | 65 (15.7) | 19 (22.9) | 46 (13.9) | 0.063 |
| At a gym | 38 (9.2) | 8 (9.6) | 30 (9.0) | 1.00 |
| Church/religious service | 2 (0.5) | 0 (0.00) | 2 (0.6) | 1.00 |
| Social organization | 30 (7.2) | 7 (8.4) | 23 (6.9) | 0.813 |
| Bar/club | 171 (41.2) | 51 (61.4) | 120 (36.1) | <0.001 |
| Cruising area | 16 (3.9) | 6 (7.2) | 10 (3.0) | 0.104 |
| Bathhouse/sex venue | 44 (10.6) | 16 (19.3) | 28 (8.4) | 0.008 |
| Video store | 28 (6.8) | 8 (9.6) | 20 (6.0) | 0.353 |
| Strip Club | 11 (2.7) | 4 (4.8) | 7 (2.1) | 0.242 |
| Gay Party | 50 (12.1) | 20 (24.1) | 30 (9.0) | <0.001 |
| Sex Party | 24 (5.8) | 10 (12.0) | 14 (4.2) | 0.014 |
| Online | 322 (77.6) | 73 (88.0) | 249 (75.0) | 0.017 |
| Public Bathroom | 7 (1.7) | 4 (4.8) | 3 (0.9) | 0.032 |
| Through friends | 161 (38.8) | 46 (55.4) | 115 (34.6) | <0.001 |
| Other | 27 (6.5) | 7 (8.4) | 20 (6.0) | 0.584 |
Non-popper, non-marijuana, non-alcohol use in the last 12 months (bath salts, crystal meth, GHB, ecstasy, LSD, heroin, ketamine, crack, other).
Figure 1.
Venues where MSM most frequently met sex partners in Rhode Island, by substance use.
*Significant difference between venue and substance use at p < 0.05.
In the multivariate logistic analyses, being non-white were associated with being 43% less likely to report substance use (adjusted odds ration [aOR] 0.57, 95% confidence interval [CI] 0.33–0.97). Several behavioral characteristics were associated with increased odds of reporting substance use, including engaging in transactional sex (aOR 4.63, 95% CI 2.04–10.49), finding sex partners online (aOR 2.21, 95% CI 1.07–4.56), finding sex partners through friends (aOR 2.33, 95% CI 1.39–3.91), meeting their sex partner at a bar or club(aOR 3.16, 95% CI 1.88–5.33), and meeting their sex partner at a gay party (aOR 3.56, 95% CI 1.83–6.93).
Discussion
This study is among the first to describe substance use, social networks, and sexual risk behavior among MSM. Similar to prior studies of substance use among MSM, approximately 20% of our study cohort reported substance use. Individuals who identified as white and those who reported at least some college education were statistically associated with substance use. This is similar to prior studies and reflects the higher rate of substance use among whites in the US.30 Two high risk behaviors, transactional sex and reporting more than 20 lifetime partners, were statistically associated with substance use. Although the percentage of individuals who reported participating in transactional sex is low, this group is at particularly elevated risk for STI and HIV infection.
This study also identifies the most common venues for meeting sexual partners, namely social media dating apps, bars or clubs, sex parties, and bathhouses or public bathrooms. Meeting sexual partners via any of these venues were statistically associated with substance use. Among social media apps, Grindr was the most popular app. Scruff, Facebook, Tinder and other social media apps were used considerably less, but they were all significantly associated with substance use. These data suggest that online hookup sites may be an effective approach to reach substance-using MSM who are at-risk of HIV and other STIs. Online hook-up sites are an important platform for interventions to promote HIV and STI screening, risk reduction strategies, and other preventive measures including preexposure prophylaxis (PrEP).21,22 One such study found that using online social networking, such as Grindr, has the potential to reach high risk groups and promote HIV and other STI prevention messaging.31 Developing effective and scalable interventions poses a challenge to public health authorities and health care providers as this population frequently encounters barriers to care for both substance use and STIs.23 Social media apps have enormous potential for substance use interventions focused on high risk MSM. However, intervention studies on dating apps must be carefully considered as the high cost of advertising and varying levels of social responsibility practiced by respective companies may act as a barrier to implementation.
There are limitations to this study. The study cohort were MSM presenting to a single STI clinic and findings may not generalize to other settings. Additionally, many MSM have limited access to STI services and their substance use and sexual networking characteristics may differ from this study cohort. This is particularly true for the most vulnerable members of the MSM community, including those who engage in transactional sex. Additional information on the substance use behaviors, including mechanism for administration such as injection drug use (IDU), social networking and other STI/HIV risk factors would provide key insights into interventions that would reduce STI risk and address substance use. Additionally, substance use among MSM has been rooted in a sense of belonging and coping, in addition to enhancement of pleasure.32 However, better understanding the relationship between substance use and other STI/HIV risk behaviors including condomless sex would enhance the development of future interventions to reduce STI risk.
Conclusions
This study provides important details on social, behavioral and sociodemographic associations with substance use among MSM. Substance use is prevalent among MSM and associated with certain sexual risk behaviors, including higher levels of lifetime sex partners and transactional sex. Additionally, substance use is associated with meeting sexual partners in several venues, including social media apps, bars or clubs, sex parties, and bathhouses or public bathrooms. Certain websites and social media apps, including the most popular, Grindr, are also associated with reported substance use. This study provides important information on the intersections of substance use and sexual networks while providing key insights for the future development of interventions that address both substance use and STI risk.
Table 3.
Online hookup sites where met partners in Rhode Island, last 12 months.
| Substance use* | ||||
|---|---|---|---|---|
|
|
||||
| Total N (%) |
Yes n (%) |
No n (%) |
p-Value | |
|
| ||||
| Adam4Adam | 60 (14.5) | 12 (20.0) | 48 (80.0) | 1.00 |
| Bareback.com | 4 (1.0) | 2 (50.0) | 2 (50.0) | 0.18 |
| Black Gay Chat | 1 (0.2) | 0 (0.0) | 1 (100.0) | 1.00 |
| Craigslist | 40 (9.6) | 10 (25.0) | 30 (75.0) | 0.53 |
| 40 (9.6) | 16 (40.0) | 24 (60.0) | 0.001 | |
| Grindr | 252 (60.7) | 60 (23.4) | 192 (76.2) | 0.02 |
| Manhunt | 33 (8.0) | 7 (21.2) | 26 (78.8) | l.00 |
| Jack’d | 53 (12.8) | 15 (28.3) | 38 (71.7) | 0.15 |
| Mister | 1 (0.2) | 0 (0.0) | 1 (100.0) | 1.00 |
| OKCupid | 42 (10.1) | 9 (21.4) | 33 (78.6) | 0.97 |
| Recon | 3 (0.7) | 0 (0.0) | 3 (100.0) | 1.00 |
| Scruff | 114 (27.5) | 26 (22.8) | 88 (77.2) | 0.46 |
| Tinder | 71 (17.1) | 25 (35.2) | 46 (64.8) | <0.001 |
| Growlr | 30 (7.2) | 7 (23.3) | 23 (76.7) | 0.81 |
| Other | 37 (8.9) | 6 (16.2) | 31 (83.8) | 0.70 |
Includes results of syphilis, gonorrhea (urine, oral, rectal), and chlamydia (urine, oral, rectal) testing.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Footnotes
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
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