This is the accepted version of the manuscript and provided here for open access. The published version can be found at:
Berlin, G. W., Dermody, S. S., Noor, S. W., Skakoon-Sparling, S., Ghauri, Y., Zahran, A., … & Hart, T. A. (2024). Minority Stress, Psychological Distress, Sexual Compulsivity, and Avoidance-Based Motivations Associated with Methamphetamine Use Among Sexual Minority Men Living with HIV: Examining Direct and Indirect Associations Using Cross-Sectional Structural Equation Modeling. Substance Use & Misuse, 59(11), 1629-1639. https://doi.org/10.1080/10826084.2024.2369159
Minority stress, psychological distress, sexual compulsivity, and avoidance-based motivations associated with methamphetamine use among sexual minority men living with HIV: Examining direct and indirect associations using cross-sectional structural equation modeling
Graham W. Berlin[1], Sarah S. Dermody1, Syed W. Noor1,2, Shayna Skakoon-Sparling1,3, Yusuf Ghauri1, Adhm Zahran1, Kiffer G. Card4,11, Nathan J. Lachowsky4, Joseph Cox5,6, David M. Moore7, Gilles Lambert6,10, Jody Jollimore9, Daniel Grace8, Haochuan Zhang1, Herak Apelian6, Jordan M. Sang7, Milada Dvorakova6, Allan Lal7, & Trevor A. Hart1,8
Affiliations
Abstract
Objective: Sexual minority men (SMM) living with HIV report significantly greater methamphetamine use compared with heterosexual and HIV-negative peers. Greater use may be related to stressors (e.g., HIV-related stigma) faced by SMM living with HIV and subsequent psychological and behavioral sequelae. We tested an integrated theoretical model comprised of pathways between stigma, discrimination, childhood sexual abuse, psychological distress, sexual compulsivity, and cognitive escape in predicting methamphetamine use among SMM living with HIV. Method: Among 423 SMM living with HIV, we tested a structural equation model examining factors hypothesized to be directly and indirectly associated with methamphetamine use. Analyses were adjusted for demographic covariates and sampling bias. Results: The model showed good fit (CFI = .96, RMSEA = .01). Heterosexist discrimination was associated with psychological distress (β = 0.39, p < .001) and psychological distress was associated with sexual compulsivity (β = 0.33, p < .001). Sexual compulsivity was associated with cognitive escape (β = 0.31, p < .001), which was associated with methamphetamine use (β = 0.51, p < .001). Psychological distress was associated with methamphetamine use via serial indirect effects of sexual compulsivity and cognitive escape (β = 0.05, p < .05). Conclusions: Heterosexist discrimination contributed to psychological distress among SMM living with HIV. Psychological distress is linked to methamphetamine use via sexual compulsivity and cognitive avoidance. Interventions seeking to reduce the likelihood that SMM living with HIV use methamphetamine should include coping strategies specific to heterosexism and related psychological distress.
Keywords: sexual compulsivity; HIV; sexual minority men; methamphetamine; minority stress; psychological distress
Minority stress, psychological distress, sexual compulsivity, and avoidance-based motivations associated with methamphetamine use sexual minority men living with HIV: Examination of direct and indirect associations using cross-sectional structural equation modeling
Methamphetamine use is relatively common among sexual minority men (SMM), with estimates suggesting 8 to 20% of SMM have used methamphetamine in the past 6 to 12 months (Card et al., 2018; Hart et al., 2023). Moreover, SMM living with HIV have 3 to 6 times higher odds of reporting methamphetamine use in the past 6-12 months compared to HIV-negative SMM (Card et al., 2018; Frankis et al., 2018). Much of the research examining methamphetamine use among SMM has focused on sexual health outcomes, as the majority of methamphetamine use among SMM occurs within a sexual context (Lafortune et al., 2020; Maxwell et al., 2019). Indeed, sexualized methamphetamine use is associated with poorer HIV medication adherence and the transmission of blood borne infections (STBBIs); however, methamphetamine use is also associated with mental health outcomes, such as dependence, symptoms of depression, and psychosis (Darke et al., 2008; Hart et al., 2023). Although sexual and mental health outcomes associated with methamphetamine use are well documented, there is less information available about the psychosocial factors that may directly or indirectly increase the likelihood that SMM living with HIV will use methamphetamine (Platteau et al., 2019).
Despite these limitations, qualitative studies strongly suggest a complex interconnectedness among factors associated with methamphetamine use (Lafortune et al., 2020). This evidence suggests that some SMM are motivated to use methamphetamine to manage feelings of loneliness or social isolation (Fulcher et al., 2022), cope with stigma (e.g., HIV-related stigma; Berlin et al., 2022; Lafortune et al., 2020), and to avoid or escape negative emotions and cognitions (Gaspar et al., 2022). Quantitative findings also support an association between symptoms of depression and methamphetamine use as well as between cognitive escape (i.e., one’s propensity to use substances to cognitively avoid negative or uncomfortable thoughts/emotions during sex; Card et al., 2019; McKirnan et al., 2001) and methamphetamine use (Colyer et al., 2020). Broadly, there is a robust literature linking experiences of discrimination and stigma, including HIV-related stigma, with depressive symptoms and greater substance use among SMM living with HIV (Earnshaw et al., 2020; Goldbach et al., 2014; Meyers-Pantele et al., 2022) but limited quantitative studies that directly examine the interrelation of these factors with methamphetamine related outcomes.
Theoretical Frameworks
Although theoretical frameworks related to SMM’s methamphetamine use have often been discussed or referenced in empirical studies (e.g., Card et al., 2018; Hibbert et al., 2019), few have been directly tested and even less has been done to integrate complementary theories that may explain the higher prevalence of methamphetamine use seen among SMM living with HIV. To address this gap, we identified the following empirically supported theories that incorporate constructs supported in past qualitative and quantitative research with SMM who use methamphetamine: minority stress theory, cognitive escape theory, and theories of sexual compulsivity.
Minority Stress
Minority stress theory (Brooks, 1981; Meyer, 2003) posits that SMM and other sexual and gender minority populations experience a higher prevalence of mental health disorders compared to heterosexual men due, in part, to their experience of additional stress related to their stigmatized sexual identity (Pakula et al., 2016). Such stressors include external or distal stressors, such as harassment and discrimination, as well as more internal or proximal stressors such as internalized homonegativity, sexual orientation concealment, and fears of sexual orientation-related rejection (Meyer, 2003). Minority stress theory has consistently been supported in empirical research: SMM who report greater distal or proximal stressors also report higher levels of depression, anxiety, and substance use (Feinstein & Newcomb, 2016; Hoy-Ellis, 2023).
The minority stress framework has also been extended to include unique stressors experienced by SMM living with HIV, specifically HIV-related stigma, which contributes to psychological distress (Rendina et al., 2017). For example, sexual rejection and fears of sexual rejection because of one’s HIV status are commonly reported among SMM living with HIV and are associated with psychological distress, greater substance use, and sexual compulsivity (Berg et al., 2017; Earnshaw et al., 2020; Rendina et al., 2017). The additive effects of sexual orientation- and HIV-related stigma; therefore, contribute to psychological distress among SMM living with HIV. In turn, SMM living with HIV may be more likely to employ cognitive and behavioral strategies to manage negative emotions related to stigma and discrimination compared to both HIV negative SMM and heterosexual men (Rendina et al., 2017). Some of these strategies, such as sexual compulsivity and cognitive escape may increase their likelihood of using methamphetamine.
Sexual Compulsivity
Emotion regulation models of sexual compulsivity (e.g., Pachankis et al., 2015), suggest that some SMM may use sex as a means of managing negative emotions like anxiety and depression (i.e., psychological distress). According to these models, sex provides effective short-term relief from negative emotions but ineffective long-term relief, with negative emotions reemerging (Chaney & Burns-Wortham, 2017). Over time, the use of sex to manage unpleasant emotions may develop into a maladaptive cycle whereby individuals increasingly experience strong negative emotions and subsequent urges or desires to reduce these emotions through sex. As a result, sexual thoughts and behaviors may become so frequent and intrusive that they interfere with important areas of functioning (i.e., symptoms that characterize sexual compulsivity; Kalichman & Rompa, 2001). As negative emotions reemerge and intensify, sex itself may evoke negative emotions (e.g., guilt, shame), and SMM may in turn seek to manage these emotions by using substances such as methamphetamine (Garcia & Thibaut, 2010).
Further, sexual compulsivity has been shown to be associated methamphetamine and stimulant use, with greater sexual compulsivity corresponding to a 46% higher odds of stimulant use in the past 6 months among a probability sample of American SMM (Carrico et al., 2012; Pirnia et al., 2015). As with distal minority stressors, distal factors may increase some SMM’s likelihood for sexual compulsivity. One such factor supported in the literature is a history of childhood sexual abuse (Chaney & Burns-Wortham, 2017). This may be particularly relevant as meta-analytic results found that SMM reporting a history of childhood sexual abuse had 50% higher odds of reporting an HIV diagnosis compared to SMM without a history of childhood sexual abuse (Lloyd & Operario, 2012). Further, childhood sexual abuse has been shown to be associated with greater psychological distress (Mimiaga et al., 2009), sexualized substance use (Lloyd & Operario, 2012), and methamphetamine use (Lopez-Patton et al., 2016). Along with HIV stigma and minority stressors, childhood sexual abuse may be related to greater levels of psychological distress and sexual compulsivity.
Cognitive Escape
Cognitive escape theory suggests that some SMM may be motivated to use substances during sexual encounters to avoid thinking about HIV-related concerns (e.g., HIV transmission, HIV-related sexual rejection), restrictive sexual norms, negative emotions (e.g., anxiety, guilt) associated with certain sexual behaviors (e.g., condomless anal sex), and negative thoughts and emotions more generally (Card et al., 2019; McKirnan et al., 2001). Cognitive escape can be conceptualized as an avoidant coping strategy employed by SMM when negative thoughts and emotions are experienced, particularly within sexual situations. SMM with a greater propensity for cognitive escape may be more likely to use methamphetamine to manage negative emotions to enjoy sexual experiences more fully. This is supported by findings from a Canadian sample of SMM living with HIV, which showed that greater cognitive escape corresponded to an 8% higher odds of reporting methamphetamine use in the past 6 months (Colyer et al., 2020).
Theoretically Integrative Multiple Mediation (TIMM) Model of Methamphetamine Use
Based on the a priori integration of the theoretical frameworks, we hypothesized that distal factors (i.e., heterosexist discrimination, HIV stigma, and childhood sexual abuse) and proximal stressors would be positively associated with psychological distress among SMM living with HIV’s (hypothesis 1a). In turn, psychological distress would be associated with a greater likelihood of using methamphetamine indirectly through coping strategies, specifically sexual compulsivity and cognitive escape (hypothesis 1b, see Figure 1). To further test the interrelatedness of these factors, we hypothesized the following indirect effects (Hypotheses 2a-d): (a) psychological distress associated with methamphetamine use in the past six months indirectly through cognitive escape and sexual compulsivity, (b) heterosexist discrimination associated with psychological distress indirectly through proximal stress, (c) proximal stress associated with cognitive escape indirectly through psychological distress, and (d) childhood sexual abuse associated with sexual compulsivity indirectly through psychological distress.
[Figure 1 here]
Method
Participants and Procedure
This study is a secondary analysis of cross-sectional baseline data from the Engage Cohort Study, a large multi-site cohort of 2,449 Canadian SMM from Toronto (N = 517), Montreal (N = 1179), and Vancouver (N = 754). Between February 2017 and August 2019, respondent-driven sampling (RDS) was used to recruit participants at the three study sites. RDS approximates probabilistic sampling by calculating weights based on the size of participants’ social networks (Volz & Heckathorn, 2008). Data from participants with smaller social networks are given greater weight and vice versa (Wejnert & Heckathorn, 2011). Eligible participants were self-identified cis- and transgender men, 16 years or older, able to read French or English, willing to undergo STBBI testing, and who reported sex with another man in the previous six months. A total of 423 SMM reported living with HIV. Non-RDS weighted descriptive statistics are reported in Table 1. For a more detailed description of the baseline sample and recruitment method see (Cox et al., 2021; Hart, Moore, et al., 2021). Study protocols were approved by institutional review boards of Research Institute of the McGill University Health Centre, Toronto Metropolitan University, University of Toronto, St. Michael’s Hospital, University of British Columbia, and University of Victoria.
[Table 1 here]
Measures
Demographic Covariates. The model was adjusted for race/ethnicity, sexual orientation, annual income, age, and city of recruitment. To assess participants’ racial/ethnic and sexual orientation identities, participants were asked “what single ethnic group or family identity do you most identify with?” and “if you had to choose one term that you felt best described your sexual orientation, which would you choose?”, respectively. Responses for both questions were dichotomized with ‘0’ representing European/Canadian ethnicity/ancestry and gay sexual orientation, respectively, and ‘1’ representing all non-European/Canadian ethnicity/ancestry and non-gay sexual orientations, respectively.
Primary Outcome
Methamphetamine Use in the Past Six Months. Methamphetamine use in the past six months was assessed by a single item that asked “in your life, have you EVER used any of the following substances?” Response options were: “never”, “yes, in the past 6 months”, “yes, in my lifetime, but more than 6 months ago”, and “don’t know/don’t remember”. Individuals reporting methamphetamine use in the past six months were categorized as “yes” (coded ‘1’) and all other responses categorized as “no” (coded ‘0’).
Latent Variables
Proximal Stress. The mean scores of the 3-item internalized homonegativity (e.g., “I wish I were heterosexual”), acceptance concerns (e.g., “I can’t feel comfortable knowing that others judge me negatively for my sexual orientation”, and concealment motivation (e.g., “I prefer to keep my same-sex romantic relationships rather private”) subscales of the Lesbian, Gay, and Bisexual Identity Scale (LGBIS; Mohr & Kendra, 2011) were used to derive the latent proximal stress variable (Figure 2). Items are scored on a 6-point Likert-type scale ranging from “strongly disagree” to “strongly agree”. Higher scores represent higher levels of that construct. Research indicates good psychometric properties of these subscales, including convergent and divergent validity (Dyar et al., 2018; Szymanski et al., 2008). In this sample, internal reliability estimates ranged from α = .78 to .83.
Psychological Distress. The latent psychological distress variable was derived using the subscales of the Hospital Anxiety and Depression Scale (HADS; Zigmond & Snaith, 1983)
and a question about lifetime suicidality. The anxiety (α = .83) and depression (α = .77) subscales are composed of seven items scored on a 4-point Likert-type scale ranging from “most of the time” to “not at all.” Higher scores indicate more anxiety or depression symptomatology. The anxiety and depression subscales have demonstrated concurrent validity with other measures of anxiety and depression (Bjelland et al., 2002). The question pertaining to lifetime suicidality asked, “have you ever thought about or attempted to kill yourself?” The six possible responses were (sample frequencies in parentheses): 1 = never (36%); 2 = it was just a brief passing thought (30%); 3 = I have had a plan at least once to kill myself but did not try to do it (14%); 4 = I have had a plan at least once to kill myself and really wanted to die (6%); 5 = I have attempted to kill myself, but did not really want to die (6%); 6 = I have attempted to kill myself, and really hoped to die (7%).
Observed Variables
HIV Stigma. HIV stigma was assessed via participants’ selection of a categorical response option from the Everyday Discrimination Scale (Sternthal et al., 2011) asking them if they believed their everyday experiences of discrimination were a result of their HIV status. Participants’ indicating that experiences of discrimination were related to their HIV status were categorized as having experienced HIV stigma (coded ‘1’) while individuals who did not were categorized as not having experienced HIV stigma (coded ‘0’).
Childhood Sexual Abuse. Childhood sexual abuse was measured using the sexual abuse subscale of the Childhood Trauma Questionnaire – Short Form (CTQ-SF, α = .93; Bernstein et al., 2003), which is composed of five items that are scored on a 5-point Likert-type scale ranging from “never” to “very often.” Higher scores indicate greater childhood sexual abuse. The CTQ-SF has demonstrated good test-retest reliability (Bernstein et al., 2003).
Past Year Heterosexist Discrimination. Heterosexist discrimination was measured using the 14-item Heterosexist Harassment, Rejection and Discrimination Scale (HHRDS, α = .93; Szymanski, 2006), which is scored on a 6-point Likert-type scale ranging from “never” to “almost all of the time.” The scale assesses experiences of harassment and rejection, workplace and school discrimination, and other experiences of discrimination (e.g., “how many times have you been treated unfairly by your family because you are a gay/bisexual man”). For this study, an additional item was added that asked “before the age of 18, how many times were you made fun of, picked on, pushed, shoved, hit, or threatened with harm because you were gay/bisexual?” Mean scores were calculated for the 15 items. Higher scores indicate greater past year discrimination. The HHRDS has demonstrated good construct and convergent validity across diverse SMM samples (Feinstein et al., 2012, 2023; E. R. Smith et al., 2020).
Cognitive Escape. Cognitive escape was measured using the 12-item Escape Motives Scale (EMS, α = .94), which is scored on a 4-point Likert-type scale ranging from “strongly disagree” to “strongly agree” (McKirnan et al., 2001). The EMS assesses one’s motivation to use substances to cognitively avoid thinking about HIV-related risks and norms in sexual contexts (e.g., “after getting drunk or high, I am more sexually responsive”). Higher scores indicate greater cognitive escape. The EMS has been shown to have good construct validity (McKirnan et al., 2001).
Sexual Compulsivity. Sexual compulsivity was measured using the 10-item Sexual Compulsivity Scale (SCS, α = .89; Kalichman & Rompa, 2001). Each item is scored on a 4-point Likert-type scale ranging from “not at all like me” to “very much like me”. An example item is “my sexual appetite has gotten in the way of my relationships before.” Mean scores were calculated for the 10 items. Higher scores indicate greater sexual compulsivity.
Data Analysis
Data used in the analysis, analysis code, and research materials are available upon request. Data inspection, descriptive statistics, bivariate correlations were conducted using R, version 4.0.0 (R Core Team, 2020) and structural equation models were estimated using Mplus, version 7.4 (B. O. Muthén & Muthén, 2015). Item-level missing data were computed for individuals with 80% or more of a scale completed by calculating the mean of completed items. Participants missing more than 80% of any individual scale were coded as a missing data point for that measure.
The measurement model (containing only latent variables) was estimated first followed by the full structural model depicted in Figure 2 (Kline, 2016). Both models were estimated using weighted least squares with robust standard errors, a mean and variance adjusted test statistic (WLSMV), and RDS-II weights. Lifetime suicidality and methamphetamine use in the past 6 months were specified as ordinal and binary variables, respectively. All other variables were continuous or exogenous, and therefore not required to be specified if categorical. Absolute model fit was assessed via chi-square (χ2), the comparative fit index (CFI), root-mean-square error of approximation (RMSEA), and weighted root mean square residual (WRMR). Acceptable model fit were considered to be CFI ≥ .95, WRMR ≤ 1.0 (DiStefano et al., 2018; Hu & Bentler, 1999), RMSEA ≤ .08 (MacCallum et al., 1999), and a non-significant chi-square. The full structural model was adjusted for age, race/ethnicity, sexual orientation, annual income, and city of recruitment with all endogenous variables regressed on demographic covariates. Standard errors of indirect effects were estimated using the delta method (L. K. Muthén & Muthén, 2017) as Mplus and other commonly used statistical software does not allow for bootstrapped standard errors in estimates of weighted structural equation models.
The categorical covariates race/ethnicity and sexual orientation were entered into the model as binary variables with European/Canadian race/ethnicity and gay sexual orientation serving as the reference categories, respectively. Post-hoc analyses were conducted to examine differences in study variables by race/ethnicity and sexual orientation. The details, rationale, and results for these analyses can be found in the Supplemental Materials.
Results
Non-RDS adjusted means, standard deviations, and bivariate correlations for all study variables are presented in Table 2. Non-RDS adjusted estimates were used as most statistical software packages, including those used for this analysis, cannot calculate weighted Kendall’s tau correlation coefficients.
[Table 2 here]
Measurement Model
Modification indices indicated that model fit could be improved by correlating the residuals of concealment motivations and anxiety. After allowing for this correlation, the model evidenced an acceptable fit for the data (χ2[df = 7, N = 415] = 6.62, p = .47; RMSEA = .00, 90% CI [.00, .06]; CFI = 1.00; WRMR = .36) and was maintained in the estimation of the full structural model.
Full Structural Model
In estimating the full structural model, modification indices indicated that model fit could be significantly improved by adding a direct path from sexual compulsivity to cognitive escape. Though not originally specified in our hypothesized model, this addition maintained the integrity of the hypothesized model and was theoretically defensible (Carrico et al., 2012). With the addition of this direct path, the model was a good fit for the data (χ2[df = 65, N = 423] = 67.12, p = .34; RMSEA = .01, 90% CI [.00, .03]; CFI = .96; WRMR = .61). See Figure 2 for standardized estimates, factor loadings, and the R2 of dependent variables.
[Figure 2 here]
Three pathways from distal stressors were not statistically significant: 1) the indirect effect of heterosexist discrimination (α1) to psychological distress (β1) via proximal stress (α1β1= 0.02, SE = 0.03, p = .48), 2) the indirect effect of proximal stress (β1) to cognitive escape (α3) via psychological distress (β1α3 = -0.01, SE = 0.02, p = .35), and 3) the indirect effect of childhood sexual abuse (α2) to sexual compulsivity (α4) via psychological distress (α2α4 = 0.02, SE = 0.04, p = .62). The total standardized indirect effect of psychological distress (α4) to methamphetamine use via sexual compulsivity (β2) and cognitive escape (β3) was also not statistically significant (α4β3β4 = 0.02, SE = 0.05, p = .78).
There were statistically significant specific indirect effects from psychological distress to cognitive escape (β2) via sexual compulsivity (α4) (α4β2= 0.10, SE = 0.03, p = .002) and from sexual compulsivity (β2) to methamphetamine use via cognitive escape (β3) (β2β3 = 0.16, SE = 0.05 p = .003). Serial indirect effects indicated a significant positive indirect association between psychological distress (α4) and methamphetamine use through sexual compulsivity (β2) and cognitive escape (β3) (α4β2β3= 0.05, SE = 0.02, p = .012).
Discussion
Among a large sample of Canadian SMM living with HIV, greater psychological distress corresponded to a higher odds of reporting methamphetamine use in the past 6 months indirectly through associations with sexual compulsivity and cognitive escape. However, this indirect association occurred only via the serial indirect effects of both sexual compulsivity and cognitive escape, suggesting that psychological distress may only correspond to a higher odds of methamphetamine use indirectly through behavioral and motivational factors. These findings are consistent with studies demonstrating a link between psychological distress and sexual compulsivity (e.g., Parsons et al., 2012) and extend the association to an additional population: SMM living with HIV who use methamphetamine. Our findings also align with emotion regulation models of sexual compulsivity (Pachankis et al., 2015) and further suggest that sexual compulsivity itself may be associated with additional emotion regulation strategies, particularly avoidant strategies, which may increase the likelihood that SMM living with HIV use substances during sex to escape negative thoughts and emotions.
Though the associations are cross-sectional, the findings suggest that specific methods of coping with psychological distress increase the odds of methamphetamine use rather than the direct effects of psychological distress. Though not supported directly in previous research, the association between sexual compulsivity and cognitive escape makes theoretical sense. Sexual compulsivity is hypothesized to develop as a means to manage negative emotions but over time becomes its own stressor that evokes negative emotions (e.g., shame, guilt; Garcia & Thibaut, 2010). Individuals continuing to use sex to manage negative emotions may use substances to manage negative emotions associated with their sexual behaviors (i.e., cognitive escape). Our findings therefore extend previous research that shows links between cognitive escape, or similar measures of avoidant coping, and methamphetamine use among SMM (Carrico et al., 2012; Colyer et al., 2020; Halkitis & Shrem, 2006) by showing the interconnectedness of psychological distress, sexual compulsivity, cognitive escape, and methamphetamine use.
Our findings also potentially clarify mixed findings surrounding the association between symptoms of psychological distress and sexual compulsivity with methamphetamine use (Halkitis et al., 2007; Semple et al., 2006). That is, the effects of psychological distress on methamphetamine use may occur through multiple mechanisms and the connection among these variables may only be elucidated when tested within a single model that accounts for their complex interrelationships. In this regard, our findings align most closely with, and extend, Carrico and colleagues’ (2012) findings by demonstrating the serial indirect effects of psychological distress on methamphetamine use through sexual compulsivity and cognitive escape. Given that our study used different measures of sexual compulsivity, avoidant coping, and stimulant use than Carrico et al. (2012), the similarity of our findings underlines the importance of these variables in understanding SMM’s use of methamphetamine.
Statistical support for our model provides preliminary evidence that minority stress plays a role in methamphetamine use among SMM living with HIV through its associations with psychological distress. Our model provides support for a more unified theoretical framework through which to understand methamphetamine use among SMM living with HIV. Proximal stressors, childhood sexual abuse, and HIV stigma were not significantly associated with psychological distress within our model. While unexpected, the lack of associations does suggest that heterosexist discrimination may be the stressor primarily responsible for greater psychological distress among SMM living with HIV.
Finally, post-hoc examinations of associations of study variables with race/ethnicity and sexual orientation found only significant associations with proximal stress (see Supplemental Materials). Specifically, Indigenous, South Asian, and Black identities were associated with significantly greater proximal stress as were bisexual and Two-Spirit identities. As proximal stress was not significantly associated with psychological distress or cognitive escape, the significance of these findings in relation to methamphetamine use remains unclear. However, given the large body of evidence supporting the detrimental effects of proximal stressors on the wellbeing of SMM and evidence of unique motivations for sexualized methamphetamine use among Black SMM (Jerome & Halkitis, 2009), further exploration of motivations for methamphetamine use among SMM of color, Two-Spirit, and bisexual individuals living with HIV is needed.
Clinical Implications
Given the critical importance of sexual compulsivity in the association between psychological distress, cognitive escape, and methamphetamine use, interventions that help to reduce sexual compulsivity may play a pivotal role in reducing methamphetamine use and methamphetamine harms. For instance, Gay Poz Sex (GPS) is a peer-administered group-based sexual health counseling intervention designed to support SMM living with HIV that has been shown to reduce rates of sexual risk behaviors, including sexual compulsivity (Hart et al., 2021). Interventions like GPS also align with calls from SMM who use methamphetamine for greater integration of peer support and facilitators with lived experience (Fulcher et al., 2022). Interventions that target emotion regulation to decrease sexual compulsivity should also be further explored given preliminary evidence of their efficacy (Parsons et al., 2017).
The importance of cognitive escape in the associations of psychological distress and sexual compulsivity with methamphetamine use further suggests the need to account for SMM’s motivations for using methamphetamine in the design and delivery of intervention services[2]. Though cognitive escape was the focal motivational factor in our model, research suggests multiple and mutually inclusive motivations for methamphetamine exist among SMM, particularly belongingness and sexual disinhibition (Lafortune et al., 2020). Interventions and approaches that incorporate and tailor services according to SMM’s motivations for using methamphetamine are likely to be better received and more effective (Fulcher et al., 2022).
Given the direct and indirect pathways to methamphetamine use via psychosocial factors, interventions seeking to prevent or reduce methamphetamine use among SMM may be most effective when underlying psychosocial factors are simultaneously targeted. Thus, general and SMM-specific methamphetamine treatments with demonstrated efficacy, including gay-specific CBT (Reback & Shoptaw, 2014) and contingency management (Carrico et al., 2016), could potentially be improved with adjunctive interventions that address experiences of minority stress (e.g., development of coping skills; Pachankis et al., 2019). Scale up of existing interventions and implementation of evidence-informed interventions is also needed, as community reports indicate growing community interest in, but limited availability of, specialized programs that address the sexualized context in which SMM’s methamphetamine use often takes place (Arthur et al., 2021).
The present findings also highlight the potentially vital role of preventative interventions that target heterosexism at the structural (Hatzenbuehler et al., 2010) and interpersonal levels (e.g., gay-straight alliances in schools; Heck et al., 2013) as well as interventions designed to help young SMM cope with minority stress (e.g., Smith et al., 2016) to reduce their likelihood of relying on methods of coping that may increase their likelihood of using methamphetamine. Moreover, post-hoc analyses suggest that SMM of color, particularly Indigenous, Black, and South Asian SMM, may be more likely to experience high levels of proximal stress and therefore may require greater support and targeted interventions that address their unique experiences and needs as SMM with multiple marginalized identities. Interventions might include adapted treatments that target stressors related to sexual orientation as well as those related to race/ethnicity (e.g., protocols for racial trauma; Williams et al., 2022).
Limitations and Future Directions
This study examined methamphetamine use as a binary variable, limiting the types of conclusions that can be drawn concerning frequency or severity of use. Future research examining differential predictors of methamphetamine use (yes/no) versus methamphetamine use severity are needed (Batchelder et al., 2017). The use of methamphetamine during sex is not inherently pathological and interventions should target those desiring support with reducing or stopping their methamphetamine use as well as the psychosocial factors most strongly associated with methamphetamine use problems. Longitudinal research is needed to better understand the directionality of effects as are tests of bidirectional relationships among these variables. There is good reason to believe a number of these associations may be cyclical in nature (e.g., low mood increases chances of using methamphetamine, withdrawal from methamphetamine worsens mood; Mimiaga et al., 2012).
As demonstrated in substance use research broadly, and as indicated in research with SMM who use methamphetamine, substance use motives are diverse and differentially associated with substance use outcomes (Cooper et al., 2015; Feinstein & Newcomb, 2016). Therefore, future research is needed to identify the diverse motivations for using methamphetamine among SMM living with HIV and investigate how motivations differentially relate to and mediate the associations of psychosocial factors with methamphetamine use and related outcomes. Given the diversity of motivations reported in qualitative literature, such as the use of methamphetamine to reduce sexual inhibitions, increase sexual pleasure, and achieve belongingness (Lafortune et al., 2020), future research should explore the unique associations of substance use motives with methamphetamine use patterns and outcomes among SMM.
Future research should also examine how methamphetamine use and associated psychosocial factors differ based on the various intersectional identities (e.g., racial, gender experiences; Crenshaw, 1989) that SMM hold, and the unique challenges and strengths associated with these identities (e.g., religious affiliations, cultural identity/community). Within this sample, racial and ethnic differences were only significantly associated with proximal stress; however, research with Black and White heterosexual men indicates important racial/ethnic differences in coping styles and associations with psychological distress (Allen et al., 2020). Future research should examine racial and ethnic differences in coping responses among SMM living with HIV and how these responses may in turn increase or decrease their likelihood of using methamphetamine. Finally, future research is needed to examine other social and structural factors that may mitigate methamphetamine-related harms, such as access to sexual orientation affirming healthcare and socioeconomic status.
Conclusion
In a large sample of SMM living with HIV, our findings suggest that experiences of heterosexism are associated with greater psychological distress and that, in turn, psychological distress is associated with methamphetamine use indirectly through sexual compulsivity and cognitive escape. The effectiveness of interventions seeking to prevent or reduce methamphetamine use among SMM living with HIV may be improved by addressing underlying psychosocial factors. This study represents a significant contribution to the field as it uses theory to integrate past qualitative and quantitative findings into a single hypothesis-driven model demonstrating a through-line between several psychosocial variables previously identified in multiple independent studies (e.g., (Carrico et al., 2012; Colyer et al., 2020; Hart et al., 2018; Pachankis et al., 2015).
Funding Details
Engage/Momentum II is funded by the Canadian Institutes for Health Research (CIHR, TE2-138299; FDN-143342; PJT-153139), the Canadian Foundation for AIDS Research (CANFAR, Engage), the Ontario HIV Treatment Network (OHTN, 1051), the Public Health Agency of Canada (4500345082), and Toronto Metropolitan University. Graham W. Berlin is supported by a Social Sciences and Humanities Research Council doctoral scholarship; Shayna Skakoon-Sparling is supported by postdoctoral fellowships from CIHR and CTN; David M. Moore and Nathan J. Lachowsky are supported by Scholar Awards from the Michael Smith Foundation for Health Research (5209, 16863); Trevor A. Hart is supported by a Chair in Gay and Bisexual Men’s Health from the OHTN; Daniel Grace is supported by a Canada Research Chair in Sexual and Gender Minority Health. Adhm Zahran is supported by an Ontario Graduate Scholarship.
Disclosure Statement
The authors report there are no competing interests to declare.
References
Allen, J. O., Watkins, D. C., Mezuk, B., Chatters, L., & Johnson-Lawrence, V. (2020). Mechanisms of racial health disparities: Relationships between coping and psychological and physiological stress responses. Ethnicity & Disease, 30(4), 563–574. https://doi.org/10.18865/ed.30.4.563
Arthur, S., Berlin, G., Card, K., Carson, A., Goodyear, T., Jollimore, J., Klassen, B., Krell, S., Mniszak, C., Montiel, A., Purdie, A., Knight, R., & Lachowsky, N. (2021). Supporting gay, bisexual, trans, two-spirit, and queer (GBT2Q) people who use crystal methamphetamine in metro Vancouver and surrounding areas. Community-Based Research Centre. https://www.cbrc.net/supporting_gbt2q_people_who_use_crystal_meth
Batchelder, A. W., Safren, S., Mitchell, A. D., Ivardic, I., & O’Cleirigh, C. (2017). Mental health in 2020 for men who have sex with men in the United States. Sexual Health, 14(1), 59. https://doi.org/10.1071/SH16083
Berg, M. K., Hobkirk, A. L., Joska, J. A., & Meade, C. S. (2017). The role of substance use coping in the relation between childhood sexual abuse and depression among methamphetamine users in South Africa. Psychological Trauma: Theory, Research, Practice, and Policy, 9(4), 493–499. https://doi.org/10.1037/tra0000207
Berlin, G. W., Fulcher, K., Taylor, K., Nguyen, T., Montiel, A., Moore, D., Hull, M., & Lachowsky, N. J. (2022). Links between Childhood Abuse, Insidious Trauma, and Methamphetamine Use across the Lifespan among Gay, Bisexual, and Other Men Who Have Sex with Men: A Qualitative Analysis. Journal of Homosexuality, 1–21. https://doi.org/10.1080/00918369.2022.2089075
Bernstein, D. P., Stein, J. A., Newcomb, M. D., Walker, E., Pogge, D., Ahluvalia, T., Stokes, J., Handelsman, L., Medrano, M., Desmond, D., & Zule, W. (2003). Development and validation of a brief screening version of the Childhood Trauma Questionnaire. Child Abuse & Neglect, 27(2), 169–190. https://doi.org/10.1016/S0145-2134(02)00541-0
Bjelland, I., Dahl, A. A., Haug, T. T., & Neckelmann, D. (2002). The validity of the Hospital Anxiety and Depression Scale. Journal of Psychosomatic Research, 52(2), 69–77. https://doi.org/10.1016/S0022-3999(01)00296-3
Brooks, V. R. (1981). Minority stress and lesbian women. Lexington Books.
Card, K. G., Armstrong, H. L., Carter, A., Cui, Z., Wang, L., Zhu, J., Lachowsky, N. J., Moore, D. M., Hogg, R. S., & Roth, E. A. (2018). A latent class analysis of substance use and culture among gay, bisexual and other men who have sex with men. Culture, Health & Sexuality, 20(12), 1424–1439. https://doi.org/10.1080/13691058.2018.1439186
Card, K. G., Armstrong, H. L., Wang, L., Bacani, N., Moore, D. M., Roth, E. A., Hogg, R. S., & Lachowsky, N. J. (2019). Escape expectancies and sexualized substance use among gay, bisexual, and other men who have sex with men. AIDS Care, 1–9. https://doi.org/10.1080/09540121.2019.1705961
Carrico, A. W., Pollack, L. M., Stall, R. D., Shade, S. B., Neilands, T. B., Rice, T. M., Woods, W. J., & Moskowitz, J. T. (2012). Psychological processes and stimulant use among men who have sex with men. Drug and Alcohol Dependence, 123(1–3), 79–83. https://doi.org/10.1016/j.drugalcdep.2011.10.020
Carrico, A. W., Zepf, R., Meanley, S., Batchelder, A., & Stall, R. (2016). When the party is over: A systematic review of behavioral interventions for substance-using men who have sex with men. JAIDS, 73(3), 299–306. https://doi.org/10.1097/QAI.0000000000001102
Chaney, M. P., & Burns-Wortham, C. M. (2017). Sexual compulsivity and men who have sex with men (MSM). In T. Birchard & J. Benfield (Eds.), The Routledge International Handbook of Sexual Addiction (1st ed.). Routledge. https://doi.org/10.4324/9781315639512
Colyer, S. P., Moore, D. M., Cui, Z., Zhu, J., Armstrong, H. L., Taylor, M., Edward, J., Howard, T., Dickie, C., Olarewaju, G., Montaner, J. S. G., Hogg, R. S., Roth, E. A., & Lachowsky, N. J. (2020). Crystal methamphetamine use and initiation among gay, bisexual, and other men who have sex with men living with HIV in a treatment as prevention environment. Substance Use & Misuse, 55(14), 2428–2437. https://doi.org/10.1080/10826084.2020.1833925
Cooper, M. L., Kuntsche, E., Levitt, A., Barber, L. L., & Wolf, S. (2015). Motivational models of substance use. In K. J. Sher (Ed.), The Oxford Handbook of Substance Use and Substance Use Disorders (Vol. 1). Oxford University Press. https://doi.org/10.1093/oxfordhb/9780199381678.013.017
Crenshaw, K. (1989). Demarginalizing the intersection of race and sex: A Black feminist critique of antidiscrimination doctrine, feminist theory and antiracist politics. University of Chicago Legal Forum, 1(8). http://chicagounbound.uchicago.edu/uclf/vol1989/iss1/8
Darke, S., Darke, S., Kaye, S., Darke, S., Kaye, S., McKetin, R., Darke, S., Kaye, S., McKetin, R., Duflou, J., Darke, S., Kaye, S., McKetin, R., & Duflou, J. (2008). Major physical and psychological harms of methamphetamine use. Drug and Alcohol Review, 27(3), 253–262. https://doi.org/10.1080/09595230801923702
DiStefano, C., Liu, J., Jiang, N., & Shi, D. (2018). Examination of the weighted root mean square residual: Evidence for trustworthiness? Structural Equation Modeling: A Multidisciplinary Journal, 25(3), 453–466. https://doi.org/10.1080/10705511.2017.1390394
Dyar, C., Feinstein, B. A., Eaton, N. R., & London, B. (2018). The mediating roles of rejection sensitivity and proximal stress in the association between discrimination and internalizing symptoms among sexual minority women. Archives of Sexual Behavior, 47(1), 205–218. https://doi.org/10.1007/s10508-016-0869-1
Earnshaw, V. A., Eaton, L. A., Collier, Z. K., Watson, R. J., Maksut, J. L., Rucinski, K. B., Kelly, J. F., & Kalichman, S. C. (2020). HIV stigma, depressive symptoms, and substance use. AIDS Patient Care and STDs, 34(6), 275–280. https://doi.org/10.1089/apc.2020.0021
Feinstein, B. A., Goldfried, M. R., & Davila, J. (2012). The relationship between experiences of discrimination and mental health among lesbians and gay men: An examination of internalized homonegativity and rejection sensitivity as potential mechanisms. Journal of Consulting and Clinical Psychology, 80(5), 917–927. https://doi.org/10.1037/a0029425
Feinstein, B. A., Khan, A., Chang, C. J., & Miller, S. A. (2023). Use of the heterosexist harassment, rejection, and discrimination scale with different sexual orientation, gender, and racial/ethnic groups: An examination of measurement invariance. Assessment, 30(8), 2605–2615. https://doi.org/10.1177/10731911231156135
Feinstein, B. A., & Newcomb, M. E. (2016). The role of substance use motives in the associations between minority stressors and substance use problems among young men who have sex with men. Psychology of Sexual Orientation and Gender Diversity, 3(3), 357–366. https://doi.org/10.1037/sgd0000185
Frankis, J., Flowers, P., McDaid, L., & Bourne, A. (2018). Low levels of chemsex among men who have sex with men, but high levels of risk among men who engage in chemsex: Analysis of a cross-sectional online survey across four countries. Sexual Health, 15(2), 144. https://doi.org/10.1071/SH17159
Fulcher, K., Berlin, G., Taylor, K., Wells, A., Nguyen, T., Moore, D., Hull, M., & Lachowsky, N. J. (2022). Understanding the service needs and preferences of men who have sex with men who use crystal methamphetamine in British Columbia, Canada: A qualitative study. International Journal of Mental Health and Addiction. https://doi.org/10.1007/s11469-022-00848-4
Garcia, F. D., & Thibaut, F. (2010). Sexual addictions. The American Journal of Drug and Alcohol Abuse, 36(5), 254–260. https://doi.org/10.3109/00952990.2010.503823
Gaspar, M., Marshall, Z., Adam, B. D., Brennan, D. J., Cox, J., Lachowsky, N., Lambert, G., Moore, D., Hart, T. A., & Grace, D. (2022). ‘I was just doing what a normal gay man would do, right?’: The biopolitics of substance use and the mental health of sexual minority men. Health: An Interdisciplinary Journal for the Social Study of Health, Illness and Medicine, 26(5), 643–662. https://doi.org/10.1177/1363459321996753
Goldbach, J. T., Tanner-Smith, E. E., Bagwell, M., & Dunlap, S. (2014). Minority stress and substance use in sexual minority adolescents: A meta-analysis. Prevention Science, 15(3), 350–363. https://doi.org/10.1007/s11121-013-0393-7
Halkitis, P. N., Mukherjee, P. P., & Palamar, J. J. (2007). Multi-level modeling to explain methamphetamine use among gay and bisexual men. Addiction, 102, 76–83. https://doi.org/10.1111/j.1360-0443.2007.01769.x
Halkitis, P. N., & Shrem, M. T. (2006). Psychological differences between binge and chronic methamphetamine using gay and bisexual men. Addictive Behaviors, 31(3), 549–552. https://doi.org/10.1016/j.addbeh.2005.05.040
Hart, T. A., Noor, S. W., Skakoon-Sparling, S., Lazkani, S. N., Gardner, S., Leahy, B., Maxwell, J., Julien, R., Simpson, S., Steinberg, M., & Adam, B. D. (2021). GPS: A randomized controlled trial of sexual health counseling for gay and bisexual men living with HIV. Behavior Therapy, 52(1), 1–14. https://doi.org/10.1016/j.beth.2020.04.005
Hart, T. A., Noor, S. W., Tavangar, F., Berlin, G. W., Skakoon-Sparling, S., Tan, D. H. S., Lambert, G., Grace, D., Jollimore, J., Sang, J. M., Kirschbaum, A. L., Kanji, R., Apelian, H., Cox, J., Moore, D. M., & Lachowsky, N. (2023). Crystal methamphetamine use and bacterial sexually transmitted infections (STIs) among gay, bisexual and other sexual minority men in Canada. Drug and Alcohol Dependence, 242, 109718. https://doi.org/10.1016/j.drugalcdep.2022.109718
Hart, T. A., Noor, S. W., Vernon, J. R. G., Kidwai, A., Roberts, K., Myers, T., & Calzavara, L. (2018). Childhood maltreatment, bullying victimization, and psychological distress among gay and bisexual men. The Journal of Sex Research, 55(4–5), 604–616. https://doi.org/10.1080/00224499.2017.1401972
Hatzenbuehler, M. L., McLaughlin, K. A., Keyes, K. M., & Hasin, D. S. (2010). The impact of institutional discrimination on psychiatric disorders in lesbian, gay, and bisexual populations: A prospective study. American Journal of Public Health, 100(3), 452–459. https://doi.org/10.2105/AJPH.2009.168815
Heck, N. C., Flentje, A., & Cochran, B. N. (2013). Offsetting risks: High school gay-straight alliances and lesbian, gay, bisexual, and transgender (LGBT) youth. Psychology of Sexual Orientation and Gender Diversity, 1(S), 81–90. https://doi.org/10.1037/2329-0382.1.S.81
Hibbert, M. P., Brett, C. E., Porcellato, L. A., & Hope, V. D. (2019). Psychosocial and sexual characteristics associated with sexualised drug use and chemsex among men who have sex with men (MSM) in the UK. Sexually Transmitted Infections, 95(5), 342–350. https://doi.org/10.1136/sextrans-2018-053933
Hoy-Ellis, C. P. (2023). Minority stress and mental health: A review of the literature. Journal of Homosexuality, 70(5), 806–830. https://doi.org/10.1080/00918369.2021.2004794
Hu, L., & Bentler, P. M. (1999). Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria versus new alternatives. Structural Equation Modeling: A Multidisciplinary Journal, 6(1), 1–55. https://doi.org/10.1080/10705519909540118
Jerome, R. C., & Halkitis, P. N. (2009). Stigmatization, stress, and the search for belonging in black men who have sex with men who use methamphetamine. Journal of Black Psychology, 35(3), 343–365. https://doi.org/10.1177/0095798409333620
Kalichman, S. C., & Rompa, D. (2001). The sexual compulsivity scale: Further development and use with HIV-positive persons. Journal of Personality Assessment, 76(3), 379–395. https://doi.org/10.1207/S15327752JPA7603_02
Kline, R. B. (2016). Principles and practice of structural equation modeling (Fourth edition). The Guilford Press.
Lafortune, D., Blais, M., Miller, G., Dion, L., Lalonde, F., & Dargis, L. (2020). Psychological and interpersonal factors associated with sexualized drug use among men who have sex with men: A mixed-methods systematic review. Archives of Sexual Behavior. https://doi.org/10.1007/s10508-020-01741-8
Lloyd, S., & Operario, D. (2012). HIV risk among men who have sex with men who have experienced childhood sexual abuse: Systematic review and meta-analysis. AIDS Education and Prevention, 24(3), 228–241. https://doi.org/10.1521/aeap.2012.24.3.228
Lopez-Patton, M., Kumar, M., Jones, D., Fonseca, M., Kumar, A. M., & Nemeroff, C. B. (2016). Childhood trauma and METH abuse among men who have sex with men: Implications for intervention. Journal of Psychiatric Research, 72, 1–5. https://doi.org/10.1016/j.jpsychires.2015.09.009
MacCallum, R. C., Widaman, K. F., Zhang, S., & Hong, S. (1999). Sample size in factor analysis. Psychological Methods, 4(1), 84–99. https://doi.org/10.1037/1082-989X.4.1.84
Maxwell, S., Shahmanesh, M., & Gafos, M. (2019). Chemsex behaviours among men who have sex with men: A systematic review of the literature. International Journal of Drug Policy, 63, 74–89. https://doi.org/10.1016/j.drugpo.2018.11.014
McKirnan, D. J., Vanable, P. A., Ostrow, D. G., & Hope, B. (2001). Expectancies of sexual “escape” and sexual risk among drug- and alcohol-involved gay and bisexual men. Journal of Substance Abuse, 13(1–2), 137–154. https://doi.org/10.1016/S0899-3289(01)00063-3
Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129(5), 674–697. https://doi.org/10.1037/0033-2909.129.5.674
Meyers-Pantele, S. A., Lammert, S., Rendina, H. J., Shalhav, O., Talan, A. J., Smith, L. R., Pitpitan, E. V., & Horvath, K. J. (2022). Examining HIV stigma, depression, stress, and recent stimulant use in a sample of sexual minority men living with HIV: An application of the stigma and substance use process model. AIDS and Behavior, 26(1), 138–148. https://doi.org/10.1007/s10461-021-03517-0
Mimiaga, M. J., Noonan, E., Donnell, D., Safren, S. A., Koenen, K. C., Gortmaker, S., OʼCleirigh, C., Chesney, M. A., Coates, T. J., Koblin, B. A., & Mayer, K. H. (2009). Childhood sexual abuse is highly associated with HIV risk-taking behavior and infection among MSM in the EXPLORE Study. JAIDS Journal of Acquired Immune Deficiency Syndromes, 51(3), 340–348. https://doi.org/10.1097/QAI.0b013e3181a24b38
Mimiaga, M. J., Reisner, S. L., Pantalone, D. W., O’Cleirigh, C., Mayer, K. H., & Safren, S. A. (2012). A pilot trial of integrated behavioral activation and sexual risk reduction counseling for HIV-uninfected men who have sex with men abusing crystal methamphetamine. AIDS Patient Care and STDs, 26(11), 681–693. https://doi.org/10.1089/apc.2012.0216
Mohr, J. J., & Kendra, M. S. (2011). Revision and extension of a multidimensional measure of sexual minority identity: The Lesbian, Gay, and Bisexual Identity Scale. Journal of Counseling Psychology, 58(2), 234–245. https://doi.org/10.1037/a0022858
Muthén, B. O., & Muthén, L. K. (2015). Mplus (7.4) [Computer software].
Muthén, L. K., & Muthén, B. O. (2017). Mplus User’s Guide (Eighth Edition) [Computer software]. Muthén & Muthén.
Pachankis, J. E., McConocha, E. M., Reynolds, J. S., Winston, R., Adeyinka, O., Harkness, A., Burton, C. L., Behari, K., Sullivan, T. J., Eldahan, A. I., Esserman, D. A., Hatzenbuehler, M. L., & Safren, S. A. (2019). Project ESTEEM protocol: A randomized controlled trial of an LGBTQ-affirmative treatment for young adult sexual minority men’s mental and sexual health. BMC Public Health, 19(1), 1086. https://doi.org/10.1186/s12889-019-7346-4
Pachankis, J. E., Rendina, H. J., Restar, A., Ventuneac, A., Grov, C., & Parsons, J. T. (2015). A minority stress—Emotion regulation model of sexual compulsivity among highly sexually active gay and bisexual men. Health Psychology, 34(8), 829–840. https://doi.org/10.1037/hea0000180
Pakula, B., Shoveller, J., Ratner, P. A., & Carpiano, R. (2016). Prevalence and co-occurrence of heavy drinking and anxiety and mood disorders among gay, lesbian, bisexual, and heterosexual Canadians. American Journal of Public Health, 106(6), 1042–1048. https://doi.org/10.2105/AJPH.2016.303083
Parsons, J. T., Grov, C., & Golub, S. A. (2012). Sexual compulsivity, co-occurring psychosocial health problems, and HIV risk among gay and bisexual men: Further evidence of a syndemic. American Journal of Public Health, 102(1), 156–162. https://doi.org/10.2105/AJPH.2011.300284
Parsons, J. T., Rendina, H. J., Moody, R. L., Gurung, S., Starks, T. J., & Pachankis, J. E. (2017). Feasibility of an emotion regulation intervention to improve mental health and reduce HIV transmission risk behaviors for HIV-positive gay and bisexual men with sexual compulsivity. AIDS and Behavior, 21(6), 1540–1549. https://doi.org/10.1007/s10461-016-1533-4
Pirnia, B., Mansour, S., Rahmani, S., & Soleimani, A. A. (2015). Sexual behavior and age differences in methamphetamine dependent and non-dependent men who have sex with men (msm). Practice in Clinical Psychology, 3(4), 273–282.
Platteau, T., Pebody, R., Dunbar, N., Lebacq, T., & Collins, B. (2019). The problematic chemsex journey: A resource for prevention and harm reduction. Drugs and Alcohol Today, 19(1), 49–54. https://doi.org/10.1108/DAT-11-2018-0066
R Core Team. (2020). R: A language and environment for statistical computing [Computer software]. URL https://www.R-project.org/
Reback, C. J., & Shoptaw, S. (2014). Development of an evidence-based, gay-specific cognitive behavioral therapy intervention for methamphetamine-abusing gay and bisexual men. Addictive Behaviors, 39(8), 1286–1291. https://doi.org/10.1016/j.addbeh.2011.11.029
Rendina, H. J., Gamarel, K. E., Pachankis, J. E., Ventuneac, A., Grov, C., & Parsons, J. T. (2017). Extending the minority stress model to incorporate HIV-positive gay and bisexual men’s experiences: A longitudinal examination of mental health and sexual risk behavior. Annals of Behavioral Medicine, 51(2), 147–158. https://doi.org/10.1007/s12160-016-9822-8
Semple, S. J., Zians, J., Grant, I., & Patterson, T. L. (2006). Sexual compulsivity in a sample of HIV-positive methamphetamine-using gay and bisexual men. AIDS and Behavior, 10(5), 587–598. https://doi.org/10.1007/s10461-006-9127-1
Smith, E. R., Perrin, P. B., & Sutter, M. E. (2020). Factor analysis of the heterosexist harassment, rejection, and discrimination scale in lesbian, gay, bisexual, transgender, and queer people of colour. International Journal of Psychology, 55(3), 405–412. https://doi.org/10.1002/ijop.12585
Smith, N. G., Hart, T. A., Moody, C., Willis, A. C., Andersen, M. F., Blais, M., & Adam, B. (2016). Project PRIDE: A cognitive-behavioral group intervention to reduce HIV risk behaviors among HIV-negative young gay and bisexual men. Cognitive and Behavioral Practice, 23(3), 398–411. https://doi.org/10.1016/j.cbpra.2015.08.006
Sternthal, M. J., Slopen, N., & Williams, D. R. (2011). Racial disparities in health. Du Bois Review: Social Science Research on Race, 8(1), 95–113. https://doi.org/10.1017/S1742058X11000087
Szymanski, D. M. (2006). Does internalized heterosexism moderate the link between heterosexist events and lesbians’ psychological distress? Sex Roles, 54(3–4), 227–234. https://doi.org/10.1007/s11199-006-9340-4
Szymanski, D. M., Kashubeck-West, S., & Meyer, J. (2008). Internalized heterosexism: Measurement, psychosocial correlates, and research directions. The Counseling Psychologist, 36(4), 525–574. https://doi.org/10.1177/0011000007309489
Volz, E., & Heckathorn, D. D. (2008). Probability based estimation theory for respondent driven sampling. Journal of Official Statistics, 24(1), 79.
Wejnert, C., & Heckathorn, D. (2011). Respondent-driven sampling: Operational procedures, evolution of estimators, and topics for future research. In M. Williams & W. Vogt (Eds.), The SAGE Handbook of Innovation in Social Research Methods (pp. 473–497). SAGE Publications Ltd. https://doi.org/10.4135/9781446268261.n27
Williams, M. T., Holmes, S., Zare, M., Haeny, A., & Faber, S. (2022). An evidence-based approach for treating stress and trauma due to racism. Cognitive and Behavioral Practice, S1077722922001146. https://doi.org/10.1016/j.cbpra.2022.07.001
Zigmond, A. S., & Snaith, R. P. (1983). The hospital anxiety and depression scale. Acta Psychiatrica Scandinavica, 67(6), 361–370. https://doi.org/10.1111/j.1600-0447.1983.tb09716.x
[1] Correspondence concerning this article should be addressed to Graham W. Berlin and Trevor A. Hart, Department of Psychology, Toronto Metropolitan University, 350 Victoria St. Toronto, Ontario M5B 2K3, Canada. Emails: gberlin@torontomu.ca and trevor.hart@torontomu.ca
[2] We would like to sincerely thank an anonymous reviewer who provided feedback on an earlier draft of the manuscript. Their critical analysis of our findings and the limitations of our model ultimately promoted a more fruitful discussion, including considerations for practitioners supporting SMM living with HIV who use methamphetamine and avenues of future research.
EngageTO
September 24th, 2024