Open in a separate window aIncludes one participant who stated that he was negative. Personal identifiers were not included in the demographic survey. Approximately half of the participants were bisexual, defined here as self-reporting sex with both male and female partners in the prior 12 months. Thirteen percent reported sex with male-to-female transgender partners.
Each focus group session lasted minutes, was audiotaped, and transcribed verbatim. To ensure confidentiality, no personal identifiers were included in the transcripts of the group discussions or on the post-group surveys.
Verbal informed consent was obtained using IRB-approved procedures. Once informed consent was obtained, nametags were distributed, whereby participants were free to print a pseudonym or their real first names.
After completing the group, participants were asked to complete a short demographic survey. Probes were used when necessary to solicit additional or more detailed responses. The analysis team consisted of six members, including the principal investigator, co-principal investigator, two investigators from the collaborating CBOs, the project director, and one co-facilitator. In the first phase of analysis, members read the sections of each focus group transcript that discussed alcohol or drug use, meeting weekly to discuss the phenomena they identified relevant to drug use and sexual identity and behaviors.
Major themes identified in each transcript were summarized in matrix form and circulated to the group for feedback.
In the second phase of analysis, the group met to discuss themes identified across transcripts, identify common domains, and refine them into categories that were then applied consistently to quotations across all transcripts using Atlas.
Results In most groups, participants listed drug use and addiction as one of the major health problems facing African American men. Alcohol and crack cocaine were the most frequently discussed drugs, with alcohol referenced by participants in all but one focus group and crack cocaine mentioned in all groups.
In response to focus group questions preceding the specific discussion of drug use, participants described specific expectations of African American men that reflected traditional masculine role norms including heterosexism , racist sexual stereotypes, the importance of family, and a recognition of a shared history of racism and struggle.
This sociocultural context is partially reflected in the following quotations: It can be conservative, it can be liberal on civil rights issues and all those issues, but when it comes to the issue of homosexuality, sexuality, same-sex marriage, it can be very conservative. So, you guys have to realize that we come from a very religious-based community also.
Families that grew up in church, families that are very religious, and they instill that in you as you grow up. So, it puts you in a whole different perspective of how you want to, I guess, be who you are.
Being gay or bisexual is not accepted and is even condemned in many contexts that are central to African American communities.
So, many men may struggle with who they are and finding places where they can be more comfortable with their sexuality. We identified 18 subthemes directly related to drug use and sex in the population and grouped them under four overarching domains.
They include drug and alcohol use and transactions as motivators, allowers, rationalizers, and facilitators for having sex with other men. Further, we discuss how these four roles help to decrease cognitive dissonance regarding issues of masculinity and participation in same-sex sexuality but also how they complicate a fifth domain, recovery from drug addiction, for some African American MSM.
Drugs as Motivators Drugs as motivators of same-sex activity refer to instances in which men report having sex with other men solely or primarily because of their own drug use or dependence. Three subthemes were identified, which described how drugs motivated or influenced same-sex activity including: A small number of participants seemed to indicate that, for them, sex with men was limited to periods of active druguse and generally occurred within the context of exchange sex. Exchange sex or sex for drugs, money, or shelter was referenced by multiple participants and in all but one of the focus group discussions.
In some instances, exchange sex was described as a means to meet multiple needs, including obtaining drugs or money and fulfilling desires for sex with men. In others, the drugs or the means to buy them were discussed as a sole motivator for sex with men. I only messed around [with men] because I am such a stone-cold crack head that I had to have it When it came to crack cocaine, you know and then I discovered crystal meth.
I think, uh, that drug use and alcohol abuse is the major reason why HIV is out of control today. Because even straight men know that they can go and make money with having a guy suck their dick so they can get that next hit, you know. You know, you going. Some participants questioned, however, whether any man would engage in sex with another man without having some same-sex attractions. For one participant, exchange sex was part of his early, formative sexual experiences with other men and led to years of prostitution as a means to access drugs.
Like I said, I was just a straight prostitute out there because I had to get the next hit Uh, I think I turned my first little trick for a six-pack of beer when I was like In other instances, participants indicated that sex with men was a response to the sexual compulsion and desire that was brought on by stimulant use.
For example, this participant seems to indicate that one is more susceptible to same-sex attractions when high and that an easily aroused man who is also high makes the ideal potential sexual partner in these circumstances: The participant below indicates that crack cocaine use causes him to want to play the receptive rather than the insertive role in sexual intercourse when asked to identify the factors that affect his sexual behavior.
Rock cocaine, Rock cocaine I mean, it flips the script on me just like that. Instead of me poking, I want to get poked, I mean, just like that. HIV-negative group Drugs as Allowers Drugs as allowers of same-sex behavior refer to instances where drug intoxication allows a man to act out his desire for sex with another man despite a personal intention to avoid the behavior.
This domain encompassed four subthemes: You know, at the time when I used to do cocaine While you were using? Or, what I was thinking. HIV-negative group Below, this participant refers to being involved with sex with men while drunk and later regretting the action when sober.
I think it almost kind of reinforces the You kind of try to separate yourself even further from that lifestyle. I think that it becomes-you can almost demonize it a little bit, you know. Like, I think I hate to be drunk. Subthemes included concern about 1 fulfilling masculine gender role expectations and 2 homophobia among peers. Often, both roles came into play. This excuse was one they could give to others and to themselves in order to avoid admitting to or thinking about the implications of their sexual desires and actions.
I think that drugs, alcohol, and sex and the MSM have been a major factor because what it has done for men that were on the down low that really had the feelings or had it inside of them.
Once we got loaded, once we hit the pipe, once we were using speed, or once we had the alcohol, then, when I fucked around with you, I can say I was fucked up last night laughter.
So, what it does, or what it has done, or what it did; it opened up the door to bring the down low, to expose it more. Because now we found something that lets us do what we want to do, be who we want to be. And, we have an excuse to do it.
It enhanced our feelings, it gives an excuse for our feelings, and enabled us to do what we enjoy doing anyway. And in most cases, even if we became sober, we still do it. Well, a lot of them have inferiority complexes about their manhood being compromised, and this, that, and the other. And, they like on And then if someone says something off the record, they be ready to fight and this, that, and the other because somebody might, you know, say something derogatory, call them a punk, or whatever the case may be, and then they feel as if they have to defend their manhood, you know what I mean?
And, you know, they have issues. They use drugs as an excuse. Ok, cause you know how the crack epidemic is And, I think that guys mess with gay people for two reasons. They like what you can do for them, for the most part. So, if any number of reasons that a person comes up with, worried about what their homeboys got to say I cannot see myself being that, but I can see myself having sex with a man all the time.
For example, a few men discussed public and social settings that served both as pick-up spots for MSM and as venues where drugs or alcohol were sold and used, thus contributing to a tendency for MSM to have sex under the influence. These settings included bars, clubs, and private parties.
Much illicit drug use, however, as with sex between men, occurs in secret with people who either accept drug use or use drugs themselves. Therefore, the two activities can very easily coexist. For example, the participant above described men who, under the guise of using drugs, would go off secretly with known drug-using MSM in order to have sex with them.
This participant felt less inhibited in approaching someone he was attracted to when under the influence. That influence or something, it gives me more courage to say what I want to say. HIV-negative group Another described how drugs may be used to deal with the feelings and stress associated with secretly engaging in sex with men. HIV-negative group Some participants indicated that when they were high and very sexually aroused, they preferred male to female sexual partners.
Participants indicated that male partners were easily aroused and required less emotional commitment and initiated fewer conflicts than did women. One participant, however, described how his female drug-using partners were more aroused and ready to have sex when under the influence of stimulants.
Hence, these drugs seem to have the benefit of also making some females primarily interested in sex. Below, this participant indicated that his drug-using female partners also tended to accept his bisexual behavior, a statement that was supported by other group participants.
Okay, and then on the flip side, with the women See in addiction community, women are more accepting of men who mess with men, then just straight women. And I never, ever, I never hid it in the addiction community. One participant explained that he was currently in drug treatment for the ninth time and that his only chance for success is if he does not hide his same-sex activity and deals with his sexuality.
Because, because but, for the ah, ah, the seriousness of my disease, my life is at stake here, I have to get this off of me, I have to be able to divulge this to another human being. These included decreased motivation for using protection or thinking about HIV risk, increased HIV susceptibility, increased sexual performance and enhanced sexual experiences, risk of sexual dysfunction and relationship difficulties with prolonged use, and the ability to separate from negative feelings related to being HIV infected.
Along with enhancing sexual encounters, men described alcohol use and illicit drug transactions, use, and abuse as motivating sex with other men, allowing and rationalizing same-sex activity, and facilitating access to male sex partners. Those in recovery for substance abuse indicated that an unwillingness to admit their same-sex activity or to come to terms with their homosexuality or bisexuality contributed to drug relapses.