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. Author manuscript; available in PMC: 2023 Mar 1.
Published in final edited form as: Drug Alcohol Depend. 2022 Jan 10;232:109282. doi: 10.1016/j.drugalcdep.2022.109282

Cannabis use and sexual risk among MSM who drink: Understanding why more frequent cannabis users may engage in higher rates of condomless sex

Maria Jose Bustamante 1,*, Tibor P Palfai 1, Peter Luehring-Jones 1, Stephen A Maisto 2, Jeffrey S Simons 3
PMCID: PMC8885905  NIHMSID: NIHMS1773858  PMID: 35066459

Abstract

Background:

Condomless anal intercourse (CAI) is the major risk factor for HIV transmission among men who have sex with men (MSM). MSM who are heavier cannabis users engage in CAI more frequently. However, little is known about the processes that may underlie this association. This study sought to understand the potential role of condom attitudes and condom-related planning in the association between cannabis use and CAI.

Methods:

This is a secondary data analysis of a study on alcohol use and sexual decision-making among MSM. Two hundred and fifty-eight MSM with moderate to heavy drinking were enrolled. Measures included CAI, cannabis use, attitudes about the influence of condoms on sexual pleasure, condom use planning, age, heavy episodic drinking, and use of pre-exposure prophylaxis (PrEP).

Results:

We conducted a negative binomial regression analysis controlling for age, PrEP, and heavy episodic drinking. Cannabis use frequency was a significant predictor of CAI (b = .333, p < .001). Indirect effects showed that while heavier cannabis users exhibited less condom-related planning (b = −0.106, p = 0.015) and more negative attitudes toward the impact of condom use on pleasure (b= −0.177, p = 0.004), cannabis use had a significant indirect effect on CAI only through attitude ratings.

Conclusions:

MSM who are heavier cannabis users engage in more frequent CAI and exhibit an indirect effect on CAI through negative attitudes toward the impact of condoms on pleasure. These findings suggest the potential importance of addressing these condom attitudes in HIV-prevention interventions among MSM who use cannabis.

Keywords: MSM, cannabis, condom use, pleasure, condomless anal intercourse

1. Introduction

Although cases of HIV infection have been decreasing over the years, approximately 34,800 new HIV diagnoses occurred in the United States in 2019, with 69% of new cases among men who have sex with men (MSM) (Centers for Disease Control and Prevention, 2021). Substance use has been shown to be a central risk factor for condomless anal intercourse (CAI), a major driver of HIV infection among MSM (Heath et al., 2012). Cannabis is the most commonly used of these substances with approximately 22.2 million people in the U.S. reporting past-month use (NIDA, 2019). Rates of cannabis use are particularly high for those who use alcohol, with estimates of 2–3 times higher rates of use among heavy drinkers (Subbaraman et al., 2015)

Previous work suggests that cannabis use among MSM may be associated with higher rates of risky sexual behaviors, including multiple partners and condomless anal intercourse (Bellis et al., 2008; Morgan et al., 2016; Starks et al., 2020). This risk may be heightened for those who engage in unhealthy drinking (Saitz, 2005) as rates of cannabis use among MSM who engage in unhealthy drinking are higher than those who do not (Ogbuagu et al., 2019).

Despite evidence for the association between level of cannabis use and sexual risk, there is little known about why those who use cannabis more frequently may engage in more frequent CAI. One potential mechanism may be the importance of maximizing pleasure during sex among those who are heavier cannabis users. Cannabis produces a number of subjective effects that heighten the experience of sex, including euphoria, relaxation, and heightened sensation (Green et al., 2003) and is used among MSM before sex specifically to enhance the experience of sexual pleasure (Brodbeck et al., 2006; Colby Passaro et al., 2019)). Consequently, MSM who are heavier cannabis users may have more negative attitudes about the potential impact of condoms on pleasure during intercourse.

Another potential reason why heavier cannabis users may show higher rates of CAI are deficits in condom use planning. Planning involves the development of strategies to attain specific goals in advance of a given event. This includes anticipation of barriers to implementation of plans and generation of possible solutions to overcome these barriers (Gutiérrez-Doña et al., 2009; Luszczynska & Schwarzer, 2003). More frequent cannabis use has been associated with cognitive flexibility impairments and inhibition, both involved in decision-making and planning (Casey & Cservenka, 2020; Crean et al., 2011). Impairments are more apparent among heavier and longer-term cannabis users (Becker et al., 2014; Gonzalez et al., 2012), and is observed even after several weeks of abstinence (Hanson et al., 2010; Medina et al., 2007). More frequent cannabis users exhibit planning deficits particularly in complex and novel situations that require higher-level thinking (Grant et al., 2012). In addition, research suggests that cannabis users show specific deficits in episodic foresight (Mercuri et al., 2018), which may underlie the capacity to identify circumstances that require planned action and rehearse potential strategies to attain outcomes. These planning impairments have also been shown in studies of health-related behaviors, including planning related to condom use (Bryan et al., 2012; Noar et al., 2006).

Thus, previous work has suggested that deficits in condom-related planning and condom attitudes regarding pleasure may account, in part, for the higher rates of CAI among MSM who use cannabis more frequently. These psychological factors have not, however, been examined among MSM. The current study seeks to replicate and extend previous work on the association between cannabis use frequency and CAI among MSM by examining potential factors that may account for the higher rates of CAI among heavier cannabis users.

2. Material and Methods:

This research study was a secondary analysis of data from a study on the influence of alcohol on sexual decision-making among MSM conducted at two urban study sites in the northeastern US (Maisto et al., 2021).1 Individuals were eligible for the current study if they completed both laboratory sessions and survey measures using experiencing sampling methods (ESM) from the parent study. Two hundred and fifty-eight MSM ages 21 to 50 (M = 28.1 years, SD = 6.9 years) with patterns of moderate to heavy drinking were enrolled in the study. Informed consent was obtained from all participants prior to enrollment. Additional inclusion criteria were: (1) at least one sexual episode with a man in the past 90 days, (2) a Kinsey scale (Kinsey et al., 1949) score of at least 3 (indicating that participants considered themselves to be at least equally heterosexual and homosexual), and (3) not currently in a monogamous relationship. Participants were recruited using flyers and social media advertising. Assessments included the following: (1) frequency of cannabis use over the past 3 months as measured by the NIDA modified ASSIST (Alcohol, Smoking, and Substance Involvement Screening Test; Humeniuk et al., 2008), (2) number of condomless anal intercourse episodes in the past 90-days as measured by the Sexual Behavior Questionnaire (Gordon, Carey, & Carey, 1997), (3) pleasure experienced with the use of condoms as measured by the Multidimensional Condom Attitudes Scale (MCAS; Helweg-Larsen & Collins, 1994), (4) condom use planning as measured by a condom specific form of the Goals Systems Assessment Battery (Karoly & Ruehlman, 1995). Heavy episodic drinking, age, and use of pre-exposure prophylaxis (PrEP) medication were also assessed as covariates. The Binge Drinking Questionnaire (NIAAA National Advisory Council, 2004) was used to index heavy episodic drinking measured based on the frequency that individuals consumed 5 +standard drinks over the past 3 months.

Sixty-five percent of the sample identified as White (n=167), 13% as Black or African American (n=33), 7% as Asian (n=19), 4% as mixed-race (n=9), and less than one percent as American Indian, Alaska Native, Native Hawaiian or Pacific Islander (n=3). Eighteen percent of the sample identified as Hispanic (n = 47). The modal self-reported Kinsey classification of sexuality reported more than half of the study population was homosexual only (n=155, 60%).

3. Results

Descriptive statistics showed that the mean cannabis frequency score on the ASSIST was 1.39 (SD = 1.340, median = 1) which indicated that participants in the sample as a whole used cannabis less than monthly. However, over two-thirds of the sample reported using cannabis in the past 3 months with 23.3% percent reporting at least weekly or greater use. Participants reported a mean of 4.93 episodes of CAI (SD= 9.217, median = 2) with a range of 0 – 75. Pleasure associated with condom use was 3.92 (SD=1.31) based on Likert scale scores anchored with “strongly disagree” (1) and “strongly agree” (7). Participants reported a mean of 2.76 (SD=.928) on the items of the condom planning scale which were anchored with 0 (not at all true for me) to 4 (describes me very well). Table 1 provides zero-order correlations between cannabis use level, CAI, condom attitudes, condom planning, and frequency of heavy episodic drinking.

Table 1.

Zero-order Correlations Among Cannabis Use, Condom Pleasure Attitude, Condom Planning, CAI, Heavy Drinking, Age and PrEP Use.

1 2 3 4 5 6 7 Mean SD Min Max
1. Cannabis Use −.185** −.161** .278** .139* .059 −197** 1 .940 0 3
2. MCAS Pleasure Subscale .468** −.232** 0.14 −132* .013 3.92 1.31 1.20 7
3. Condom Planning −.118 −.038 −.175** −.018 2.76 0.928 0 4
4. CAI .036 .125* −.057 4.93 9.21 0 75
5. Heavy Alcohol Use −.105 −.098 1.39 1.33 0 4
6. On PrEP .024 0.21 .405 0 1
7. Age 28.10 6.87 21 50
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**

Correlation is significant at the table 0.01 level (2-tailed)

*

Correlation is significant at the table 0.05 level (2-tailed)

To examine the association between cannabis use frequency and frequency of CAI in the past three months, we conducted a negative binomial regression analysis in Mplus 8.5 (Muthén & Muthén, 2021) controlling for age, study site, heavy episodic drinking, and PrEP use. Cannabis use was a significant predictor of CAI (b = 0.333, p < .001). The indirect effects of cannabis use on CAI through condom planning and individual differences in pleasure-related condom use attitudes were examined with a negative binomial path analysis in Mplus 8.5 using 10,000 bias-corrected bootstrapped samples with condom planning and the MCAS pleasure subscale as simultaneous mediators of the cannabis use-to-CAI association. PrEP use, age, study site, and heavy alcohol use (MacKinnon et al., 2002) were used as covariates by applying these four variables as covariates to all endogenous variables (i.e., condom planning, MCAS pleasure, and CAI). Direct and indirect effects are presented in Figure 1.

Figure 1. Direct and Indirect effects of the Association between Cannabis Use Frequency and CAI.

Figure 1.

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Mediational Model. Unstandardized regression coefficients representing direct and indirect effects: a = direct effect of the independent variable to mediator. b= direct effect of the mediator to the dependent variable. ab = indirect effect. c= total effect of independent variable on the dependent variable. c’= remaining effect of independent variable on the dependent variable when the two mediators are in the model. PrEP was included in the model as a covariate and its effect on CAI was .550, (p = .009). *p < .05; ** p < .01.

In the mediated model, the direct effect of cannabis use on CAI was significant, b = 0.333, 95% CI: 0.165, 0.514. Examination of indirect effects showed that while heavier cannabis users exhibited lower condom planning (b = −0.106, 95% CI: −0.191, −0.021, p = .0.015) and more negative attitudes towards the effect of condoms on pleasure (−0.177, 95% CI: −0.299, −0.057, p = .004), cannabis use had a significant indirect effect on CAI only through the MCAS pleasure ratings. The point estimate of the indirect effect of cannabis use through the MCAS pleasure subscale was 0.055 with the 95% bias-corrected bootstrapped confidence interval of the indirect effect being 0.012 to 0.120. The non-significant point estimate of the indirect effect of cannabis use through the condom planning scale was 0.001, 95% CI: −0.023, 0.030. PrEP was a significant covariate on CAI (b = 0.550, p = 0.012) and on condom use planning (b = −0.375, p = .007), but not on the MCAS pleasure subscale (b = −0.351, p = .070).

Age, heavy episodic drinking, and study site were not significant covariates for any of the three variables. The R2 value for condom use planning was 0.059 (p = .049) and for the MCAS pleasure subscale was 0.056 (p = .052). The residual covariances of the condom planning and MCAS pleasure subscale variables were significantly correlated, r = 0.502, p < .001.

4. Discussion

In the current study, we found that MSM who used cannabis more frequently were more likely to engage in CAI and that this association appeared to show a significant indirect path through more negative attitudes about the impact of condoms on sexual pleasure. Although there have been some exceptions (Gorbach et al., 2019), the finding that MSM who use cannabis more frequently engage in more sexual risk behavior is largely consistent with previous work (Bryan et al., 2012; Kingree et al., 2000). Results of this study suggest that negative attitudes about the impact of condoms on pleasure may be one mechanism that underlies the higher rates of CAI among this population.

Although more frequent cannabis use was associated with less condom-related planning, planning was, unexpectedly, not associated with CAI and there was no evidence of a significant indirect effect of planning to account for the association between cannabis use frequency and CAI. This may suggest that usual planning strategies assessed by this self-report measure are less important for the occurrence of CAI, which tended to be a low-frequency event for most participants, than attitudes and other contextual factors such as relationship status (casual vs monogamous) (Kerr et al., 2015; Tucker et al., 2019). Future work may consider the use of other indices of planning abilities to further explore these questions (Grant et al., 2012). The current study is limited, as it is a cross-sectional analysis of cannabis use and CAI frequency in a sample of MSM with specific characteristics (e.g., relationship status, drinking, sexual behavior) which may limit generalizability. It is important to note that these data do not indicate that the use of cannabis “causes” negative perceptions of condoms on pleasure. Rather, the assessment of indirect effects provides insight into potential reasons that those who use cannabis more frequently are more likely to engage in higher CAI. Methods such as experience sampling could help to identify between, and within-subject effects of cannabis use on CAI (Simons et al., 2019). Findings of the current study suggest that attitudes about the effects of condoms on pleasure may be particularly important to address in HIV-prevention interventions among MSM who use cannabis.

Highlights.

  • MSM who are heavier cannabis users engaged in more frequent CAI

  • Negative effects of condoms on pleasure are more salient for heavier cannabis users

  • MSM who use cannabis more frequently exhibit poorer condom planning abilities

  • More frequent cannabis use is associated with more CAI through condom attitudes.

Role of Funding Sources

This study was funded by grant 5R01 AA022301 (MPI: Maisto, Palfai, Simons) from the National Institute on Alcohol Abuse and Alcoholism. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Footnotes

1

Three previous secondary analysis papers have been published from baseline self-report data collected in this study (Anderson et al., 2020; Luehring-Jones et al., 2019; Tahaney et al., 2020)

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