Methamphetamine and Young Men who have Sex with Men: Patterns, Correlates and Consequences of Use

Abstract

Objectives

To examine patterns, consequences and correlates of methamphetamine use among adolescent/young adult men who have sex with men (YMSM).

Design

Descriptive, bivariate and hierarchical regression analyses of cross-sectional data.

Setting

Howard Brown Health Center, a community-based facility in Chicago, IL from 2004-2005.

Participants

310 YMSM age 16-24 completed an anonymous, computer-assisted survey.

Main Outcome Measure

Methamphetamine use in the past year.

Results

Participants ranged in age from 16-24 years (M=20.3); 70% were of color. Participants reported a number of high-risk sexual and substance use behaviors. Thirteen percent used methamphetamine in the past year. Methamphetamine use was more common among HIV-infected participants, odds ratio (OR) = 2.8; 95% confidence interval (CI) = 1.3-5.3, and varied by age and race/ethnicity; substantially higher prevalence was reported by older and non African-American YMSM (p<0.001). Compared to other illicit substance users, methamphetamine users reported more memory difficulties, impairments in daily activities and unintended risky sex resulting from substance use (all p<0.01). Hierarchical regression identified sexual risk (unprotected intercourse and multiple partners), sexualized social context (e.g. internet sex, sex in a bathhouse/sex club, sex with older partners, and commercial sex), lower self-esteem and psychological distress as correlated with methamphetamine use among participants (p<0.05).

Conclusions

A substantial proportion of YMSM in this sample use methamphetamine. Methamphetamine use is a public health problem with significant implications for the health and well-being of adolescent/young adult MSM. Methamphetamine use was associated with HIV-related risk and patterns of use were predicted by demographics, sexualized social contexts, and psychological variables.

Crystal methamphetamine is an addictive stimulant whose use nationwide has become a troubling epidemic.¹ Although methamphetamine use is widespread among a variety of populations, it is particularly prevalent and consequential among men who have sex with men (MSM).^1-3 Data from national and non-representative samples have found annual prevalence rates of methamphetamine use in adult MSM ranging from 12-30%.⁴ The popularity of methamphetamine among MSM appears to stem from its association with sexual activity and its strategic use by gay and bisexual men in negotiating sexual encounters and increasing sexual pleasure.⁵ As a result, a strong association has been described between methamphetamine use and high-risk sexual behaviors such as unprotected anal intercourse and sex with multiple sexual partners in both HIV+ and HIV- adult MSM, and the substance has emerged as a significant risk factor for the acquisition of HIV and other sexually transmitted infections (STIs).^6-10 Over the course of the past decade, methamphetamine use and risky sex, particularly within the context of specific, highly charged sexual environments (e.g. the Internet, circuit parties, bathhouses, sex clubs), has been reported in adult MSM in multiple urban centers.^2,11-14 In addition, individual-level psychological factors such as self-esteem, loneliness or isolation have also been implicated as correlates of methamphetamine use in adult MSM. For example, it has been reported that MSM may use methamphetamine as a means of “escaping” underlying psychological distress such as low self-esteem, loneliness, grief or depression; each factors potentially exacerbating HIV risk in this vulnerable population.^15-18

In response to growing concerns about methamphetamine use and sexual risk for HIV infection among MSM the Centers for Disease Control and Prevention (CDC) sponsored a consultative meeting to identify directions for much-needed methamphetamine-specific research and clinical practice, in January 2005.¹⁹ Suggestions for future research included: (1) exploring the natural history of methamphetamine use and its association with sexual risk behaviors, (2) exploring the social and sexual context of methamphetamine use in populations for whom use is associated with sexual risk behaviors, and (3) exploring the relationship between methamphetamine, sexual risk behaviors and HIV infections in subpopulations of MSM.

For one understudied subpopulation, adolescent and young adult MSM (YMSM), methamphetamine use and HIV risk is of specific public health importance. Younger MSM may use methamphetamine more frequently than older MSM; preliminary data from the National HIV Behavioral Surveillance System shows a 21% annual prevalence of methamphetamine use among YMSM age 18-24, compared to 12% in the overall adult MSM sample.⁵ In addition, YMSM represent one of the highest risk groups for the acquisition of HIV. The CDC's Young Men's Survey of over 4,000 YMSM age 15-22 in seven U.S. cities found 7.2% to be HIV+, a prevalence rate higher than comparable samples of youth.²⁰ Risky sex continues to be observed in YMSM samples and is often associated with alcohol and substance use.^14,21-25 Although much has been written about young MSM, HIV risk and substance use, there has been a paucity of research exploring the patterns, consequences and social and psychological correlates of methamphetamine use in this adolescent/young adult subgroup at very high risk for HIV infection.

This study explores methamphetamine use in an ethnically-diverse sample of YMSM from the urban Midwest. We had two main objectives: (1) To describe patterns and consequences of methamphetamine use; and (2) To examine the relationship between methamphetamine use and sexual risk, individual-level psychological factors and specific sexualized social contexts. These data will be useful in the design and development of HIV and substance use prevention interventions tailored to the unique determinants of risk of young MSM.

Methods

Participants and Procedures

A community-based sample of 496 ethnically-diverse, 16-24 year old, lesbian, gay, bisexual and transgender (LGBT) youth from Chicago participated in the study. For the purposes of this analysis, biological females (N = 153) and male-to-female transgender youth (N = 33) were excluded, leaving a final sample size of 310 self-identified young MSM. Youth were recruited consecutively over 12 months in 2004-2005 from multiple sources including: flyers posted in retail locations frequented by LGBT individuals (i.e. stores, coffee shops, restaurants), flyers posted in LGBT youth-serving agencies, email advertisements posted on high school and college list-serves, palm cards distributed in LGBT-identified neighborhoods, and snowball sampling. No data was collected on the specific recruitment source for individual participants; however, recruitment venues specifically excluded traditionally high-risk settings such as bars, dance clubs, sex clubs, or bathhouses.

Prior to enrolling any participant, trained staff assessed his/her decisional capacity to consent, and reviewed study procedures and risks and benefits of participation. To maximize confidentiality we obtained only verbal rather than written consent. Parental consent was not required. The informed consent procedure highlighted that participation was voluntary and anonymous, and that declining would have no impact on access to services. Surveys were administered in a private room at one of two settings, a local youth center or a community-based health center providing primary care, STI and HIV specialty care and social services to the LGBT community. Participants completed a 90 minute, Computer Assisted Self-Interview (CASI) interview assessing sociodemographics, psychological variables, alcohol and drug use, and sexual behaviors. Participants received $30 for participating. The Institutional Review Boards of Children's Memorial Hospital and Howard Brown Health Center approved all study procedures prior to data collection.

Measures

Demographic measures included age, self-reported race/ethnicity, sexual orientation, housing status and socioeconomic status. Participants were also asked whether or not they had ever been diagnosed with HIV or other STIs.

Our dependent variable, methamphetamine use, was determined with the following question, “Have you used methamphetamine (meth, tina, chalk, ice, crystal, glass) anytime in the past year?” Participants responding in the affirmative were asked approximately how many times they used methamphetamine in the past year.

Independent variables included sexual risk behaviors, social context variables and psychological measures.

A version of the AIDS-Risk Behavior Assessment (ARBA) adapted for sexual minority youth was used to assess sexual risk behaviors.²⁶ Participants reported their overall numbers of anal receptive and anal insertive sex partners over the previous year and previous three months, and the percentage of time they used condoms with their anal sex partners over the previous 12 months using a Likert ordinal scale with options ranging from “always” to “never.” They also described the age of their last three receptive and last three insertive partners. For these analyses we focused on two variables: any unprotected anal sex over the previous year, and multiple partners over the previous three months. Unprotected anal sex was coded positive for individuals who reported anything less than 100% condom use for either receptive or insertive anal sex in the past 12 months. Multiple anal sex partners was coded positive for individuals reporting more than one receptive or insertive anal sex partners in the past 3 months.

Separate items addressed the social context of participants' sexual activity. Participants were asked if they had ever (lifetime) had sex in venues such as sex clubs or bathhouses, had any (oral or anal) sex with a partner met through the Internet, or had sex “in exchange for money or drugs.” In addition to these binary items, participants indicated the approximate age of their last three receptive and last three insertive anal sex partners. We coded any participant who reported any anal sex with a partner 10 or years older than themselves as having had sex with an “older partner.” The Internet sex question was not added until after the first 22 participants had completed the assessment, thus this item had a higher rate of missing data, although it was missing completely at random as defined by Little and Rubin.²⁷

Psychological factors were measured by validated instruments previously used with adolescents or populations at-risk for HIV. They include:

Psychological Distress

The Brief Symptom Inventory-18 (BSI-18; Derogatis, 1983) is an 18-item measure commonly used to screen for psychological distress and psychiatric disorders in medical and community populations.^28,29 Responses were recorded on a five-point scale from “not at all” to “extremely.” The Global Symptom Inventory (GSI) of the BSI-18 was used to measure psychological distress among participants; higher scores = increased distress. The GSI has a reported alpha coefficient of 0.89; our sample's alpha was 0.92.

Self-Esteem

The Rosenberg Self-Esteem Scale (RSES; Rosenberg, 1965) is a 10-item global measure of self-esteem with responses recorded on a 4-point scale from “strongly disagree” to “strongly agree.”³⁰ For the purposes of this study, higher scores = lower self-esteem. The RSES has been widely used with adolescents with alphas coefficients >0.70; our samples alpha was 0.87.

Loneliness

The Social and Emotional Loneliness Scale for Adults (SELSA; DiTomasso & Skinner, 1993) is a multi-dimensional measure of emotional and social loneliness and connectedness.³¹ The SELSA has a 12-item romantic loneliness subscale with responses scored on a 7-point scale from “very strongly disagree” to “very strongly agree.” For the purposes of this study, higher score = more loneliness. The romantic subscale of the SELSA has a reported alpha coefficient of 0.89; our sample's alpha was 0.90.

Consequences and other negative patterns of methamphetamine use were assessed with 5 items: (1) “During the past year how often have you failed to do your regular activities or take care of your responsibilities (taking medications, completing school work, going to work, etc.) because of using drugs other than alcohol?” (2) “How often during the past year have you been unable to remember what happened the night before because you had been using drugs other than alcohol?” (3) “In the past year, how often have you had receptive anal sex while high?” (4) “After using drugs other than alcohol have you ever done something sexually that you had not intended to do (had unplanned sex, not used a condom, etc.)?” (5) “Have you ever used dugs other than alcohol only because a date or sexual partner wanted you to?” For each item participants were coded positive if they reported any drug-related activity.

Statistical Analyses

Statistical analyses were conducted in four steps using SPSS 13.0 (SPSS, Chicago, IL). Listwise deletion was used for participants with missing data, which included the 22 participants who were missing the Internet sex question and two participants who were missing data on other variables. In step one, we examined frequencies of the demographic data, methamphetamine use, and sexual and substance use risk behaviors for descriptive purposes. In step two, we used Pearson's Chi-square test statistic to test the association of methamphetamine use with the demographic characteristics of age, race/ethnicity and HIV sero-status, and to test the association of methamphetamine use negative drug-related consequences and patterns of use. The latter analyses included only participants who reported recreational substance use (i.e. street drugs, marijuana, etc.) other than alcohol in the previous 12 months (n = 172, or 55.5% of the original sample). We contrasted participants who reported any methamphetamine use (n = 39) to those who reported using any drug other than methamphetamine (n = 133). Effects were considered significant at p<0.05. In step three, the effect of each independent variable on methamphetamine use was assessed with separate hierarchical regression analyses, using age, race/ethnicity and HIV sero-status as covariates in an initial step, followed by the independent variable. Race was dummy coded with White as the reference group. Finally, in step four, multiple hierarchical logistic regression modeling was used to determine the variables most highly correlated with methamphetamine use after adjusting for the effects of the other variables in the model. Correlations between independent variables were initially computed to screen for multicolinearity prior to inclusion in the regression analyses. The correlation between self-esteem and depression was 0.64; the majority of the other correlations were less than 0.3 and the highest was 0.39 (between multiple anal sex partners and history of unprotected anal sex). To minimize the number of independent variables in the model, only those significant from the initial bivariate analyses were included in the multiple regression analysis. We entered the covariates as a block in an initial step, followed by the complete set of independent variables in a second step. To adjust for multiple statistical tests we set alpha to p<.025 for this analysis.

Results

Demographics, sexual behavior and drug use

Table 1 summarizes the demographic characteristics, and the sexual and substance use risk behaviors of the sample (n=310). Participants ranged in age from 16-24 years (M=20.3, SD=2.4); 54% were under age 21. Eighty-two percent self-identified as gay, 70% were from communities of color, and 70% classified the home they grew up in as middle class. Participants endorsed a number of high risk sexual and substance use behaviors: 25% ever had sex in exchange for resources (i.e. money or drugs), 26% ever had sex in either a sex club or bathhouse, 44% reported unprotected anal intercourse. Fourteen percent of the sample reported a known HIV+ sero-status. Fifty-one percent reported using marijuana in the past 12 months, and 13% (n=39) reported methamphetamine use in the past year. Greater than 70% of methamphetamine users reported using the substance more than twice in the past year.

Table 1. Demographics, sexual behavior and drug use (N=310).

	N	%
Identity – Gay	254	82
Bisexual	49	16
Other/Questioning	7	2
Race/Ethnicity – White	94	30
African-American	102	33
Hispanic/Latino	80	26
Asian/Pacific Islander	10	3
Other	24	8
Age – 16-18	83	27
19-21	128	41
22-24	99	32
Living Situation – Living with Parents	131	42
Living Independently	139	45
Living with Romantic/Sex Partner	24	8
Homeless	13	4
Socioeconomic Status – Lower Class	57	18
Middle Class	217	70
Upper Class	35	11
HIV Seropositive (HIV+)	43	14
Ever Arrested	97	31
Ever Incarcerated	53	17
Sexual Risk Behaviors – Any UAI (12 mo.)	136	44
UAI – Receptive (12 mo.)	106	34
UAI – Insertive (12 mo.)	100	32
Mult. Anal Sex Partners (3 mo.)	178	57
Anal Sex while High (12 mo.)	155	50
Sex in Bathhouse or Sex Club	79	26
Sex with Internet Partner	130	42
Commercial Sexual Activity	76	25
Sex with Older Partners	95	31
Substance Use (12 mo) – Marijuana Use	158	51
Any “Street Drug”	72	23
-Ecstasy	35	11
-GHB	20	7
-Cocaine (not Crack)	51	17
-Heroin	19	6
-Benzodiazepines	22	7
-Crack Cocaine	10	3
-Hallucinogens	29	6
Viagra	20	7
Recreational Over-The-Counter Meds	47	15
Methamphetamine Use (12 mo)	39	13

^**UAI = Unprotected Anal Intercourse

Objective #1: Patterns and Consequences of Methamphetamine Use

Methamphetamine use was associated with the age of participants; annual methamphetamine use was reported by 3.6% (3/86) of 16-18 year old participants, compared 11.7% (15/128) of participants age 19-21 and 21.2% (21/99) of participants age 22-24. Participants age 21-24 were almost three times more likely than those age 16-20 to have used methamphetamine in the past year X² (1, n=310) =7.6, p<.01, OR=2.6, 95% CI=1.3 – 5.3. While age-related differences in annual prevalence rates were seen with other illicit substances (e.g. ecstasy, cocaine); no significant age-related differences were seen with marijuana use. Methamphetamine use was substantially more common among White (20.2%) and Latino/Hispanic (16.3%) youth then among African-American (2.9%) participants, X² (3, n=310) = 14.6, p<.01, and was more common among HIV-positive participants, 23.3% vs. 10.9%, X² (1, n=308) = 5. p=.02, OR = 2.8, 95% CI = 1.1 – 5.5.

In comparison to other illicit substance using participants (n=172), methamphetamine users were more likely to report: failure to remember what happened the previous night X² (1, n=172) =10.4, p < 0.01, OR=3.4, 95% CI=1.6-7.2; failure to do regular day-to-day activities X² (1, n=172) =19.0, p < 0.001, OR=5.0, 95% CI=2.4-10.7; and doing something sexually unintended, such as not using a condom X² (1, n=172) =28.7, p < 0.001, OR=7.3, 95% CI=3.4-16.1. Methamphetamine users were more likely than other substance using participants to report receptive anal sex while high X² (1, n=172) =30.1, p < 0.001, OR=7.7, 95%CI=3.4-17.4, and to report using drugs because a romantic or sexual partner encouraged them to so X² (1, n=172) =20.7, p < 0.001, OR=5.8, 95%CI=2.6-13.1.

Objective #2: Correlates of Methamphetamine Use

Tables 2 details results of the initial multivariate analyses of individual correlates of methamphetamine use. All analyses controlled for age, race / ethnicity and HIV sero-status. Methamphetamine use was associated with risky sex as well as each individual social context variable (p≤0.05). Young MSM who used methamphetamine were more than 6 times more likely than their peers to report unprotected anal intercourse in the past 12 months, more than 4 times more likely to report multiple anal sex partners in the past 3 months, and substantially more likely to report sex in a bathhouse or sex club, with a partner met through the Internet, in exchange for resources, or with older partners. Methamphetamine use was modestly associated with lower self-esteem and increased psychological distress (ps<0.05), but not with romantic loneliness.

Table 2. Contextual and Psychological Correlates of Methamphetamine Use^*.

	Odds Ratio	95% C.I.	P-value
Unprotected Anal Sex (12 months)	6.5	2.7-15.9	.000
Multiple Anal Sex Partners (3 months)	4.6	1.7-12.6	.003
Bathhouse/Sex Club	4.74	2.2-10.3	.000
Internet Sex	2.35	1.0-5.5	.050
Commercial Sex	5.07	2.3-11.2	.000
Older Sex Partners	3.79	1.8-8.0	.000
Global Symptom Inventory	1.03	1.00-1.06	.016
Romantic Loneliness	1.25	0.95-1.62	.108
Self-Esteem	2.05	1.08-3.89	.028

^*All analyses adjust for the effects of age, race, and HIV status

Table 3 shows the results of our final hierarchical logistic regression model. This model entered all the independent variables found to be statistically significant in our initial analysis. In this combined model, methamphetamine use was strongly related to the set of psychosocial and context variables: the Nagelkerke approximation of variance in methamphetamine use explained by the block of psychosocial and context variables was 27% beyond the effect of the demographics. Significant independent correlates of methamphetamine consisted of increasing age, non African-American race/ethnicity, having unprotected anal intercourse, and history of commercial sex activity (all ps ≤ 0.025).

Table 3. Hierarchical Multiple Regression Results – Overall Model Methamphetamine Use in Past 12 Months (N = 310).

	Nagelkerke R2	Odds Ratio (95 % CI)	p
Step 1	.16
Age		1.28 (1.08 – 1.52)	.005**
African-American (white as ref)		0.19 (0.05 – 0.69)	.011**
Hispanic (white as ref)		0.95 (0.40 – 2.26)	.906
Other (white as ref)		0.67 (0.20 – 2.25)	.524
HIV seropositive		1.97 (0.76 – 5.07)	.159
Step 2	.43
Unprotected Anal Sex (12 months)		3.9 (1.32 - 11.30)	.014**
Multiple Anal Sex Partners (3 months)		1.52 (0.47 - 4.95)	.467
Bathhouse/Sex Club		3.20 (0.99 – 7.02)	.052
Internet Sex		0.90 (0.32 – 2.59)	.905
Commercial Sex		3.35 (1.32 – 8.49)	.011**
Older Sex Partners		2.15 (0.85 – 5.44)	.106
Global Symptom Inventory		1.02 (0.98 – 1.06)	.415
Self-Esteem		1.16 (0.46 – 2.93)	.755

^**p<0.025

Comment

This study underscores the significant and potentially devastating effects of methamphetamine use among adolescent and young adult MSM, particularly as it pertains to HIV-related sexual risk. The 13% annual prevalence rate for methamphetamine use among our 16-24 year old sample is higher than national representative samples of youth, but consistent with use patterns described in studies of older MSM.⁴ Our findings are also consistent with prior research showing White and Latino YMSM reporting more methamphetamine use than do African-American YMSM. Consistent with adult MSM research, our data show increased methamphetamine use among HIV+ YMSM, and a strong link between methamphetamine and several indicators of sexual risk among both HIV+ and HIV- adolescent and young adult MSM. Methamphetamine use among YMSM thus has clear implications for both primary and secondary HIV prevention. Finally, although cross-sectional data does not allow for testing of developmental effects, the dramatic age-related increase in methamphetamine use in this sample calls for additional research geared towards gaining a better understanding of both initiation patterns and the natural history of methamphetamine use among this population of youth. In particular, these data indicate that understanding the broader social and psychological context surrounding methamphetamine use and initiation may be crucial for developing targeted substance use and HIV prevention efforts in adolescent and young adult MSM.

Specifically, prevention efforts may need to address the social and psychological context of sexuality for these young men as our data suggests that similar to adult MSM, these factors (i.e. the Internet, older partners, commercial sex venues, and exchanging sex for resources) as well as psychological distress and self esteem play an important role in contributing to methamphetamine-related sexual risk in this adolescent/young adult population. However, unlike adult MSM, adolescent and young adult MSM may not be developmentally mature enough to navigate the challenges and stressors associated with their sexual minority identity or the perceived stigma surrounding same-sex activity. They may find it difficult to identify friends or age-appropriate romantic partners, as peers of similar experiences may not be readily available in their day-to-day lives.^32,33 These processes may contribute vulnerability to depression or social isolation, substance use or to seeking sexual partners within traditionally adult social settings, where casual sexual exchanges are anticipated or desired.³³ Within these contexts, young MSM may partner with older men or may experiment with substances like methamphetamine because of partner pressures, or simply because drug use is more prevalent in these settings. For example, the YMSM methamphetamine users in our sample were substantially more likely than their substance using peers to report sex with older partners, sex while high, or drug simply in response to pressures from a sex partner.

For YMSM struggling with self-identity, self-expression, loneliness or isolation, methamphetamine use may also serve as an escape mechanism to self-medicate underlying psychological distress or low self-esteem. Methamphetamine used for self-medication, or in contexts where imbalances in social power constrain the adolescents' decision making may adversely affect both impulse control and sexual decisions. Appreciating the complex social milieu in which YMSM develop, and the interrelations among contextual and psychological factors in their decision making is critical to fully comprehending the link between methamphetamine use and HIV risk for this vulnerable subgroup. Our results suggest that sexual risk or highly charged sexual contexts, such as commercial sex work or sex in public venues, may be stronger predictors of methamphetamine use among this population of youth than individual-level psychological predictors. However, further examination with a larger, more diverse sample will be needed to fully delineate mediators and moderators of these behaviors and relationships.

This study had several important limitations. Since the data are cross-sectional we cannot draw conclusions about causality. For example, we cannot determine whether sexual risk or psychological distress was a consequence of methamphetamine use, or if young MSM who generally engage in high risk behaviors or experience psychological distress use methamphetamine. All data were collected by self-report and were subject to social desirability biases in reporting, e.g., risk behaviors. However, research suggests that self-reports of sensitive data collected via computer self-interviews are prey to less bias.^34,35 The sample was derived from one city, and interviews were administered at a community-based site offering HIV specialty services in addition to primary care and social support services. As such, our findings may not generalize to other samples of YMSM. In addition, the survey instrument asked only about general sexual activity and did not allow us to examine unprotected sexual behaviors within specific social contexts. Nonetheless, this study is among the first to examine patterns and consequences of methamphetamine use in a young, ethnically diverse, sample of YMSM, a high-risk group that relatively little is known about.

In conclusion, methamphetamine use is a public health problem with significant implications for the overall health and well-being of adolescent and young adult MSM. These data complement and add to the growing body of literature on HIV risk and methamphetamine conducted in older MSM samples, and indicates clearly that additional research is needed to understand the social and psychological context of substance use and sexual risk among these men.