Initiation into Methamphetamine Use For Young Gay and Bisexual Men

Abstract

Research over the past ten years has suggested that methamphetamine use has become a significant problem and is associated with risky sexual behaviors among gay and bisexual men. In order to better understand initiation into methamphetamine use among gay and bisexual men, qualitative analyses were performed on a sample of young gay and bisexual men (ages 18-29) in New York City. Participants were recruited as part of a larger study which used time-space sampling to enroll club-going young adults who indicated recent club-drug (ecstasy, ketamine, GHB, methamphetamine, cocaine, and/or LSD) use. The data for this paper are derived from the qualitative interviews of 54 gay and bisexual male methamphetamine users. At initiation (1) Methamphetamine was used in a social, non-sexual setting for a majority of the participants; (2) participants expressed limited knowledge of methamphetamine; and (3) many participants used cocaine as a basis for comparison when describing various effects of the drug. The understanding that at initiation methamphetamine was not solely used as a sexual enhancement for members of this community may enable health workers to more accurately target potential users when putting forth intervention efforts. Future research should aim to gain a better understanding into the role that methamphetamine plays in non-sexual contexts, particularly among gay and bisexual men who may not be part of the club “scene.” The relationship between attitudes towards methamphetamine and other drugs, particularly cocaine, among gay and bisexual men should be explored.

1. Introduction

Methamphetamine use has emerged as a significant health issue among gay and bisexual men in North America, Europe, and Australia (Worth and Rawstorne, 2005). As a group, gay and bisexual men often face difficulties beyond the regular stresses and strains of everyday life – persistent worries related to HIV/AIDS, problems of alienation from families and society, homophobia, and other feelings of isolation and loneliness – and often cope with such stressors through sexual activity and substance use (Barrett et al., 1995). High rates of substance use have been found among gay and bisexual men throughout the United States. Roughly two thirds of young (15-22) gay and bisexual men reported using drugs in the past 6 months and 19% reported using drugs weekly or more frequently across seven large cities in the United States (Thiede et al., 2003). In another sample of urban gay and bisexual men in four cities in the United States, 52% reported any drug use in the past 6 months; this included 23% of the sample reporting stimulant use in the past 6 months, and nearly 20% reporting either using at least three drugs in the prior 6 months or at least weekly use (Stall et al., 2001). Nearly half (47%) of a sample of gay and bisexual young men in New York City indicated that they had used at least one club drug (i.e. MDMA, LSD, Ketamine, methamphetamine, and GHB) in their lifetime (Parsons et al., 2006a).

Research over the past ten years has suggested that methamphetamine (commonly known as Tina, crystal, meth, ice, T, speed) use and abuse has become a key problem in gay communities (Fernandez et al., 2007; Martin et al., 2006; Parsons et al., 2006a; Nanin and Parsons, 2006; Reback and Grella, 1999). Although methamphetamine use is more prevalent among gay and bisexual men in the western part of the United States (Hirshfield et al., 2004; 2006), it has made its way eastward, as well as in other parts of the world. An Internet-based survey of gay and bisexual men from across the United States conducted in 2002 found that 6% reported methamphetamine use in the previous six months (Hirshfield et al., 2006). In our previous study of a sample of young adults between the ages of 18-25 in New York City collected in 2002, 14.3% of the gay and bisexual men indicated lifetime methamphetamine use, significantly more than the 6.5% of heterosexual women and 4.9% of lesbian and bisexual women (Parsons et al., 2006a). Our more recent study of 18-29 year old young adults in New York City using time-space sampling in 2005, found that the 21.5% of gay and bisexual men reporting lifetime methamphetamine use was significantly greater than the rates of 15.5%, 13.2%, and 9.8% reported by lesbian/bisexual women, heterosexual men, and heterosexual women, respectively (Kelly et al., 2006). In the United Kingdom, surveys administered to gay men in London gyms from 2003-2005 found that between 17.8% and 20.7% reported methamphetamine use in the previous year (Bolding et al., 2006).

Numerous studies of gay and bisexual men have documented the association between methamphetamine use and unprotected sexual behaviors, multiple sex partners, increased incidence of HIV and other STDs, and sexual compulsivity (Parsons and Bimbi, in press; Bolding et al., 2006; Fernandez et al., 2006; Hirshfield et al., 2004; 2006; Nanin and Parsons, 2006; Purcell et al., 2005; Reback and Grella, 1999; Schilder et al., 2005; Semple et al., 2006). Despite the strong connection, sex is not the only motivation for methamphetamine use among gay and bisexual men. A qualitative study with 48 gay and bisexual men who had recently used methamphetamine in a sexual encounter found that although using methamphetamine for sexual purposes (i.e. prolonging sexual encounters, reducing anxiety, and increasing openness about sexual activities) was the most common motivation for use, a variety of other motivations were provided (Halkitis et al., 2005). Participants in this study described using methamphetamine (1) to socialize in the contexts of parties, dance clubs, and bars, (2) to change their behavior by becoming more social with others, enhancing productivity, staying up longer, and losing weight, and (3) to impact their emotional state by changing one's mood to a happier more carefree state, increasing their self-esteem, making them feel removed from their lives, and making them feel less alone and safer. However, as this particular study required reported sexual behavior under the influence of methamphetamine for eligibility purposes, it remains unclear how generalizable these findings are to gay and bisexual men.

Other motivations found for methamphetamine use have included escaping loneliness, dealing with feelings of sexual unattractiveness, aging, illness, and lowering sexual inhibitions (Kurtz, 2005). Among current and former methamphetamine users, although participants reported linking methamphetamine use to sex, they also reported methamphetamine use to enhance other non-sexual work related and/or creative tasks, such as improving their ability to focus directly on particular tasks without other mental interferences and allowing them to remain on the task for longer periods of time (Reback, 1997). Some participants even described methamphetamine use as a tool for allowing individuals to move across various boundaries (e.g. age, class, race, socioeconomic subgroups) to socialize with people that they would be less likely to encounter apart from methamphetamine use (Reback, 1997).

Much of the research on methamphetamine use among gay and bisexual men has explored motivations for methamphetamine use as well as general characteristics of these users, yet little has been published about how these men initiate use. In a Los Angeles-based sample, 44% were introduced to methamphetamine by a male sexual partner or lover, 40% by a gay male friend in a gay-related social situation, and the remaining 16% of the interview participants were introduced to methamphetamines in a non-sexual/non-gay centered environment (Reback, 1997). A recent study (Brecht et al., 2007) of treatment seeking methamphetamine users with 13% of the sample being gay and bisexual men (Brecht et al., 2004) found that earlier age of methamphetamine initiation was related to race (being non-African American), criminal behavior, and initiating methamphetamine for sensation-seeking reasons.

Although previous research has documented the correlation between methamphetamine use and risky sexual behaviors, as well as motivations for using methamphetamine, little is known about the contextual situations in which gay and bisexual men are introduced to methamphetamine. With gay communities mobilizing with public health media campaigns focused on reducing methamphetamine use (Nanin et al., 2006), it is important to ascertain the patterns of initiation of methamphetamine use so that messages can be tailored accordingly for primary and secondary prevention efforts. In order to gain a broader understanding into the contexts in which young gay and bisexual men were first initiated into methamphetamine use, we analyzed 54 initiation narratives from qualitative interviews.

2. Methods

The Club Drugs and Health Project, broadly conceived, is a study of health issues among young adults (ages 18–29) involved in New York City dance club scenes. More specifically, the project is designed to examine the patterns and contexts of club drug use and its associated risks among club-going young adults with the intent of assessing the potential for prevention and education efforts. The specific club drugs of interest were ecstasy (MDMA), ketamine, GHB (Gamma hydroxybutyrate), methamphetamine, cocaine, and acid (Lysergic acid diethylamide or LSD). The assessments utilized in the study were designed to capture a broad understanding of the patterns and contexts of club drug use among club-going young adults as well as basic information on other health issues relevant to this population. The data drawn upon for this paper are derived from the baseline assessments conducted for this project, described below.

2.1. Participants and Procedures

Time–space sampling was used to systematically generate a sample of club-going young adults in New York City (MacKellar et al., 1996; Muhib et al., 2001; Steuve et al., 2001). Though designed for sampling hard-to-reach populations, it is also useful for estimates of location-based populations, such as club-going young adults. Venues were selected at random from a list of enumerated dance clubs and lounges in New York City as well as special events throughout the city (see Kelly et al., 2006; Parsons et al., 2006b). Each weekend recruitment teams were sent to randomly assigned venues. Initially, field staff randomly approached club patrons (e.g., every fifth person) during three-hour shifts selected with random start times (ranging from 9pm to 3am). However, the individual level randomization of this process was modified during the course of the project in response to challenges faced by randomly approaching patrons. For example, when a group of friends were about to enter a club, and only one individual was randomly selected, often the selected person's friends would deter them, thereby leading to increased refusals to be screened. As such, the sampling procedures were modified such that the field staff attempted to approach all club patrons during each recruitment shift.

Individuals were asked to complete a brief eligibility screening survey for which they received no compensation. If the patron consented, trained staff conducted the surveys with the use of Palm Pilots ©. If the patron refused, field staff noted the refusal and estimated age, gender, and race/ethnicity. Eligibility criteria for participation in the longitudinal study were embedded in this survey. To be eligible, the individual had to report using any of the 6 club drugs (listed above) at least 3 times in the previous year and at least once in the prior 3 months. Additionally, as this was a study of emerging adults, only individuals aged 18-29 were eligible. If a patron was found eligible, staff explained the project, distributed recruitment materials with project contact info, and collected contact information from the individual (either phone number or e-mail address). During the course of recruitment, 432 gay and bisexual men were screened as eligible for the study in the field, and of those 100 (23%) enrolled in the longitudinal study. Those who were screened as eligible but refused to participate did not significantly differ from those who did participate with regard to age, self-identification as gay or bisexual, or race/ethnicity.

2.2 Measures

The longitudinal study assessed participants every 4 months for a year (BL, 4m, 8m, and 12m). All assessments were comprised of both qualitative and quantitative components, which were pilot tested (n = 20) and subsequently revised prior to their use in the final study. All assessments were conducted at the community-based research offices of the investigators in private rooms to ensure confidentiality. During the BL assessments, upon completing informed consent procedures, trained research staff conducted a semi-structured qualitative interview. Interviewers received intensive training on the use of qualitative methods, open-ended questioning, the use of probes, and the intent behind each section of the interview. Interviewers conducted practice interviews and pilot interviews, which were reviewed by the senior investigators for quality. Additional training and supervision was provided as needed, and ongoing quality assurance occurred throughout the data collection period.

The semi-structured interview utilized Critical Incident Measures (CIM) to draw out specific narratives about their club drug using and sexual experiences (Ross et al., 1993; Leonard and Ross, 1997). CIM serve to both reduce recall bias and contextualize behaviors in specific events. Using CIM facilitates the elicitation of data on both the situational and contextual aspects of club drug use. The club drug use module of the qualitative interview covered initiation, recent club-associated, and recent non-club-associated experiences for each of the six club drugs. Participants were asked to provide this information in the form of extensive and descriptive narratives. In addition, interviewers probed to gather information surrounding the contexts and patterns of club drug use. Specific probes were used to query participants regarding sexual activity during their initiation to methamphetamine use.

The participants also completed a computer-assisted survey that measured demographics, a variety of psychosocial factors, and information concerning frequency of use for each of the six club drugs, as well as other drug and alcohol use. In total, BL assessments ranged from 2-3 hours, after which participants were compensated and, when necessary, provided any requested referrals for other services (STI/HIV screening, psychological counseling, substance abuse counseling, etc.).

The data analyzed for this paper were from the qualitative interviews of the 58 (out of 100) gay and bisexual men who indicated lifetime methamphetamine use at their BL assessment. These individuals enrolled in the study between December, 2004 and August, 2006. The 58 interviews were transcribed and reviewed for quality assurance and subsequently coded and analyzed; four of the qualitative interviews did not contain sufficient data on methamphetamine use, two due to equipment failure and two due to other interview complications, resulting in a final sample of 54 gay and bisexual males who had used methamphetamine.

2.3 Analysis

A thematic analysis was employed to generate descriptive understandings of methamphetamine initiation among the young gay and bisexual men in the sample. Thematic analyses have proven to be an effective method for evaluating qualitative data of many varieties (Miles and Huberman, 1984; Patton, 1990). We employed a team analytic strategy for the analysis. Based upon preliminary transcript reviews, the senior staff developed an overall coding scheme focused on themes and factors related to methamphetamine use and initiation among participants. The coding scheme, consisting of free and tree codes, was systematized in a project codebook. After team training on coding protocols, five interviews were coded by each member of the coding team and subsequently reviewed for reliability. Upon the achievement of >90% reliability, the coding team applied codes to the remainder of the interviews with regular oversight from senior staff. Efforts were made to maintain this scheme during the data analysis through regular meetings and discussions, during which the research team discussed coding protocols and the development of analytic frameworks. Subsequent waves of coding and analysis were conducted by the writing team. Thematic analyses were performed with the assistance of a qualitative software package, NVIVO7. Such programs have been used extensively in the analysis of observational and interview data given their utility for both indexing and coding qualitative data.

3. Results

3.1. Sample Characteristics

The mean age of the 54 participants with methamphetamine initiation narratives was 24.9 years (SD = 2.8). Over fifty percent (59.3%) of these young men were White. The demographics of the 54 methamphetamine-using participants who enrolled in the study did not significantly differ from the 196 gay and bisexual methamphetamine-using individuals who were screened eligible but failed to participate. More than half of the final sample worked full-time (51.9%) and had at least a 4-year college degree (59.3%), and nearly eighty percent (79.6%) of the sample considered their parents' class background to be middle class or higher (See Table 1). With regards to drug use, 42.6% of the lifetime methamphetamine users had recently used methamphetamine (past 4 months). Use of multiple club drugs was prevalent in this population in that 96.3% of the sample indicated lifetime cocaine use and 90.7% of the sample indicated lifetime ecstasy use. Table 2 displays more specific data on club drug and other drug use among these 54 young gay and bisexual methamphetamine users.

Table 1.

Sample Characteristics of Methamphetamine Users (N = 54)

	% (n)
Race
European/White	59.3% (32)
Hispanic/Latino	24.1% (13)
African American/Black	7.4% (4)
Asian/Pacific Islander	3.7% (2)
Mixed/Other	5.6% (3)
Sexual Identity
Gay, Queer, or Homosexual	90.7% (49)
Bisexual	9.3% (5)
Relationship Status
Partner, Lover, or boyfriend or girlfriend	22.2% (12)
Single	77.8% (42)
Education level
Some high school, High School diploma, or GED	11.2% (6)
Some college or Associates Degree	22.2% (12)
Currently enrolled in college	7.4% (4)
4-Year College Degree or Graduate Degree	59.3% (32)
Employment Status
Full-time	51.9% (28)
Part-time	25.9% (14)
Part-time work-full time student	11.1% (6)
Unemployed – Student	5.6% (3)
Unemployed – Other	5.6% (3)
Parents' Class Background
Rich	11.1% (6)
Upper Middle Class	14.8% (8)
Middle Class	53.7% (29)
Working Class	18.5% (10)
Poor	1.9% (1)
HIV Status
Have been tested for HIV	94.4% (51)
Of those who have been tested:
Positive	2.0% (1)
Negative	94.1% (48)
Unsure/Didn't get the results	3.9% (2)

Table 2.

Methamphetamine and Other Drug Use (N = 54)

	% (n)
Methamphetamine Use
Recent Use (4 months)	42.6% (23)
Of those who used during the past 4 months:
Mean +/− S.D. (days)	8.8 (18.7)
Range (days)	1-90
Have used Methamphetamine at:
Home	68.5% (37)
A Club	64.8% (35)
A Bar	33.3% (18)
A Public Place	18.5% (10)
Work	13.0% (7)
A Sex Club	9.3% (5)
A Concert	5.6% (3)
Have used Methamphetamine in combination with another drug	64.8% (35)
Drug Use
	Lifetime Use	Recent (Past 4 Months) Use
	% (n)	% (n)
Club Drugs
Cocaine	96.3% (52)	94.4% (51)
Ecstasy	90.7% (49)	42.6% (23)
Ketamine	72.2% (39)	25.9% (14)
GHB	46.3% (25)	13.0% (7)
LSD	53.7% (29)	5.6% (3)
Other Drugs
Alcohol	100% (54)	88.9% (48)
Marijuana	96.3% (52)	96.3% (52)
Poppers	72.2% (39)	48.1% (26)
Crack Cocaine	22.2% (12)	7.4% (4)
Heroin	18.5% (10)	5.6% (3)

*Out of the 6 club drugs, one participant has only used Methamphetamine.

3.2. A Descriptive Profile of Methamphetamine Initiation

The typical participant was initiated into methamphetamine in a social setting, most generally a club, bar, house, or an apartment, amongst a group of friends or social acquaintances. Generally, the participant acquired the drug from the same person with whom he used the drug (i.e. friend, acquaintance). The typical participant had very little knowledge about methamphetamine at initiation, although he had prior experience with other club drugs. Most often, initiation occurred via nasal inhalation of a small quantity of methamphetamine. Although this was considered to be typical of a methamphetamine initiation experience, further analyses explored the variety of contexts and underlying themes that emerged.

The initiation narratives revealed that the participants were most commonly initiated into methamphetamine use in a house/apartment or a club/bar (See Table 3). Although the initiation experiences did not greatly differ across locations, some patterns emerged when the initiation experiences of those initiated into methamphetamine in a public setting (i.e. club or bar, streets, rave, festival) were compared with those initiated in a private setting (i.e. house or apartment). All of those initiated in a public setting snorted methamphetamine at their initiation, whereas some (n = 6) of those initiated in a private setting reported smoking methamphetamine at initiation. The participants seemed to have a general sense that smoking methamphetamine was more hazardous and intense than snorting. One participant stated:

Table 3.

A Descriptive Profile of Methamphetamine Use Initiation (N = 54)

Location of Initiation to Methamphetamine
House/apartment	44.2% (19)
Club/bar	39.5% (17)
A rave	7.0% (3)
Around the streets	4.7% (2)
Circuit party	2.3% (1)
Festival	2.3% (1)
Unreported	20.4% (11)
Social Context of Initiation to Methamphetamine
Friends	46.9% (23)
Individuals that they had just met that evening	16.3% (8)
Significant others	14.3% (7)
Acquaintances	8.2% (4)
Sex partners or intended sex partners	8.2% (4)
Alone	6.0% (3)
Unreported	9.3% (5)
Acquisition of Methamphetamine During Initiation
Friends	32.6% (15)
Individuals that they had just met that evening	21.7% (10)
Significant others	13.0% (6)
Dealers	13.0% (6)
Acquaintances	8.7% (4)
Sex partners or intended sex partners	8.7% (4)
Family members	2.2% (1)
Unreported	14.8% (8)

• Smoking it's really addictive. They say you can get instantly addicted if you smoke it, and I've heard that people that say that smoking it is so much better but, I'd never go there, cause I'm not trying to - I don't really have an addictive personality, I don't think, but I don't want to even mess with the chance of getting addicted to smoking crystal. (ID # 5327, 22 years, White)

Other themes emerged when comparing public and private initiation experiences. Though most men did not have sex at initiation, a majority of the participants who did have sex at initiation were initiated in a private setting. Furthermore, some of the participants who were initiated in a public setting reported accidental methamphetamine use; they thought that they were taking cocaine rather methamphetamine. Both of these themes are more fully explored in subsequent sections.

The majority of young men were initiated into methamphetamine use in a social setting, with very few (n = 3) reporting using methamphetamine for the first time alone. Furthermore, most of the participants acquired methamphetamine at their initiation from the same person(s) who they initiated with. More specific breakdowns of the wide range of social settings in which participants were initiated into methamphetamine and who they acquired the drug from are displayed in Table 3.

3.3 Prior Exposure to Methamphetamine and other Club Drugs

Several participants stated that they knew very little about methamphetamine before they used the drug for the first time.

• I'd never seen it, never. I didn't know anything about crystal when I took it. I didn't even know it was a powder, snorted through the nose, I didn't know anything about it. (ID # 5141, 19 years, Mixed Race)

  I had heard it called “speed.” I had heard it called “crystal meth”. I didn't know if I was doing crack. I didn't know what it was. (ID # 5324, 26 years, White)

  I had met this guy online who lived around the corner. We met and hung out and, you know, were generally agreeable and attracted to one another and - so we had - we hooked up once and he offered me drugs and he called it “C” or “T” and I was like, “T? What's a T?” But I didn't ask, I was like, “No, no, it's okay.” And then the second time we hooked up he - you know he gave me this pipe to smoke and I first thought it was just marijuana, but then I looked down and I was like, “That's not a marijuana pipe and I know better than that.” (ID # 5065, 27 years, White)

Beyond a general lack of knowledge about methamphetamine at their initiation, some participants who were initiated into the drug at a club or bar reported that they accidentally used the drug, thinking that it was cocaine.

• I assumed it was coke. When I saw the white powder I didn't think it could be anything else besides coke. (ID # 5141, 19 years, Mixed Race)

• We were out at a club and I was drunk. I was completely drunk. And, so my friends were like, “Here, do a bump”. And I thought that it was coke, but it was crystal, so, and it was a mistake. But I didn't even realize and even understand or know. So that was crazy. I just met a group of people who were apparently doing crystal, but I didn't know. Because I was 17 and I didn't even think to ask stuff like that. (ID # 5346, 21 years, White)

Most of the participants (n = 33) did not actually plan to use methamphetamine at the time they first used the drug. Only three indicated that they actually planned in advance to use methamphetamine that first time. The remaining others described trying the drug by accident, with little knowledge about what methamphetamine actually was, or they reported using the drug for the first time spontaneously, in the heat of the moment.

Although only three participants stated that they planned to use methamphetamine, others stated that they were very open to drug experimentation in general.

• Me and my friend are sitting on his floor and his stepbrother knocks on the door and he asks if we wanted to try something and we're like - I'm always like, I want to try everything. I'll push every button. I'll do whatever. (ID # 5331, 25 years, Latino)

• I'm the kind of person who won't say no to anything. It's a character flaw in my mind. I don't like being that person. It's the type of person I am, with the exception of GHB, like nothing has been put in front of me that I haven't taken. So, it was kind of like yeah, why not. It's here. I'll try it, see what it does. (ID # 5242, 24 years, White)

Interestingly, neither of these men reported sexual activity in conjunction with their initiation to methamphetamine (nor did they report ever having sex under the influence of methamphetamine at their BL assessment).

Several young men (n = 15) stated that their initiation experience was the only time that they ever used methamphetamine. Although some of them (n = 5) stated that they did not use it again because they had little access to the drug and that it was generally not in their circle, most (n = 10) reported making an active decision not to use methamphetamine again after their first experience.

• I was like, “Why the hell did I do this?” So I vowed that I would never touch it again. And I never touched it again. (ID # 5225, 26 years, White)

  Then I started finding out how it started infecting the gay community and what it can do to you when it comes to gay sex. You know, you hear these horror stories of these guys on crystal meth binges who have like anonymous sex, unprotected with 50 guys. I was like, “this is the worst, most disgusting thing in the world and I can't believe anyone would do this” … And that was the only time I did that. (ID #5143, 24 years, White)

  I won't ever do it again because of what I've heard about the addiction and the process recovering from that and what it's done to people's lives. That's something I don't want to get stuck in. I have enough problems. (ID # 5084, 26 years, White)

One participant (ID # 5117, 22 years, Latino), stated “I'm not gonna destroy my life” when asked if he would ever use methamphetamine again.

Although many participants knew little about methamphetamine at their initiation, many reported prior experience with other drugs. When looking at the context of methamphetamine use for these participants, it is important to consider their prior drug use to determine where methamphetamine fits in the trajectory of their use of club drugs in general. Very few (n = 3) of the participants reported that methamphetamine was the first of the six club drugs that they had used and only slightly more (n = 7) indicated that it was the second of the club drugs that they had used. Thus, a majority (n = 38) had used at least two other club drugs before using methamphetamine. The sentiment commonly expressed was that methamphetamine is generally not a drug for inexperienced club-drug users.

• The thing is, I was always curious about doing drugs or whatever, but that's (methamphetamine) a crazy first drug to try. That's the one you try last, right?” (ID # 5058, 23 years, African American)

Several young men (n = 17), without any probing and regardless of their experience with methamphetamine, used cocaine as a basis of comparison when describing their first experience with methamphetamine.

• It felt like coke but twenty times stronger. It just wakes you up. I don't know. It's so much stronger. And the high lasts way longer than coke. Like you can do a line of Tina and it'll last like I don't know, four hours and it'll still be pretty intense. (ID # 5309, 19 years, Latino)

• It was a prolonged cocaine sensation, whereby on those two or three little bumps I was able to sustain that feeling for a longer period of time. With cocaine, after a while the effect wore off. You have to do another line and, you know, and then of course with Tina you are awake. (ID # 5233, 29 years, White)

Many of these participants expressed that this elongated more intense sensation that they felt from methamphetamine (in comparison to cocaine) is what they actually liked most about the drug at initiation.

• It was a much more intense euphoria than coke. Coke - I still feel like myself, I just feel like wacky, and funny, and jittery, and like I'm more alert. [On] Crystal, I did not feel like myself, I felt totally - it was like amazing. It was, I mean I've never loved a drug like that before, and never since. (ID # 5305, 28 years, White)

• I'd been doing a ton of coke that night and I was like, ‘Well, this just really isn't doing it anymore.’ Ten minutes later I was so high and I was just bouncing around this party like there was no tomorrow. It was just a really, really, really fun time. (ID # 5126, 22 years, White)

Another participant similarly stated that he viewed frequent methamphetamine users as people who are in search of a more intense cocaine high:

• People that did so much coke that it's not even affecting them anymore. They need like high amounts of coke to feel anything. People that don't get a drip off of a bump. They move onto better things. (ID # 5309, 19 years, Latino)

Another participant described cocaine as, “Crystal's younger, weaker, disabled sister.” (ID # 5378, 22 years, White)

Although, most of the participants who used cocaine as a basis of comparison when describing their methamphetamine initiation described how methamphetamine was similar to cocaine, some of these participants used cocaine as a frame of reference to describe how their methamphetamine experiences differed from their cocaine experiences.

• I remember trying to equate it to cocaine, which you can't do. There's not a feeling of euphoria associated with it, as with ecstasy and cocaine. (ID # 5041, 27 years, African American)

• [Crystal meth] didn't feel glamorous like coke did. This was like a crack den. This is, you know, broken off glass pipe with a lighter and we just need like a spoon and syringe and you know a baby crying in another room. (ID # 5324, 26 years, White)

This is further exemplified by one man who stated:

• There is a sort of rush that I get from cocaine that doesn't translate at all for methamphetamine. And I feel like I want to compare them, even though they are probably extremely different drugs.” (ID # 5392, 24 years, White)

3.4. The Effects of Methamphetamine at Initiation

Several participants described the effects of methamphetamine in a positive manner, based on their initiation experience. Methamphetamine helped them feel more alert and awake. Several men explicitly used the term “speed” or “speedy” to describe the initial impact of methamphetamine. One man (ID # 5143, 24 years, White) stated, “I'm just like really speedy and talkative.” Other participants also mentioned that methamphetamine made them incredibly talkative and hyper. Another (ID # 5123, 26 years, White) stated, “My heart started pounding and I started talking a lot.” Some described the effect of heightened awareness:

• It got me feeling a little drunk, but still aware. My mind was aware. That was good for staying up and getting a bit of energy - necessary if you want to remain awake. (ID # 5084, 26 years, White)

Several participants described increased confidence as an effect of methamphetamine use during their initiation experience. One man (ID # 5305, 28 years, White) stated, “I felt like I could talk to anybody without any hesitation, completely confidently.” Another (ID # 5083, 26 years, Latino) stated that, “It made me feel like I was invincible. Like I had super powers or something.” One participant (ID # 5058, 23 years, African American) even stated that methamphetamine, “Gave me an air of confidence. Like I thought I was the only one in the world.” The participants describing the increased energy and confidence as a positive impact does not come as a surprise given that many of the participants were initiated into methamphetamine use in social settings.

Another positive effect reported by some participants was the effect of methamphetamine on focus and productivity. Some participants mentioned that when they were initiated into methamphetamine use, that they were able to focus on a particular task, ranging from housework to professional work, and achieved high levels of productivity.

• When I do crystal I can really, really focus and not get sidetracked by anything. With crystal I can really focus and really get things done. (ID # 5327, 22 years, White)

• People gave it to me so I would help them get stuff done. And it worked actually. I mean, and it was, it was weird, I remember the first time I did it, I was like this is stupid. I'm not going to want to paint now just because you gave me this drugs and I did. I thought I could paint straight for like six or seven hours. It was like 4 o'clock in the morning. I was like why am I still painting? It didn't dawn on me at the time that it was actually the Tina I had done five hours before. It's more for a purpose, for productivity's sake. (ID # 5242, 24 years, White)

However, some of the reported positive effects came with a price. Many of the participants reported that the increased amount of energy often resulted in difficulty sleeping. One man (ID # 5058, 23 years, African American) stated that, “I couldn't sleep because it keeps you up so much. I was up that day for at least 48 hours all together.” Others expressed feeling a great amount of distress due to not being able to fall asleep.

• I went home and I tried to go to bed, and I couldn't. I could not go to bed. That was when I was like going crazy because I just wanted to fall asleep and just could not. My eyes were stinging and I just felt horrible. I got kind of depressed like towards because I couldn't fall asleep. I was like, ”Why the hell did I do this?” (ID # 5225, 26 years, White)

• I was lying in bed until 10-11am, could not fall asleep, was trying to fall asleep, like felt really, not paranoid but just really edgy, like, “Why am I not falling asleep?” And it was freaking me out – not freaking me out, but just like, it's like the worst feeling in the world. It was a really bad come down and I could not fall asleep, and I think I did eventually fall asleep at like 3 or 4 but when I feel asleep I fell asleep but it was just terrible after that cause you're just like really jittery and you're really jittery and you feel like you have to keep moving. You can't sit still. (ID # 5209, 24 years, Asian or Pacific Islander)

In addition to having trouble sleeping, several participants discussed having a hard time coming down from the drug at initiation. One man (ID # 5045, 20 years, White) described the comedown as his being “…antsy, very antsy. Wanting more.” Another participant (ID # 5305, 28 years, White) stated that, “The comedown was horrible. I mean it ruined the whole trip.” Other participants even expressed that they felt sick when coming down from the drug. One man (ID # 5058, 23 years, African American) said, “It was good but afterwards it was horrible. Maybe a few hours afterwards I just all of a sudden felt dead tired and like crap and it was just the worst feeling.” Another stated:

• I had a really bad fever and had the chills. You know I was throwing up. I was just really, really sick. Like I had the chills like the worse I've ever had them like where you're so cold and like where you go to touch your skin and it just hurts. That kind of feeling. You know headaches. I didn't eat anything for like two days and that was sort of all coming down at me at the same time. (ID # 5331, 25 years, Latino)

3.5 Methamphetamine and Sexual Behavior

Another theme pertaining to the effects of methamphetamine at initiation was that the drug had an effect sexually. Few participants (n = 8) reported that they had sex in conjunction with their initiation into methamphetamine use, although an additional 15 men reported combining methamphetamine with sex at some point beyond initiation.

• I met this guy online, or whatever, and then like I was over at his house and we were just chilling out watching movies and talking and then one thing led to another. It was my birthday and I was just like “Oh, what's that?” you know – and I was like “no, no, no.” And then he was like “Oh, just do it. Blah, blah, blah, like it's not going to hurt you.” So then he did it, and I was like, “Well, he's OK, he's not dead, so let me just try it.” And then I tried it, and honestly like – well, it was combined with sex, though. (ID #5058, 23 years, African American)

There was a general sentiment from these participants that the drug made them more aggressive sexually.

• Tina, it just made me like - I don't know, it's like more, like sexual, more like aggressive, like sexual. I just wanted to have sex. Sex was amazing. You could do it for hours. It was great. It was great. And, actually it was more intense, I think. It was more intense. (ID # 5103, 25 years, African American)

• It was just the two of us in his apartment and it was pretty apparent that sex was going to happen also. So he actually, before anything had even happened after we smoked he shoved Viagra down my throat. He's like, “Here, you're going to need this”. I was like, “Oh yeah”. Because I guess he wanted to get fucked all night. And we did. And like you know it was, you know, it made me, I had a lot of sort of energy and it made me really, really aggressive. (ID # 5324, 26 years, White)

Although only eight of the participants actually reported having sex in conjunction with their initiation to methamphetamine use, several of the other participants did mention how the drug did have some effect on them sexually at their initiation.

• I felt great, I felt completely without reservation, without inhibition. I feel like I'm reading off like a textbook or something, of things that makes drugs fun. But, I was just completely liberated and I was like very, very, very sexually confident. (ID # 5305, 28 years, White)

Furthermore, one participant, when asked if methamphetamine affected him sexually, responded:

• Yeah, but I can kind of control myself. Like some people like all going to the [bathhouse] to have sex. But for me, I'm just scared getting about stuff like HIV or something. I'm a pretty much safe person. So I just can handle the control. You can feel so much desire in here, but I'd rather just do orgasm by myself. (ID # 5006, 29 years, Asian or Pacific Islander)

Some differences were identified qualitatively between those who did not report having sex at their methamphetamine initiation and those who did. Specifically, those who reported having sex during their initiation were more likely to report first use with a significant other, someone they were dating, or an anonymous sex partner. That is, often the initiation was via the sex partner, and thus the first time using the drug was combined with sexual activity. Although the majority of participants did not report a methamphetamine-sex connection during their initiation to the drug, this was particularly true for those who reported a general propensity for drug experimentation and for those who reported using methamphetamine when they thought they were using cocaine. Further, when methamphetamine initiation took place in a club setting, it rarely led to sexual activity; methamphetamine initiation was more often combined with sexual behaviors when the initiation took place in the home of the participant or their sexual partner.

4. Discussion

Methamphetamine was used in a purely social, non-sexual setting for an overwhelming majority of the participants. In fact, only a minority of the young men actually engaged in any sort of sexual act when they were initiated into methamphetamine use. This finding, given the recent research that links methamphetamine use to sexual behavior in gay and bisexual male communities (Bolding et al., 2006; Fernandez et al., 2006; Halkitis et al., 2006; Hirshfield et al., 2004; 2006; Nanin and Parsons, 2006; Parsons and Bimbi, in press; Purcell et al., 2005; Reback and Grella, 1999; Schilder et al., 2005; Semple et al., 2006), may come as a surprise and indicate that among young gay and bisexual men (1) methamphetamine use is not always associated with sex and (2) even among those who do combine methamphetamine and sex, initiation does not always occur in the context of a sexual setting.

It is possible that the overwhelming majority of our participants were initiated to methamphetamine in a purely social, non-sexual setting simply because they were all recruited at club settings. The young gay and bisexual methamphetamine users who use the drug primarily for sexual purposes may not frequent club venues. However, it also may be that the methamphetamine-sex connection is stronger among older gay and bisexual men since the participants in many of the studies that found a strong methamphetamine-sex connection were, on average, older (Bolding et al., 2006; Fernandez et al., 2006; Nanin and Parsons, 2006; Parsons and Bimbi, in press; Semple et al., 2006) than the participants in our sample. Although an additional subset of the participants reported an eventual combination of methamphetamine and sex after their initiation to methamphetamine, the total reporting any connection remained less than half. Members of the public health community designing methamphetamine prevention campaigns should not solely focus on the link between methamphetamine and sex, as this is likely to miss a significant number of gay and bisexual young methamphetamine users.

Many participants expressed limited knowledge about methamphetamine prior to initiation. For many of the participants, at the time of their initiation, methamphetamine was not a drug that was on their radar. However, most of these young men had used other club drugs before initiating into methamphetamine. This demonstrates that among young gay and bisexual men in New York City, methamphetamine was typically used for the first time after other drugs. Thus, it is not generally a drug that is used by the naïve drug user but rather is a drug that individuals will try after previous experimentation with other club drugs.

The fact that participants had limited knowledge about methamphetamine before initiating could be a result of a variety of factors. It is possible that many of these participants were initiated into methamphetamine before it became a major public health concern and received the attention that it has received in the media over the past few years (Nanin et al., 2006). It is also possible that since gay men tend to have higher rates of drug use than members of the general population (Thiede et al., 2003; Parsons et al., 2006a), they may be more desensitized to drug use in general and in turn may be more open and willing to try different drugs that are new to their scene. This would not be surprising given the fact that some participants self-identified as risk takers with regard to drug experimentation.

The participants' willingness to use methamphetamine in the absence of much information has a variety of implications. This demonstrates the need to continue to educate members of the gay community about methamphetamine. In particular, gay community centers located in places that have yet to see a methamphetamine epidemic should take preemptive measures to educate members of their community before the drug becomes embedded within it.

This research can be used to educate individuals about specific effects so that they can be fully aware of the potential consequences they may face by trying methamphetamine. For instance, had some of the participants who were accidentally initiated into methamphetamine use known more about the drug, then they may have been generally more aware of methamphetamine's presence and may have been less likely to inadvertently use the drug. As researchers have argued that knowledge of possible adverse effects of drug use acts as a deterrent on initiation (Behrens et al., 1999), early education is imperative to halt the initiation of new individuals.

Many participants used cocaine as a basis for comparison when describing various effects during their initiation to methamphetamine. More specifically, many described the drug as a more severe and more potent version of cocaine. This finding, although not surprising given that the drugs are both white powdery stimulants, does have a great deal of relevance and should not be overlooked. The participants' association of methamphetamine with cocaine—combined with the attention that the media that has been dedicating to addressing methamphetamine and its association with high-risk behaviors in the gay community—has implications for drug trends within the gay community. Recent stigmatization of methamphetamine through media campaigns (Nanin et al., 2006) may be leading members of the gay community to seek out a drug that they may view as more socially acceptable and that has less severe negative impacts (i.e. cocaine). The association between methamphetamine and cocaine use in the gay community is a topic of great importance that deserves further exploration.

4.1 Limitations

As is the case with any retrospective study, the data may have been limited by subject recall. Some participants initiated the use of methamphetamine several years ago. However, CIM were used to minimize problems associated with recall, by permitting the participant to recall the entire scenario and story associated with their methamphetamine initiation. Semi-structured interview guides are extremely useful for producing rich narrative data regarding drug use, and initiation to drug use. Such interviews allow the respondent to take the narrative of an event elicited by a CIM in a direction that is most meaningful to him and relevant to his experience of the phenomenon. However, the lack of a total structure may at times lead to missing data for specific items. In the course of such interviews, details deemed insignificant by the respondent may not be fully described. Incisive probing can help to reduce the amount of missing data, yet even the best of interviewers may at times miss details that do not seem significant until analysis. In the course of this study, some interviews yielded missing data on some issues, such as age at methamphetamine initiation. As a result, we are unable to comment on the role that age plays in contextual issues surrounding initiation. While this does not invalidate the data, it does not account for the full sample and as such remains something to be noted.

The Club Drugs and Health Study was limited to a club-going sample of young adults who live in the New York City metropolitan area. In this sense, the sample was comprised of individuals who frequent dance clubs, which perhaps influences their drug behaviors and opportunities for the initiation of methamphetamine. Additionally, these participants all reside in and around a major urban center, which may also have influenced their exposure to club drugs, and initiation to methamphetamine in particular. Finally, as with the majority of studies of substance users utilizing non-treatment seeking samples, these data were limited to a sample of those willing to participate in a research study, wherein they will need to discuss the intimate details of their illegal drug use. Although the use of time-space sampling imposed a systematic method of recruiting participants in order to reduce potential bias, ultimately those who consented and participated may be different from the broader club population.

Despite these limitations, these findings have clear implications for prevention, intervention, and for future research that addresses methamphetamine use among gay and bisexual men, particularly those who frequent club venues. Although much of the previous research characterizes methamphetamine as a “sex drug” for members of this community, the present study demonstrates that, at least upon initiation, for many gay and bisexual men this is not the case. The understanding that methamphetamine is not solely used as a sexual enhancement for members of this community may enable health workers to more accurately target potential users when putting forth intervention efforts. Media campaigns and other prevention materials regarding the dangers of methamphetamine should be targeted to gay and bisexual club venues, as they are likely to reach an important group at risk for both the initiation of and continued use of methamphetamine.

4.2 Conclusions

As methamphetamine use continues to be a pressing health issue on several continents, much work remains in the areas of research, prevention, and treatment. Future research on methamphetamine use among gay and bisexual men should more fully account for the intersection of methamphetamine and sexual behavior over the social course of methamphetamine use. Clearly, the patterns of use for young men may change over the trajectory of their methamphetamine using careers. In addition, further explorations of the relationship on attitudes towards methamphetamine and cocaine among members of this community is needed to determine if the stigma increasingly placed upon methamphetamine is having any impact on cocaine or other drug use by gay and bisexual men. Prevention and education efforts must account for the range of ways methamphetamine is used by gay and bisexual men as well as attend to the generational influences on patterns of use.