Testing the drug use and condomless anal sex link among sexual minority men: The predictive utility of marijuana and interactions with relationship status

Highlights

• Relationship status contextualized drug use and casual partner CAS associations.

• Marijuana increased odds of CAS for single and monogamous SMM.

• Club drugs increased CAS odds and frequency for single and non-monogamous SMM.

• Associations between marijuana and CAS were smaller than club drugs.

Abstract

Background

The association between drug use and condomless anal sex (CAS) is well documented among sexual minority men (SMM). Less is known about whether this association generalizes to marijuana and across relationship status and sexual agreements groups (single, partnered monogamous, partnered open –outside partners permitted, and partnered monogamish –outside partners permitted when main partners are together).

Methods

A nationwide sample of SMM (N = 65,707) were recruited through a geosocial networking app between November 2017 and November 2019. Participants reported on drug use and instances of CAS with casual partners in the previous 30 days.

Results

Both marijuana and club drug use were associated with the occurrence of CAS with casual partners among single men. Only club drug use was associated with CAS frequency in this group. The association between marijuana and the occurrence of CAS did not differ significantly among monogamous men, while the associations between club drug use and the occurrence as well as frequency of CAS were significantly weaker. Meanwhile, the associations between club drug use and the occurrence as well as frequency of CAS did not differ significantly between single and non-monogamous (open and monogamish) subgroups; however, the association between marijuana and the occurrence of CAS was significantly weaker.

Conclusions

Findings largely replicated the robust association between club drug use and CAS with casual partners. They support the assertion that marijuana use predicts sexual risk for some SMM subgroups. Finally, they illustrate the potential for relationship status – and sexual agreements – to contextualize associations between drug use and CAS.

Introduction

Sexual minority men (SMM) accounted for over two-thirds of all new HIV diagnoses in the United States in 2018, despite only accounting for 2% of the population (Centers for Disease Control and Prevention, 2018). While a substantial body of research on HIV risk has focused predominantly on sexual transmission risk behaviors such as condomless anal sex (CAS) with casual partners among single SMM, the past decade has seen increasing attention directed towards HIV transmission risk in the context of relationships. This shift is grounded in epidemiological research indicating that main partner transmissions account for one to two-thirds of all new HIV infections (Goodreau et al., 2012; Sullivan et al., 2009).

Extensive research has shown that SMM who use drugs are more likely to engage in CAS with casual partners, which increases their risk of HIV acquisition or transmission (Rendina et al., 2015; Theodore et al., 2014). The purpose of the current study is to address two contextual issues in this area of research. First, despite being consistently reported among the drugs most commonly used during sex (Centers for Disease Control and Prevention, 2016), links between marijuana use and CAS with casual partners are less well studied than other substances. Second, the agreements male couples form about sex with outside partners predict both drug use and sexual behavior (Mitchell, 2016; Mitchell et al., 2014; Parsons, Starks, et al., 2013; Starks et al., 2019a, 2019b); however, no study has directly tested whether relationship status and sexual agreements moderate the association between drug use and CAS with casual partners.

Available evidence suggests that partnered SMM use drugs during sex at rates potentially approaching those observed among single SMM. Thirty-one percent of SMM reported using drugs (e.g., marijuana, cocaine and crack, and amphetamines) during sex (Centers for Disease Control and Prevention, 2016). Among partnered SMM, rates of drug use during sex between main partners varied between 12.5% (for club drugs) and 33% (for marijuana) (Mitchell, 2016). Meanwhile, the use of drugs specifically during sex with outside partners varied between 10.6% (for club drugs) and 31% (for marijuana) (Mitchell et al., 2016; Parsons and Starks, 2014).

While both partnered and single SMM consistently identify marijuana among the drugs most commonly combined with sex, there is little data evaluating the relationship between marijuana and CAS with casual partners. Much of the research on drug use and CAS with casual partners has been primarily concerned with “club drugs” (e.g., cocaine, methamphetamine, GHB, ketamine, LSD and ecstasy) (Theodore et al., 2014; Vosburgh et al., 2012). There is at least some evidence that marijuana may be associated with increased sexual risk taking as well. While some findings are equivocal (Carey et al., 2008; Hendershot et al., 2010), others have found that partnered SMM who use drugs – inclusive of marijuana – during sex are more likely to engage in CAS with casual partners (Mitchell et al., 2016; Parsons and Starks, 2014). Furthermore, poly-substance use – inclusive of marijuana – contributes to the prediction of lapses in HIV prevention communication between main partners (Starks et al., 2016).

Despite the abundance of research linking drug use and CAS with casual partners, no studies have tested whether this association is moderated by relationship status. This gap in the literature is important because research from the past decade has indicated that sexual agreements – the rules or boundaries couples establish related to sex with partners outside their relationship – are a consistent predictor of sexual behavior with casual partners and drug use. Men in relationships in which agreements around monogamy have been formed – where sex with casual partners is prohibited – are less likely to have sex with casual partners compared to those in non-monogamous relationships (Parsons et al., 2013a, 2013b; Spicer et al., 2019; Starks et al., 2019a, 2019b). They are also less likely to use club drugs and marijuana compared to those in non-monogamous relationships (Mitchell et al., 2013; Parsons and Starks, 2014). There is some evidence that monogamish agreements – a specific subtype of non-monogamy in which sex with casual partners is limited to instances where both main partners are present – predict higher rates of marijuana use compared to both monogamous and non-monogamous agreements that permit main partners to have sex with casual partners independently (Starks et al., 2019a, 2019b).

To date, no studies have specifically evaluated the association between marijuana use and CAS above and beyond club drug use. In addition, no studies have tested whether associations between drug use and CAS are equivalent across single and partnered men – accounting for sexual agreements among those men in relationships. The purpose of the current study was to address these gaps. This study has two specific objectives. First we evaluated the contributions of marijuana and club drug use to models predicting CAS with casual partners. Second, we tested whether relationship status moderated the associations between drug use and CAS with casual partners. We utilized hurdle models in order to simultaneously predict the occurrence of CAS with casual partners as well as the frequency of CAS with casual partners among SMM reporting at least one instance.