Clinical Pearls & Morning Reports
Published July 21, 2021
The association of drug use with sexual behavior and sexually transmitted infections is particularly strong among men who have sex with men (MSM). Read the NEJM Review Article here.
Q: Is substance use higher among MSM than among other men?
A: Substance use, across a range of licit and illicit substances, is higher among gay, bisexual, and other MSM than among men who do not have sex with men. This disparity is important, given the overdose crisis in the United States, rising rates of infectious disease transmission among people who use drugs, and engagement in high-risk sexual behaviors among some MSM who use drugs. Bisexual MSM have been found to have higher rates of substance use and substance use disorders than other subgroups of MSM and higher rates than heterosexual men.
Q: Is it helpful to view MSM as a uniform category?
A: Viewing MSM as a uniform category is an oversimplification. The term MSM is a broad behavioral descriptor that includes persons who identify as gay or bisexual, as well as men who identify as heterosexual but engage in sex with other men, including those who trade sex for money or drugs but do not identify as gay or bisexual. Even within subgroups of MSM, the degree of stigma and social factors related to race, ethnic group, and culture vary, and each of these factors influences substance use and related risk behaviors.
A: Especially in the United States, methamphetamine is used more frequently among MSM than among other men. Methamphetamine use is associated with multiple sexual partners, inconsistent use of condoms, and poor adherence to antiretroviral preexposure prophylaxis or antiviral treatment generally and has been identified as a factor contributing to rising rates of HIV transmission. A U.S. longitudinal study involving 4786 men, transgender men, and transgender women who have sex with men showed that methamphetamine use accounted for 35.7% of the incident HIV infections over a 1-year period; this represents an increase in the incidence of HIV seroconversion that is 7 times as high as the incidence among such persons who do not use methamphetamine. The recent increase in U.S. rates of fatal overdose involving methamphetamine suggest an additional concern for MSM, who disproportionately use this substance.
A: Rates of mental illness or serious mental illness among MSM are two to three times as high as the rates among other men. Research on motivations for substance use suggests that sexual minority–associated stress (e.g., from such pressures as stigma, internalized homophobia, and expectations of rejection), exposure to trauma, and adverse childhood experiences play a part in the concurrence of substance use and psychiatric illnesses among MSM. These intersecting risks related to increased rates of childhood sexual abuse, intimate partner violence, use of multiple substances (polydrug use), depression, sexual compulsivity, and HIV risk have been referred to as a syndemic (a syndrome of overlapping epidemics), underscoring the complexity in addressing the health and behavioral health needs of MSM.