Rehabilitating Our Approach to Gay Men Who Use Drugs

Much of the writing on HIV prevention is loaded with punitive clichés about gay men that highlight psychological deficits, lack of self control, and prevention fatigue. Perhaps the most repeated one since the onset of the epidemic suggests that the majority of gay men are into drugs and couldn’t care less about becoming infected while enjoying their substances.

While these clichés have persisted throughout the epidemic, a closer look at statistics shows a more nuanced portrait of gay men. The Sex Now survey (Canada’s largest survey of gay and bisexual men) showed that the vast majority of gay men report no risk for HIV in the previous year (70 percent) nor did most report any use of party drugs over the same time period (85 percent), not even once.

One issue of concern emerging from the Sex Now survey, however, is that gay men who do use drugs are nearly twice as likely to report HIV risk. Other researchers have also demonstrated this relationship. But concluding that “drugs = uncontrolled gay men = risky sex ”, and that health professionals should focus their efforts on eradicating drug use among gay men to prevent HIV, ignores the complexity of gay men’s lives and the reasons they engage in both risky sex and substance use. For example, a recent UK study looking into the narratives of gay men who use drugs suggests that only a small minority were unable to control their behaviour when doing drugs. For others, risky sex was a decision made independently of drug use, while others enjoyed their sex lives and substances without any HIV risk.

Moreover, the explanation for higher sexual risk among drug using gay men may not actually reside in drug use itself. In Sex Now, gay men who reported drug use were also likely to report an array of other psychosocial difficulties such as depression, anxiety, suicidality, experiences of violence and homophobia and episodes of binge drinking. All these factors are known in the HIV literature to increase one’s vulnerability to HIV.

Finally, it is important to consider how public health and community agencies have generally responded to the prevention needs of drug using gay men. A recent review of prevention activities in BC demonstrated that the gay drug-using population is largely ignored by prevention. Initiatives that have been implemented have tended to focus on warning gay men against the danger of mixing drugs and sex, while doing very little to empower more informed decisions. Again, this strategy does not attend to gay men’s needs – most men are familiar with the danger of drugs with sex. Fear-based campaigns ignore the co-occurring factors and health problems gay men may be experiencing in conjunction with drug use. A strategy that focuses on educating solely on the risks of drugs reinforces the cliché that gay men cannot make rational decisions.

Rather than blaming gay men, we need a more positive approach to sex and drug research that examines gay men’s experiences with substances beyond a statistical correlation with risky sex. This research needs to take into account the burden of other health issues in this sub-population. We should demand targeted health promotion initiatives that reflect gay men’s real needs and work to reduce the bias of the public health field which appears to have issues with both gay sex and substance use.

olivier ferlatte

Author: Olivier Ferlatte, Research Education Director at the Community-Based Research Centre for Gay Men’s Health, Vancouver.

**Please note that the material presented here does not necessarily imply endorsement or agreement by individuals at the Centre for Addictions Research of BC

The Power of Stigma and its Impact on Drug Use among Sex Workers

A headshot of Cecilia Benoit

Why are people involved in sex work more likely to use “hard” drugs such as cocaine and heroin than someone working as a server in a restaurant? Is it because they are “immoral” or “bad” people, or is it because their occupation is more stigmatized? If our society directed less stigma or judgment toward this group, would there be less use of hard drugs and smaller differences in substance use between sex workers and servers? Our research seems to indicate yes.

Stigma, which involves the use of defamatory labels and discriminatory actions by individuals and social institutions, is directly linked with poor physical and mental health outcomes for people who perceive that they have been stigmatized. Drug use can also be a way to cope with stigma.

Some people working in the sex industry use drugs to cope with the negative self-image and social isolation engendered by occupational stigmas, or to self-medicate in the presence of physical, mental, or emotional health challenges. The use of these “hard” drugs is also socially less acceptable, making it an additional source of stigma for the individuals using them.

We investigated the link between perceived stigma and substance use with interview and survey data from a study of three service work occupations: sex work, food and beverage serving, and hair styling and barbering. We found1 that workers from all three of these occupations reported negative societal perceptions of their jobs and experienced stigma in their interactions with the public and with health care professionals. However, perceived stigma was significantly more common and more intense for people working in the sex industry, and a larger number of these workers told us that they had come to accept perceptions that their work was disreputable. Most importantly, a high level of perceived stigma was associated with a higher level of use of “hard drugs”. Interestingly, we found that stigma did not influence the use of “softer” substances such as alcohol or marijuana.

Perceived stigma is an important factor that helps us understand differences in substance use. It is no coincidence that the occupation in our study most associated with hard drug use was also the occupation most frequently associated with immorality and criminality.

So, how do we work to reduce the stigma associated with sex work? One way is by including people with lived experience when shaping policy that affects the sex industry. Their voices and insights will be essential for designing harm reduction strategies that challenge prostitution laws and other policies that keep people working in the sex industry disciplined, controlled and excluded, and that contribute to a powerful stigma that encourages the use of addictive substances.

1Benoit, C., McCarthy, B. & Jansson, M. (In press). Stigma, service work, and substance use: A two-city, two-country comparative analysis. Sociology of Health & Illness.

Cecilia BeoitMikael Jannsonbill mccarthy
Authors: Dr.Cecilia Benoit, Scientist, Centre for Addictions Research of BC;  Dr. Mikael Jansson, Scientist, Centre for Addictions Research of BC; Bill McCarthy, Chair, Department of Sociology, UC Davis.

**Please note that the material presented here does not necessarily imply endorsement or agreement by individuals at the Centre for Addictions Research of BC