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. Author manuscript; available in PMC: 2017 Sep 1.
Published in final edited form as: Psychol Sex Orientat Gend Divers. 2016 May 19;3(3):357–366. doi: 10.1037/sgd0000185

The role of substance use motives in the associations between minority stressors and substance use problems among young men who have sex with men

Brian A Feinstein 1, Michael E Newcomb 2
PMCID: PMC5047387  NIHMSID: NIHMS783796  PMID: 27713906

Abstract

Young men who have sex with men (YMSM) report higher rates of substance use than their heterosexual peers and minority stress has been posited as a risk factor for substance use. The associations between specific types of minority stress and substance use have been inconsistent throughout the literature and few studies have examined mechanisms underlying these associations. Drawing on minority stress theory and the motivational model of alcohol use, we propose that one mechanism underlying these associations may be people's motivations for using substances, including using substances to cope with negative emotions and to enhance pleasure. The goals of the current study were: (1) to examine the associations among minority stressors, substance use motives, and substance use problems; and (2) to examine substance use motives as mediators of the associations between minority stressors and substance use problems. Baseline self-report data were used from a cohort of 370 YMSM enrolled in a larger study of substance use and sexual behavior. Results indicated that using marijuana to cope mediated the association between victimization and marijuana use problems. Using other drugs to cope mediated the associations between victimization and drug use problems and between internalized stigma and drug use problems. Drinking to cope and to enhance pleasure mediated the association between internalized stigma and alcohol use problems. In sum, substance use motives, especially using substances to cope, act as mechanisms through which certain types of minority stress influence substance use problems among YMSM.

Keywords: minority stress, substance use, motives, alcohol, drugs


Young men who have sex with men (YMSM) report higher rates of alcohol, marijuana, and other drug use compared to their heterosexual peers (Corliss et al., 2010; Garofalo, Wolf, Kessel, Palfrey, & DuRant, 1998; Hatzenbuehler, Corbin, & Fromme, 2008; Kelly, Parsons, & Wells, 2006; Marshal, Friedman, Stall, & Thompson, 2009; Newcomb, Ryan, Greene, Garofalo, & Mustanski, 2014; Talley, Hughes, Aranda, Birkett, & Marshal, 2014). In a meta-analysis, sexual minority adolescents had three times the odds of reporting substance use compared to heterosexual adolescents (Marshal et al., 2008). Given that excessive substance use is associated with negative psychosocial and health consequences (Chen & Lin, 2009; Fergusson, Horwood, & Swain-Campbell, 2002; Hingson, Heeren, Zakocs, Kopstein, & Wechsler, 2002; Perkins, 2002) and that earlier substance use is associated with subsequent substance use disorders (Brook, Brook, Zhang, Cohen, & Whiteman, 2002), it is critical to develop effective prevention and intervention efforts to reduce problematic substance use among young people. To do so, it is first necessary to understand what puts young people, especially high-risk populations such as YMSM, at risk.

Since its introduction in 2003, minority stress theory has become the predominant conceptual model used to explain sexual orientation-related health disparities. One of the main tenets of minority stress theory is that sexual minorities experience unique stressors due to their stigmatized social status, which increase their risk for mental health and substance use problems (Meyer, 1995, 2003). Meyer (2003) described minority stressors along a continuum from distal stressors, which refer to objective events and conditions (e.g., discrimination, victimization) to proximal personal processes, which are subjective and rely on individual perceptions and appraisals (e.g., the internalization of societal stigma). Hatzenbuehler (2009) extended minority stress theory by proposing that psychological factors, such as coping and emotion regulation, may be mechanisms through which minority stressors influence substance use. While minority stress theory has led to major advances in understanding sexual orientation-related health disparities, minority stress alone does not fully account for these disparities (Hatzenbuehler, 2009; Mustanski, Birkett, Greene, Hatzenbuehler, & Newcomb, 2014). One factor that may help to explain what puts YMSM at risk for substance use problems is their motivation to use substances. The current study drew on minority stress theory and the motivational model of alcohol use (M. Cox & Klinger, 1988) in an effort to better explain the mechanisms underlying the associations between minority stressors and substance use problems among YMSM.

Associations between specific minority stressors and substance use have been inconsistent throughout the literature. Research has generally demonstrated positive associations between distal minority stressors (e.g., discrimination, victimization) and substance use (Bontempo & D' Augelli, 2002; Darwich, Hymel, & Waterhouse, 2012; Espelage, Aragon, Birkett, & Koenig, 2008; Goldbach, Tanner-Smith, Bagwell, & Dunlap, 2013; Hatzenbuehler, Nolen-Hoeksema, & Erickson, 2008; McCabe, Bostwick, Hughes, West, & Boyd, 2010; Newcomb, Heinz, & Mustanski, 2012; Wong, Weiss, Ayala, & Kipke, 2010). In contrast, findings have been inconsistent for the perception of societal stigma and the internalization of stigma. While some studies demonstrated positive associations between perceived stigma and substance use (Lea, de Wit, & Reynolds, 2014; Lelutiu-Weinberger et al., 2013), others have not (Hatzenbuehler, Nolen-Hoeksema, et al., 2008). Similarly, while some studies demonstrated positive associations between internalized stigma and substance use, others have not (for a review, see Brubaker, Garrett, & Dew, 2009). Given these inconsistent findings, the current study included multiple types of substance use problems (alcohol, marijuana, and other drug use problems) in order to test the specificity of their associations with different minority stressors (victimization, perceived stigma, and internalized stigma).

The mechanisms underlying the associations between minority stressors and substance use problems remain unclear. As noted, Hatzenbuehler (2009) proposed that these associations can be accounted for by coping/emotion regulation, social/interpersonal, and cognitive processes. Coping/emotion regulation processes may be particularly relevant to substance use, given that a primary motivation for substance use is affective regulation. The motivational model of alcohol use (M. Cox & Klinger, 1988) posits that people drink to attain valued outcomes, such as to regulate negative emotions (coping motives) or to enhance pleasure (enhancement motives) (Cooper, Frone, Russell, & Mudar, 1995; Cooper, Russell, Skinner, & Windle, 1992). Coping and enhancement motives are associated with increased alcohol use and problems (for a review, see Kuntsche, Knibbe, Gmel, & Engels, 2005) and they mediate associations between stressors (general stress, bullying, and trauma exposure) and drinking outcomes (Goldstein, Flett, & Wekerle, 2010; Grayson & Nolen-Hoeksema, 2005; Lindgren, Neighbors, Blayney, Mullins, & Kaysen, 2012; Miranda, Meyerson, Long, Marx, & Simpson, 2002; Park, Armeli, & Tennen, 2004; Topper, Castellanos-Ryan, Mackie, & Conrod, 2011). However, these associations have rarely been tested in regard to the unique stressors that YMSM experience. In exceptions, two studies found that coping and enhancement motives were associated with alcohol problems among HIV-positive MSM (Kahler et al., 2015) and LGBT college students (Ebersole, Noble, & Madson, 2012), and one study found that drinking to cope mediated the association between discrimination and alcohol problems in a sample that included 68 sexual minorities (Hatzenbuehler, Corbin, & Fromme, 2011).

Finally, despite considerable attention to motives in the literature on alcohol use, research has rarely addressed motivations for using marijuana and other drugs. In an exception, Simons and colleagues found that using marijuana to cope and to enhance pleasure were associated with increased marijuana use and problems (Simons, Correia, Carey, & Borsari, 1998). To further the literature on substance use motives, the current study focused on motives for alcohol, marijuana, and other drug use.

In sum, there is considerable evidence that drinking motives influence alcohol use and problems and help explain how stressors influence alcohol use. Despite elevated rates of substance use and unique stressors among YMSM, substance use motives have rarely been examined in this population. If substance use motives are mechanisms through which minority stressors influence substance use problems, then interventions may be enhanced by teaching alternative strategies to cope with negative emotions and safer ways to enhance pleasure. Further, targeting these behaviors during adolescence and emerging adulthood may prevent the development of problematic substance use and disorders in adulthood. As such, the goals of the current study were: (1) to examine associations among minority stressors, substance use motives, and substance use problems among YMSM; and (2) to examine substance use motives as mediators of the associations between minority stressors and substance use problems. We hypothesized that minority stressors would be associated with higher coping and enhancement motives, which in turn would be associated with higher substance use problems.

Method

Participants and Procedures

The current study utilized baseline data from a cohort of 370 YMSM in the United States who participated in a larger project (BLINDED FOR REVIEW), which included a baseline assessment and a two-month diary study of substance use and sexual behavior designed to study behavioral reactivity. The data reported in this article are exclusively from the baseline assessment. Participants had to: (1) be between ages 16 and 29 at baseline; (2) be assigned male at birth and report a current male gender identity; (3) speak English; (4) report oral or anal sex with a man during the past six months; (5) report that they were HIV negative or unaware of their status; and (6) report at least one instance of binge drinking (i.e., five or more drinks on a single occasion) or illicit drug use during the past 30 days. Participants were recruited through national paid Facebook advertisements that targeted: (1) men ages 16-29 who reported being interested in men; and (2) those who “Liked” LGBT-related organizations, activities, and interests. The study was described as a study of young men's health. Participants were compensated $15 for the baseline assessment and up to an additional $60 for subsequent assessments. Demographics are reported in Table 1.

Table 1.

Demographic characteristics of the sample (N = 370).

Demographic characteristic Mean (SD) or Percent
Age 22.87 (3.17)
Sexual orientation
    Gay 87.8%
    Bisexual 11.4%
    Other (queer and pansexual) 0.8%
Race/ethnicity
    White 45.7%
    Hispanic/Latino 23.0%
    Black/African American 19.5%
    Asian/Pacific Islander 1.1%
    Native American 1.1%
    Multi-racial 8.4%
    Other 1.4%
Highest level of education
    Did not complete high school 7.7%
    High school 71.8%
    Two-year college degree 4.6%
    Four-year college degree 12.6%
    Graduate degree 3.3%
HIV status
    Negative 85.7%
    I don't know 14.3%
Current student 41.6%
Currently employed 70.0%

Note. Several participants did not provide data for highest level of education (n = 4), student status (n = 5), and employment (n = 7).

Measures

Victimization

Victimization during the past six months was assessed with 10 items used in previous research (Pilkington & Daugelli, 1995). Participants were asked how many times in the past six months they had experienced 10 types of victimization (e.g., verbally assaulted; punched, kicked, or beaten) because they are, or were thought to be, gay or bisexual. Response options included: never (0), once (1), twice (2), and three or more times (3). Total scores were computed by averaging responses across items. Cronbach's alpha was .85.

Perceived stigma

Perceived stigma was assessed with seven items from a pool of 17 items used in previous research (Kuhns, Vazquez, & Ramirez-Valles, 2008). Six items were removed to reduce redundancy and burden and four were removed based on a factor analysis of the remaining items (BLINDED FOR REVIEW, 2015). The measure was created for Latino MSM, so minor wording changes were made to increase clarity and applicability to all YMSM. Participants were asked to indicate how much they agreed or disagreed with statements about people's attitudes and beliefs, such as, “Many people have negative attitudes toward homosexuality.” Response options included: strongly disagree (1), disagree (2), agree (3), and strongly agree (4). Total scores were computed by averaging responses across items. Cronbach's alpha was .83.

Internalized stigma

Internalized stigma was assessed with a measure that was adapted from the Homosexual Attitudes Inventory (Nungesser, 1983) and the Internalized Homosexual Stigma Scale (Ramirez-Valles, Kuhns, Campbell, & Diaz, 2010). The measure initially included 22 items, but five were removed due to poor face validity. A factor analysis of the remaining items revealed three factors: desire to be straight, fear of coming out, and fear of stereotypical perception (BLINDED FOR REVIEW, 2015). The eight-item desire to be straight factor was used as the measure of internalized stigma, because the items most closely resembled the conceptualization of internalized stigma in minority stress theory. Participants were asked to indicate the extent to which they agreed or disagreed with statements, such as, “Sometimes I wish I were not gay.” Response options included: strongly disagree (1), disagree (2), agree (3), and strongly agree (4). Total scores were computed by averaging responses across items. Cronbach's alpha was .91.

Substance use motives

The coping and enhancement subscales from the Drinking Motive Questionnaire – Revised Short Form (DMQ-R SF) (Kuntsche & Kuntsche, 2009) were used to assess drinking motives. Each subscale was administered up to three times, each time referring to a different substance (alcohol, marijuana, and other drugs). Participants were asked if they had ever had a drink of alcohol, used marijuana, or used other drugs. If they responded affirmatively, then they were presented with directions for that substance. For instance, in regard to drinking, participants were presented with: “Here is a list of reasons people give for drinking alcohol. Thinking of all the times you drink alcohol, how often would you say that you drink alcohol for each of the following reasons?” Example items included “because it helps you when you feel depressed or nervous” (coping) and “because it gives you a pleasant feeling” (enhancement). Response options included: almost never/never (0), some of the time (1), half of the time (2), most of the time (3), and almost always/always (4). Subscales were computed by averaging responses across items (five items for each subscale), creating six variables: drinking to cope (α = .85) and to enhance (α = .84), using marijuana to cope (α = .90) and to enhance (α = .92), and using other drugs to cope (α = .90) and to enhance (α = .85). Participants who never used alcohol (n = 17), marijuana (n = 71), or other drugs (n = 230) were not included in analyses focused on those substances.

Alcohol use problems

The Alcohol Use Disorders Identification Test (AUDIT) (Saunders, Aasland, Babor, de la Fuente, & Grant, 1993) is a 10-item measure that assesses alcohol use and associated problems during the past six months. Items are rated on various Likert-type scales depending on the question. For instance, response options for, “How often do you have a drink containing alcohol?” include: never (1), monthly or less (2), 2 to 4 times a month (3), 2 to 3 times a week (4), and 4 or more times a week (5). Response options for, “How often do you have six or more drinks on one occasion?” include: never (0), less than monthly (1), monthly (2), weekly (3), and daily or almost daily (4). Total scores were computed by summing responses across items. Risk levels include: low-risk drinking or abstinence (0-7), alcohol use in excess of low-risk guidelines (8-15), harmful and hazardous drinking (16-19), and possible alcohol dependence (≥ 20) (Babor, Higgins-Biddle, Saunders, & Monteiro, 2001). Cronbach's alpha was .82.

Marijuana use problems

The Cannabis Use Disorders Identification Test – Revised (CUDIT-R) (Adamson et al., 2010) is an eight-item measure that assesses marijuana misuse and associated problems during the past six months. Items are rated on various Likert-type scales depending on the question. For instance, response options for, “How often do you use marijuana?” include: never (1), monthly or less (2), 2 to 4 times a month (3), 2 to 3 times a week (4), and 4 or more times a week (5). Response options for, “Have you ever thought about cutting down, or stopping, your use of marijuana?” include: never (1), yes, but not in the past 6 months (2), and yes, during the past 6 months (3). Total scores were computed by summing responses across items, with scores of 13 or higher suggesting problematic use (Adamson et al., 2010). Cronbach's alpha was .79.

Other drug use problems

The Drug Abuse Screening Test (DAST) (Skinner, 1982) is a 10-item measure that assesses other drug use problems during the past six months. Example items include: “Have you used drugs other than those required for medical reasons?” and “Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?” Response options include yes (1) or no (0) and total scores were computed by summing responses across items. Risk levels include: no problems (0), low risk (1-2), moderate risk (3-5), substantial risk (6-8), and severe risk (9-10) (Skinner, 1982). Cronbach's alpha was .68.

Analyses

Analyses were conducted in SPSS Version 22. Across measures, missing data ranged from 1.1% to 1.6% of the sample and were handled with listwise deletion. First, we examined bivariate correlations. When bivariate associations between minority stressors and substance use problems were significant, we tested motives as mediators. Mediation analyses were conducted using the SPSS Process Macro and all variables were standardized to obtain standardized regression coefficients (Hayes, 2013). Bootstrapping (5,000 resamples) was used to test the significance of indirect effects (MacKinnon, Lockwood, & Williams, 2004).

Results

Bivariate correlations are reported in Table 2. In regard to alcohol use problems, 54.6% of the sample scored in the low risk-drinking or abstinence range, 31.7% in the alcohol use in excess of low-risk guidelines range, 8.2% in the harmful and hazardous drinking range, and 5.2% in the possible alcohol dependence range. In regard to marijuana use problems, 17.0% of the sample scored in the problematic marijuana use range. In regard to other drug use problems, 62.2% of the sample reported no problems, 13.2% scored in the low risk range, 18.1% in the moderate risk range, 5.2% in the substantial risk range, and 1.4% in the severe risk range.

Table 2.

Zero-order correlations, means, and standard deviations.

Variable 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. M (SD)
1. Victimization .44 (.52)
2. Perceived stigma .23*** 3.04 (.54)
3. Internalized stigma .13* .23*** 1.82 (.74)
4. Drinking to cope .19*** .22*** .27*** 1.14 (.97)
5. Drinking to enhance .02 .05 .25*** .37*** 1.97 (1.01)
6. Using marijuana to cope .21*** .15* .10 .46*** .15* 1.26 (1.24)
7. Using marijuana to enhance .02 .07 .04 .13* .36*** .52*** 2.51 (1.32)
8. Using other drugs to cope .20* .28*** .18* .60*** .17* .36*** .03 1.20 (1.23)
9. Using other drugs to enhance −.03 .09 .11 .17* .44*** .02 .24** .34*** 2.65 (1.09)
10. Alcohol use problems ..09 .04 .19*** .38*** .41*** .10 .09 .15 .21* 8.15 (6.07)
11. Marijuana use problems .13* .06 .09 .09 .06 .52*** .42*** .03 .10 .22*** 5.69 (6.99)
12. Other illicit drug use problems .12* .07 .14** .15** .19*** .10 .11 .38*** .34*** .29*** .30*** 1.43 (2.20)

Note. Ns range from 140 to 366

*

p < .05

**

p < .01

***

p < .001.

First, we examined demographic differences in our variables of interest using bivariate correlations (for age), independent-samples t-tests (for sexual orientation), and one-way analysis of variance tests with post-hoc LSD tests (for race/ethnicity). There were significant positive associations between age and alcohol use problems (r = .15, p < .01) and drinking to cope (r = .14, p < .01). Given that age was associated with alcohol use problems and drinking to cope, we tested whether drinking to cope mediated the association between age and alcohol use problems. There was a significant indirect effect of age on alcohol use problems via drinking to cope (standardized path coefficient = .05, 95% CI = .02, .09). The direct effect of age was not significant when the mediator was included, indicating full mediation (standardized path coefficient = .07, 95% CI = −.03, .16).

Bisexual men reported greater internalized stigma (M = 2.11, SD = .84) compared to gay men (M = 1.78, SD = .72, t(364) = −2.80, p < .01)._Bisexual men also reported greater marijuana use problems (M = 8.04, SD = 7.63) compared to gay men (M = 5.36, SD = 6.84, t(362) = −2.43, p < .05). Finally, bisexual men reported greater using marijuana to enhance (M = 2.89, SD = 1.04) compared to gay men (M = 2.45, SD = 1.35, t(61.22) = −2.40, p < .05). Given that bisexual men reported greater marijuana use problems and using marijuana to enhance compared to gay men, we tested whether using marijuana to enhance mediated the association between bisexual identity and marijuana use problems. There was a significant indirect effect of bisexual identity on marijuana use problems via using marijuana to enhance (standardized path coefficient = .14, 95% CI = .03, .27). The direct effect of bisexual identity was not significant when the mediator was included, indicating full mediation (standardized path coefficient = .21, 95% CI = −.10, .52).

Black men reported greater perceived stigma (M = 3.28, SD = .50) compared to White (M = 2.97, SD = .52, p < .001), Latino (M = 3.01, SD = .58, p < .01), and other men (M = 2.98, SD = .59, p < .01). White men reported greater drug use problems (M = 1.84, SD = 2.45) compared to Black men (M = .70, SD = 1.58, p < .001). White men also reported less using marijuana to cope (M = 1.03, SD = 1.05) compared to Black (M = 1.53, SD = 1.43, p < .05), Latino (M = 1.44, SD = 1.36, p < .05), and other men (M = 1.48, SD = 1.29, p < .05).

Associations between minority stressors and substance use problems were partially consistent with hypotheses. Victimization was associated with marijuana and other drug use problems and there was a trend toward it being associated with alcohol use problems (p = .07). Internalized stigma was associated with alcohol and other drug use problems and there was a trend toward it being associated with marijuana use problems (p = .09). Perceived stigma was not associated with any substance use problems. Consistent with hypotheses, coping and enhancement motives were associated with substance use problems across substances. Additionally, coping motives were associated with enhancement motives for each substance, coping motives for each substance were associated with each other, and enhancement motives for each substance were associated with each other.

Minority stressors were also associated with substance use motives across most variables. Victimization and perceived stigma were associated with coping motives across substances. Internalized stigma was associated with drinking and using other drugs to cope and there was a trend toward it being associated with using marijuana to cope (p = .09). Internalized stigma was also associated with drinking to enhance pleasure, but none of the other associations with enhancement motives were significant.

Mediation analyses

All of the following mediation analyses controlled for age, sexual orientation, and race/ethnicity, given that they were significant demographic correlates of variables included in the models.

Victimization

Direct and indirect effects are reported in Table 3. The association between victimization and marijuana use problems was mediated by using marijuana to cope, but not to enhance. The direct effect of victimization was not significant when the mediators were included, indicating full mediation. The association between victimization and other drug use problems was mediated by using other drugs to cope, but not to enhance. The direct effect of victimization was not significant when the mediators were included, indicating full mediation. Victimization was not associated with alcohol use problems, so mediation was not examined.

Table 3.

Direct and indirect effects for victimization predicting marijuana and other illicit drug use problems.

Direct effects Standardized path coefficient 95% CI t p
Victimization → Marijuana use problems (N = 294)
    Victimization .04 −.06, .14 .69 .49
    Using marijuana to cope .39 .27, .51 6.35 < .001
    Using marijuana to enhance .21 .09, .33 3.41 < .001
    Total indirect effect .08 .02, .15
    Indirect effect via using marijuana to cope .08 .03, .14
    Indirect effect via using marijuana to enhance −.0001 −.02, .03
Victimization → Other drug use problems (N = 140)
    Victimization .03 −.14, .20 .38 .70
    Using other drugs to cope .33 .15, .51 3.44 < .001
    Using other drugs to enhance .26 .07, .44 2.72 < .01
    Total indirect effect .06 −.03, .18
    Indirect effect via using other drugs to cope .07 .01, .16
    Indirect effect via using other drugs to enhance −.003 −.06, .05

Notes. All models control for age, race/ethnicity, and sexual orientation; confidence intervals (CIs) that do not include zero are significant at p < .05.

Perceived stigma

Perceived stigma was not associated with any substance use problems, so mediation was not examined.

Internalized stigma

Direct and indirect effects are reported in Table 4. The association between internalized stigma and alcohol use problems was mediated by drinking to cope and to enhance. The direct effect of internalized stigma was not significant when the mediators were included, indicating full mediation. The association between internalized stigma and other drug use problems was mediated by using other drugs to cope, but not to enhance. The direct effect of internalized stigma was not significant when the mediators were included, indicating full mediation. Internalized stigma was not associated with marijuana use problems, so mediation was not examined.

Table 4.

Direct and indirect effects for internalized stigma predicting alcohol use and other illicit drug use problems.

Direct effects Standardized path coefficient 95% CI t p
Internalized stigma → Alcohol use problems (N = 351)
    Internalized stigma .07 −.03, .17 1.42 .16
    Drinking to cope .23 .13, .33 4.61 < .001
    Drinking to enhance .29 .20, .39 5.84 < .001
    Total indirect effect .14 .09, .21
    Indirect effect via drinking to cope .07 .03, .12
    Indirect effect via drinking to enhance .08 .04, .12
Internalized stigma → Other drug use problems (N = 140)
    Internalized stigma .12 −.06, .30 1.28 .20
    Using drugs to cope .32 .13, .50 3.42 < .001
    Using drugs to enhance .24 .06, .43 2.54 .01
    Total indirect effect .09 .01, .19
    Indirect effect via using drugs to cope .06 .01, .15
    Indirect effect via using drugs to enhance .03 −.002, .10

Notes. All models control for age, race/ethnicity, and sexual orientation; confidence intervals (CIs) that do not include zero are significant at p < .05.

Discussion

Findings revealed differential associations between specific minority stressors and types of substance use problems, suggesting that different minority stressors may have different consequences. Consistent with previous research, internalized stigma was associated with alcohol and other drug use problems (see Brubaker et al., 2009) and victimization was associated with marijuana and other drug use problems (see Goldbach et al., 2013). In contrast, perceived stigma was not associated with any substance use problems. Although others have found non-significant associations between perceived stigma and substance use (Lea et al., 2014; Lelutiu-Weinberger et al., 2013), at least one study found a significant association (Hatzenbuehler, Nolen-Hoeksema, et al., 2008). Our findings suggest that simply knowing that some people do not accept sexual minorities does not translate into risk behavior. It is likely that many YMSM have knowledge that stigma exists, but they may not have internalized it or experienced victimization. As such, they may not be at risk for problematic substance use.

Findings also revealed that minority stressors were generally associated with using substances to cope, but not to enhance pleasure. Consistent with the self-medication hypothesis (Khantzian, 1997), these findings provide a robust demonstration that YMSM who experience stress related to their sexual orientation use substances to reduce distress. Also consistent with previous research (for a review, see Kuntsche et al., 2005), coping and enhancement motives were both associated with greater substance use problems. Regardless of whether YMSM are using substances to cope or to enhance pleasure, these motives may put them at increased risk for substance use problems.

Coping, but not enhancement, motives mediated several associations, suggesting that using substances to cope may be a mechanism through which victimization and internalized stigma influence substance use problems. These findings are consistent with previous studies that have demonstrated that coping, but not enhancement, motives mediated the association between sexual assault and problem drinking (Lindgren et al., 2012) and that the association between enhancement motives and alcohol problems became non-significant when coping motives were taken into account (Carey & Correia, 1997; Cooper et al., 1995; Kassel, Jackson, & Unrod, 2000). As such, coping motives may be a particularly important intervention target for YMSM who abuse substances.

Although our cross-sectional data cannot speak to temporal associations, coping motives may be more proximal risk factors for substance use problems than minority stressors. A longitudinal study similarly demonstrated that coping motives mediated the association between sexual assault and problem drinking (Lindgren et al., 2012), suggesting that these associations operate over time. As such, efforts to teach adaptive coping strategies may result in reduced substance use problems. This may be particularly important for YMSM who experience victimization, which is largely outside of one's control. If victimization cannot be avoided, then YMSM are likely to benefit from becoming more aware of their motivation for using substances and learning adaptive ways to cope.

The association between internalized stigma and alcohol use problems was mediated by both coping and enhancement motives. This suggests that YMSM who endorse more negative attitudes toward their sexual orientation have dual motives for drinking (to cope with negative emotions and to enhance pleasure), both of which contribute to alcohol use problems. It is possible that YMSM with higher internalized stigma are less open about their sexual orientation and less connected to other YMSM, limiting their exposure to pleasurable experiences (e.g., positive experiences with other YMSM that are affirmative of their sexual orientation). If so, then their negative attitude toward their sexual orientation may lead them to seek pleasure through other sources, such as drinking. It is also possible that YMSM with higher internalized stigma use drinking to enjoy socializing in LGBT venues, which may trigger shame. In turn, these YMSM may drink to decrease shame and enhance positive emotions.

In contrast to internalized stigma being associated with drinking to enhance pleasure, none of the minority stressors were associated with using marijuana or other drugs for that purpose. For those with higher internalized stigma, alcohol may be perceived as having the ability to produce positive emotional and social effects. Most illicit drugs, on the other hand, have more pronounced psychotropic effects on behavior and perception, many of which may impede social functioning. As such, YMSM with higher internalized stigma may perceive marijuana and other drugs as primarily having the effect of numbing oneself against negative emotions rather than enhancing social functioning. Importantly, illicit drugs have varied physiological effects and it will be important for future research to examine drug use motives separately for different types of other drugs (e.g., sedatives, opiates, stimulants) in order to better understand these associations.

Drinking, using marijuana, and using other drugs to cope were all associated with each other. Similarly, drinking, using marijuana, and using other drugs to enhance pleasure were all associated with each other. These findings indicate that YMSM who use one substance to cope or to enhance pleasure tend to use other substances for the same purpose. Additionally, consistent with previous research (Cooper et al., 1995), coping motives were associated with enhancement motives for each substance, indicating that YMSM who use substances to cope also use them to enhance pleasure. In sum, these findings indicate that motivations for using substances play a role in substance use problems beyond drinking.

Several noteworthy demographic differences were found. Consistent with previous research (e.g., Newcomb et al., 2014), older men reported more alcohol use problems compared to younger men. Motivational processes help to explain this age difference, as older men also reported more drinking to cope compared to younger men, which has been demonstrated in previous research (Urban, Kokonyei, & Demetrovics, 2008). Drinking to cope mediated the association between age and alcohol use problems, suggesting that older YMSM have more alcohol use problems than younger YMSM, in part, because of their greater use of alcohol to cope with negative emotions. Also consistent with previous research (N. Cox, Vanden Berghe, Dewaele, & Vincke, 2010; Rosario, Schrimshaw, Hunter, & Gwadz, 2002), bisexual men reported higher internalized stigma compared to gay men. Bisexual men also reported more marijuana use problems compared to gay men, which is consistent with evidence that sexual minorities report greater marijuana use compared to heterosexuals (Cochran, Ackerman, Mays, & Ross, 2004; Woody et al., 2001) and that bisexuals may be at particularly high risk (Marshal et al., 2009; Russell, Driscoll, & Truong, 2002). Further, we found that using marijuana to enhance pleasure mediated the association between bisexual identity and marijuana use problems, suggesting that enhancement motives may be one mechanism underlying bisexual men being at greater risk for marijuana use compared to gay men. Black men reported greater perceived stigma compared to all other groups, which is consistent with research that has found that Black gay men report higher homonegativity compared to White men (David & Knight, 2008). Consistent with previous research (e.g., Newcomb et al., 2014), White men reported greater drug use problems compared to Black men. White men also reported less using marijuana to cope compared to all other groups. Given that other studies have found that White individuals reported lower coping motives for drinking compared to Black (Cooper et al., 1992) and Asian individuals (Labrie, Lac, Kenney, & Mirza, 2011), these findings suggest that using substances to cope may be less common among White individuals compared to other racial/ethnic groups.

Findings have important implications for theory and practice related to substance use problems among YMSM. While minority stress theory (Meyer, 2003) is the predominant conceptual model used to explain why sexual minorities report higher rates of substance use compared to heterosexuals, minority stress does not fully account for these disparities. As such, integrating minority stress theory with other empirically-supported theories, such as the motivational model of alcohol use (M. Cox & Klinger, 1988), has the potential to provide a more complete understanding of substance use problems among YMSM. Based on the current findings, a complete understanding of substance use problems among YMSM requires consideration of minority stress and motivational processes. In regard to treatment, a recent randomized controlled trial of a transdiagnostic intervention for minority stress and its consequences led to reductions in alcohol problems and minority stressors among gay and bisexual men (Pachankis, Hatzenbuehler, Rendina, Safren, & Parsons, 2015). While such an intervention can reduce substance use problems among YMSM, the efficacy of interventions may depend on motivational processes. It has been suggested that those who drink to cope may benefit from stress reduction and coping skills training, whereas those who drink to enhance pleasure may benefit from alternative sources of pleasure and restructuring expectancies for alcohol's enhancing effects (Cooper et al., 1995). Interventions focused on problematic substance use among YMSM may be enhanced by assessing and targeting motivations for using substances in addition to minority stress.

The current findings must be considered in light of limitations. First, participants were required to report at least one instance of binge drinking or illicit drug use in the previous six months in order to participate in the study. As such, findings may not generalize to YMSM who do not report recent substance use. Participants were also required to be HIV-negative or unaware of their status (based on self-report), so it is unclear if findings generalize to HIV-positive YMSM. We suspect that the associations would generalize to HIV-positive YMSM, but this remains an empirical question. HIV-positive individuals also experience stigma related to their HIV-status, so it will be important for future research to test the influence of different types of minority stress (e.g., sexual minority stress, HIV stigma) on substance use motives and problems. Our study focused on coping and enhancement motives, but other motives have been acknowledged, such as obtaining social rewards (Cooper et al., 1995; Cooper et al., 1992) and enhancing sex (Kahler et al., 2015). Given that substance use is associated with sexual risk behavior among YMSM (Drumright, Gorbach, & Holmes, 2004; Drumright, Patterson, & Strathdee, 2006; Mustanski, Newcomb, Du Bois, Garcia, & Grov, 2011; Vosburgh, Mansergh, Sullivan, & Purcell, 2012), sexual motives may be particularly relevant in this population. Our study utilized cross-sectional data, precluding our ability to test causality, so replication using longitudinal designs is necessary. Although we used an established measure of drinking motives, the measures of marijuana and other drug use motives were adapted from that measure. As such, it will be important for future research to use validated measures of these substance use motives. Given that the majority of our sample identified as gay, it will be important for future research to recruit larger samples of bisexual men. It will also be important for future research to examine these processes among sexual minority women, who are also at increased risk for substance use problems. Finally, Cronbach's alpha for other drug use problems was low, so it will be important for future studies to replicate findings.

Despite limitations, the current study filled several gaps in the literature, including testing mediators of the associations between minority stressors and substance use problems in a racially/ethnically diverse sample of YMSM, focusing on the understudied construct of substance use motives, and including multiple types of minority stressors and substance use problems. The current findings implicate motivation for using substances as a risk factor for substance use problems among YMSM, especially using substances to cope with negative emotions. Findings also add to a growing body of evidence that not all minority stressors contribute to negative outcomes. In sum, findings suggest that substance use motives may be a viable intervention target to reduce problematic substance use among YMSM.

Acknowledgments

This project was funded by a grant from the National Institute on Drug Abuse (BLINDED FOR REVIEW). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute on Drug Abuse.

Contributor Information

Brian A. Feinstein, Department of Medical Social Sciences, Northwestern University, Feinberg School of Medicine, 625 N. Michigan Ave., Suite 2700, Chicago, IL 60611

Michael E. Newcomb, Department of Medical Social Sciences, Northwestern University, Feinberg School of Medicine, 625 N. Michigan Ave., Suite 2700, Chicago, IL 60611

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