Objectives In this narrative review we illustrate the patterns of substance use among gay, bisexual and other men who have sex with men (MSM), including comparisons with heterosexual populations, subgroup analyses and settings of substance use. We also consider explanations and motivations for substance use and the impact of use on sexual health as well as wider health and well-being. Finally, we consider the implications for the provision of MSM-tailored substance use and harm reduction services.
Methods We undertook a narrative review of diverse literature across the fields of public health, psychology and sociology to synthesise complex findings relating to the use and impacts of illicit drugs and alcohol among MSM. Attempts were made to draw on literature from across the globe, including all income settings.
Results Global evidence relating to the use of substances among MSM is limited due to the lack of disaggregation of data by sexual orientation. While complicated by methodological diversity, most research indicates a higher prevalence of illicit drug use among MSM compared with their heterosexual counterparts, although the same is not necessarily true of alcohol. A sense of belonging, coping with everyday problems and the enhancement of pleasure, all feature in motivations for alcohol and drug use. Global association studies document a link between substance use and sexual risk behaviours, and event-level analyses suggest an especially strong association with respect to alcohol. While there is some evidence that generic harm reduction interventions can be effective among sexual minorities, these need to be tailored to the social and cultural circumstances of MSM.
Conclusions Associations between substance use and sexual risk behaviour among MSM have been well documented, but the nature and pathway of these are poorly understood. A focus largely on substance use and sexual risk may have served to mask the impact of alcohol and drug use on the broader health and well-being of MSM.
- GAY MEN
- HEALTH PROMOTION
- SUBSTANCE MISUSE
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This paper reviews evidence relating to substance use among gay, bisexual and other men who have sex with men (MSM) across the globe. It adopts a broad view of substance use and explores alcohol as well as illicit drugs used by MSM. We begin by considering the broad patterns of substance use across the population, before considering the possible motivations (or causes) of high rates of use among MSM, compared with heterosexual men. Attention then turns to the impacts of substance use on sexual, physical and mental well-being before finally examining issues relating to the drug use and harm reduction interventions that are needed for MSM.
Rather than a full, systematic review of the literature on very specific dimensions of drug use, this paper presents a narrative synthesis of findings across the spectrum of drug use behaviours and responses. We chose a narrative review in order to bring together an interdisciplinary range of insights. This has the advantage of drawing on a range of disciplines and genres, although such an approach is not comprehensive and may miss important perspectives. We aim to synthesise literature from disparate academic fields and contexts to build a comprehensive account of how substance use occurs, why, its implications and the means of mitigating harm. In doing so, we hope to inform drug use management and harm reduction provision in sexual health settings, and to frame future areas of enquiry.
Patterns of substance use among MSM
Data relating to the prevalence and profile of substance use among MSM are incomplete. In a large number of settings, routine national health surveys do not collect or disaggregate data by sexual orientation. In other settings, data relating to MSM are collected in isolation, rendering comparison with other populations problematic due to varied data collection and sampling approaches. In addition, varied data collection time frames (eg, drug use in the previous 7 days, 4 weeks, 3 months, etc) and conceptualisation of the issues (eg, problematic drinking, binge drinking, etc) in different studies hinder comparisons. Within this paper, we use ‘problematic’ to describe drinking or other substance use that has a negative impact of daily functioning, such as general health or work, friendship and relationship stability.
Even when taking methodological limitations into account, the general trend is for a higher prevalence of drug among MSM when compared with heterosexual men. In terms of national-level studies that disaggregate data by sexual orientation, analysis of data between 2011 and 2014 from the Crime Survey of England & Wales indicates that gay and bisexual men were three times more likely to have used an illicit drug within the previous 12 months than heterosexual men. This rises to seven times more likely when considering only stimulant drugs, such as cocaine or ecstasy.1 Similarly, the Australian household health survey of 2013 found elevated rates of past year cannabis, ecstasy and methamphetamine use among gay and bisexual compared with heterosexual men (use of the methamphetamine was nearly four times higher).2 Analysis of aggregated data from the 2001–2008 Massachusetts Behavioural Risk Factor Surveillance surveys found that 23.5% of MSM had used illicit drugs within the previous 30 days, compared with only 10.1% of heterosexual men.3
Given its important role in HIV transmission, a number of countries have focused on injection drug use (IDU) among MSM. While rates have remained low and relatively stable across much of western and central Europe, with rates rarely above 4% ever having injected,4 ,5 this drug delivery method has been shown to be more common in central Asia,6 Russia7 and parts of Sub-Saharan Africa.8 Analysis of community survey data from 2011 in Sydney, Australia, found that 5.0% of MSM had injected drugs within the previous 6 months, a figure that is considerably higher than among the general population.9
It is typically only in large-scale community surveys of MSM that analysis to establish subgroup variation in drug and alcohol use is sufficiently powered. The findings of such analyses are not always consistent, but tend to suggest further marginalisation within MSM populations. A recent subanalyses from a cross-sectional online health survey among 5799 men living in England established that men from lower socioeconomic backgrounds, minority ethnic groups and with lower levels of education were most likely to report illicit drug use within the previous 4 weeks.10 A similar pattern was observed in relation to use of alcohol on more than 3 days a week. In Australia, analysis of cross-sectional gay community survey data found that high-risk drinking (determined by responses to the alcohol use disorders identification test (AUDIT)) was associated with younger age and being Australian born.11 The use of crystal methamphetamine has been found to be correlated with lower levels of educational attainment among MSM in Australia12 although the opposite has been observed in the USA.13 A finding reported in multiple countries across the world, established by a variety of measures, is that MSM with diagnosed HIV tend to report a higher prevalence of drug use compared with men who are HIV-negative or untested.4 ,14 ,15
With regard to the setting of drug use, most published literature has drawn attention to the use of the so-called ‘club drugs’ or ‘party drugs’, so named because of their use in gay bars or nightclubs to enhance dancing and social contact. Those most commonly used in North American, European4 and Australian16 contexts include ecstasy and cocaine, which can trigger feelings of euphoria with a sense of being more tactile or talkative also often reported.17 However, it is also the case that some MSM use drugs in more sexual settings. Within the last 5 years, a phenomenon colloquially referred to as ‘chemsex’ has been documented in Western Europe. Chemsex is typically associated with the use of mephedrone, Gamma hydroxybutyrate or the pre-drug Gamma butyrolactone (GHB/GBL) or crystal methamphetamine, and frequently involves sex with multiple partners either in sequence or in group scenarios.18 While first documented in the UK,19 there have since been indications of chemsex in several other Western European countries20–22 and reports from Southern Asia.23 This phenomenon is closely aligned to the notion of ‘party and play’, a similar sexualised drug use practice documented in North America24 and Australia,25 although focusing more specifically on crystal methamphetamine.
Motivations for substance use
There remains a relatively small body of research that informs our understanding of what motivates alcohol and drug use among MSM. For the purposes of this review, we consider motivations under three broad themes that recur across the wider literature (on general populations): use to enhance a sense of belonging; use to aid coping with everyday problems; and use to enhance pleasure.
The first and probably the most historically common assumption is that alcohol and drug use is so pervasive in the social environments and peer networks of the gay community that usage is very hard to avoid.26 This argument has been applied to alcohol for many decades and certainly since the 1970s where the limited number of gay bars served as de facto social clubs—literally the only safe space in the public sphere. While the diversification of gay community infrastructure has gradually diminished the extent to which this is true in many countries, it remains the case that in much of the world gay socialising, especially among the relatively young, is focused in premises where alcohol is served and drug use is normative. While the same is true of other populations, especially among the relatively young, the cultural norms for drinking and drug-taking among gay men, and the social context within which men socialise all contribute to the extensive use of alcohol and drugs.27 This structural or environmental proximity to alcohol and illicit drugs is exacerbated by positive norms for drinking and drug-taking—with respect to alcohol in particular, research supports the role of peers and partners in shaping individual patterns of use,28 and there is a strong correlation between drinking habits and perceptions of peer drinking habits among young people generally.29
The wider literature on reasons for using illicit drugs and alcohol tends to focus on its utility in reducing or masking negative thoughts and associations. Research generally describes this motivation as an aid to coping with adverse life events or perceived personal inadequacies.30 In the context of sexual minorities, the concept of minority stress31 has come to prominence as a potential explanation in accounts of why gay men are more likely to take various substances. The central tenet is that a combination of common negative experiences (such as anti-gay stigma and victimisation) and the perceived need for sexual identity concealment gives rise to internalised biases (sometimes referred to as internalised homophobia) that arouse stress, adversely impact mental health and increase substance use as a coping strategy.32
Use of drugs and alcohol as a coping strategy is also theorised in self-medication hypothesis of addictive disorders,33 which suggests that people who use drugs understand that the specific effects of certain drugs relieve a range of painful affect states and use those drugs as a means to manage distress or maintain emotional stability. Such distress may arise from internal conflict about sexuality and/or its concealment, or the stigma experienced upon disclosure. Some authors have even suggested that use of certain drugs can also be attributed to self-medication of negative affect associated with HIV infection.34 Similarly, cognitive escape theory35 proposes a more active process by which individuals strategically engage in alcohol and drug use to avoid thoughts about personal risk for HIV acquisition.
There is very little literature on the pleasures of using drugs and alcohol, and much of the evidence that does exist only considers motivations for having sex under the influence of drugs and alcohol.36 A range of studies suggest that alcohol has a disinhibiting effect on sexual behaviour (for review, see ref. 37), and more recent research has made similar assertions about other specific drugs such as crystal meth.34 While any user can attest to the disinhibitory effects of alcohol and some illicit drugs, folk wisdom also asserts the role of alcohol and drugs in breaking down the tenacity of the will. This notion that alcohol or drugs have a causative role in risky behaviour has been the subject of many studies among men (although fewer among MSM), and a recent review of this evidence38 highlights the centrality of alcohol myopia and what has been termed ‘expectancy theory’. The first of these can be considered causal in nature, by virtue of alcohol limiting an individual's ability to perceive the wider consequences of his actions, while the second can be considered reverse causal; an individual expects alcohol to cause certain behavioural changes, and thus these are adopted. The authors of this recent review stress the importance of future research examining person-level moderators and, in the context of new HIV prevention technologies, a broader range of sexual risk indicators.
Research on positive motivations for alcohol and drug use among MSM remains sparse, but a growing literature suggests that specific drugs have specific effects that MSM understand and actively seek.36 ,39 Ostrow and Stall40 suggest that some drugs increase motivation to have sex (eg, alcohol and cannabis), while others increase the intensity of the sexual session by enhancing pleasure (such as poppers, amphetamines and ecstasy), and others still are used to increase the duration of intercourse (including crystal meth and erectile dysfunction drugs).
Impacts of substance use
While there are exceptions,41 most global association studies tend to indicate that MSM who report recent heavy alcohol use are more likely to also report HIV risk behaviour within the same time period.37 Condomless anal intercourse is particularly strongly correlated with alcohol use disorder (a clinical term determined by the Diagnostic and Statistical Manual of Mental Disorders).42 This global-level association has been documented in many countries, including Australia,11 Cambodia,43 India,44 China,45 Canada46 and the USA.47 However, in many instances, interaction effects with illicit drugs or varied psychosocial factors that also influence sexual risk-taking can confound significant findings.37
Situation-level analyses (ie, those examining frequency with which alcohol was used during sex) report conflicting findings, but with a tendency for higher risk sexual activity to be documented in the context of longitudinal studies as opposed to cross-sectional ones.48 The most clear and consistent associations between alcohol use and sexual risk behaviour are observed when conducting event-level analyses, that is, those that examine the role of alcohol within a specific sexual encounter. This association is most pronounced in relation to binge drinking (five or more alcoholic drinks on one occasion), even when controlling for other situational and person-level variables (for a review of event-level substance use and sexual risk behaviour, see ref. 49).
A recent review has articulated the associations between illicit drug use and sexual risk behaviour,50 describing patterns of use and the varied pathways by which sexual risk-taking may be facilitated. In England, these issues have returned to the forefront of debate because of concern relating to chemsex, a minority drug use behaviour5 ,51 that can nevertheless lead to significant harm. By virtue of numerous sexual partners in quick succession, coupled with inconsistent condom use and insufficient certainty in serosorting of sexual partners, the conditions are set for HIV and other STI transmission. Given the practice of IDU among some men engaging in chemsex, and a greater likelihood of high-impact sexual activities, such as fisting, the potential for hepatitis C transmission exists. However, evidence tends to indicate that many MSM are unfamiliar with this virus, its transmission routes, complications and means of prevention.52 ,53
In consideration of wider health and well-being issues, there is evidence to indicate a negative association between use of illicit substances (especially stimulants such as crystal methamphetamine) and adherence to antiretroviral therapy (ART) among MSM with diagnosed HIV.54 However, the prevalence of non-adherence among illicit drug using MSM varies considerably, suggesting confounding and methodological limitations. There is also evidence to indicate complications with the use of ART in combination with certain illicit substances, although the evidence is limited. Adherence is similarly negatively associated with alcohol use disorders, with studies from Peru,55 USA56 and Latin America57 all documenting a higher propensity for missed doses among MSM who drink alcohol more frequently.
Qualitative studies in the UK58 and Australia59 as well as quantitative findings from the UK, North America and Australia60–62 indicate associations with mental ill-health and poorer well-being among some MSM who use alcohol or drugs, especially those who do so to objectively problematic levels. Problems include acute anxiety attacks (especially under the influence of crystal methamphetamine) or psychosis, and many men engaging in chemsex in particular report that, over time, they struggle to have sex without using drugs, indicating a psychological dependency and a wider dis-satisfaction with their sexual lives.58 Linked especially to chemsex, given its association with GHB/GBL, overdose remains a significant cause for concern for some MSM who use drugs. While such adverse consequences were uncommon in relation to other club drugs (such as ecstasy or cocaine), there are increasing reports of fatal overdoses among gay men in several European cities.21 ,58 ,63
Drug and alcohol interventions
While still rare, specialist MSM drug and alcohol services have begun to emerge in the USA, UK and Australia. In the absence of a global review on this topic, correspondence with expert health and community stakeholders indicates that in most countries specialist services for MSM simply do not exist, and even where they do the majority of MSM nationally have no access to them. As a consequence, it is likely that most MSM must access generic drug and alcohol support services, which can be problematic, given most drug services are based on harm reduction models primarily designed to address opiate use, and many alcohol services are focused on cessation.
It has been suggested that generic drug and alcohol interventions are unlikely to be acceptable to MSM because providers lack understanding of the social and cultural context in which use occurs.64 However, MSM drug and alcohol treatment research remains relatively uncommon, making it difficult to draw firm conclusions about the differential impact of generic compared with MSM-specific interventions. The authors of a review published in 2012 concluded there was insufficient evidence to demonstrate the long-term benefits of LGB-specific drug and alcohol interventions over generic interventions,65 though the authors acknowledged that cognitive behavioural therapy, contingency management and motivational interviewing had all been shown to be effective as drug and alcohol interventions with gay men. A 2014 review of cognitive behavioural interventions for HIV risk reduction in substance-using MSM found only limited evidence in support of cognitive behavioural therapy and made a call for research into briefer interventions, with particular focus on episodic substance use and effectiveness trials.66
Given many drug and alcohol interventions recommend individualisation based on expressed needs, it is essential that those delivering services understand the MSM cultural context and specific patterns of use, so that they can provide appropriate care.65 ,67 In the USA, for example, clinical recommendations state that knowledge of lesbian, gay or bisexual (LGB)-specific experiences and an LGB-affirming therapeutic style are beneficial regardless of reasons for seeking treatment,68 and training in these areas is assumed to improve therapeutic relationships and decrease barriers to care.69 Guidelines for working with lesbian, bisexual, gay and transgender populations with respect to their substance use have been produced,70 as have suggestions for harm reduction interventions specifically addressing the needs of MSM71 (although, as yet, neither have been subject to evaluation).
Interest in substance use among MSM has largely emerged from a concern about how such use might increase the likelihood of acquiring or transmitting HIV. Despite being the focus of widespread research, health provider and media attention, the role of substances in sexual risk-taking behaviour is still relatively poorly understood. An over-reliance on cross-sectional, observational or correlational studies has meant that crucial event-level data are lacking in most parts of the world. While simplistic associations between substance use and risky behaviours or adverse health outcomes are often assumed, the findings reviewed here encourage caution. The specific impact of substances is difficult to isolate amidst a myriad of competing psychological, cultural and socioeconomic factors.
While sexual risk-taking and its association with substance use remains a critical issue, such a narrow research focus masks the wider health impacts of substance use among a population that is socially and legally marginalised in many parts of the world. The concern for sexual health needs to be balanced against other, possibly more acute health concerns. We should also be attentive to the changing nature of social and sexual connectivity among MSM and the use of online and mobile technologies that render gay bars and clubs less central to everyday lives.72 With these changes in mind, explanations of drug use among MSM that highlight the physical settings in which they have historically congregated and the stresses they experience require re-examination. A robust understanding of how and why substance-use patterns emerge is central to the development of interventions to help MSM minimise and manage the harms associated with alcohol and drug use.
Finally, while there may be settings or circumstances of acute substance-use need where men feel safer or more confident accessing an MSM-specific service (and such interventions should be supported wherever possible), at a population level, the greatest benefit to MSM who use drugs is likely to emerge from equal access to existing harm reduction services that are attentive to their specific needs and social or cultural circumstances. Training for generic service providers should also acknowledge that MSM are not a homogenous population, and problematic substance use is often aligned with other axes of inequality, including age, ethnicity, educational attainment or socioeconomic status.
Handling editor Jackie A Cassell
Contributors AB and PW jointly prepared and finalised this paper.
Competing interests None declared.
Provenance and peer review Commissioned; externally peer reviewed.
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