“It's not rocket science, what I do”: Self-directed harm reduction strategies among drug using ethno-racially diverse gay and bisexual men

Abstract

Background

Research on harm reduction has typically focused on broad-based or organisational strategies such as needle exchange and opiate substitute programmes. Less attention has been paid to the self-directed harm reduction practices of substance users themselves. Few studies have focused on sexual minority populations such as gay and bisexual men and fewer still on the marginalised groups that constitute these populations. This paper identifies self-directed harm reduction strategies among substance using ethno-racially diverse gay and bisexual men.

Methods

This article presents findings from the Party Drugs Study in Toronto's gay dance club scene, a community-based qualitative study in Toronto, Canada. We present a thematic analysis of interviews with 43 gay and bisexual men from diverse ethno-racial backgrounds about their substance use in the gay dance club scene.

Findings

We identify five self-directed harm reduction strategies: rationing, controlling or avoiding mixing, controlling quality, maintaining a healthy lifestyle, and following guidelines during substance use.

Conclusions

We discuss our findings in relation to prior research and to critical theory. We suggest that drug users’ awareness of possible harm, and their personal investment in harm reduction, constitute a viable platform from which community-based and public health organisations may promote and strengthen harm reduction among gay and bisexual men from ethno-racially diverse backgrounds.

Introduction

While there has been particular attention paid to substance use among lesbian, gay, bisexual, and transgendered populations (e.g., Hughes and Eliason, 2002, Rosario et al., 1997, Stall and Purcell, 2000), research on substance use practices among ethno-racially diverse gay and bisexual men remains rather sparse. Some research on the broader ethno-racial male population attempts to distinguish rates of drug use among particular ethno-racial groups (e.g., Ompad, Galea, Fuller, Edwards, & Vlahov, 2005) or to distinguish comparable or greater rates of use among gay and bisexual men within these groups (e.g., Operario et al., 2006).

From a public health perspective, research suggesting greater rates of substance use among gay and bisexual men is worrisome given the purported association between substance use and HIV risk and seroconversion (Burcham et al., 1989, Chesney et al., 1998, Penkower et al., 1991; although see Aguinaldo & Myers, 2008, for a critical perspective on this body of research). A small body of research has identified similar statistical associations between substance use and HIV risk within gay and bisexual Latino (Dolezal, Carballo-Dieguez, Nieves-Rosa & Diaz, 2000), Black (Wilton, 2008), and Asian (Operario et al., 2006) populations. Such findings have prompted heated debates about appropriate policy and programme responses related to drug use. While abstinence-premised interventions appear to remain the primary approach in North America, harm reduction has emerged as a viable option, at least in Canada (albeit with some resistance).

There is sufficient evidence to warrant the adoption of harm reduction as a policy framework for responding to illicit substance use (Ritter & Cameron, 2006). While vast in its scope, harm reduction programming as it applies to illicit substance use generally involves needle exchange and opiate substitution programmes, in addition to condom distribution and the provision of health promotion information related to substance use and sexual health. The primary objective of these interventions is to achieve immediate and pragmatic goals to reduce the harms of drug use and increase protective factors rather than eliminating drug use (although the latter is still an option for users who are motivated or determined to give up drugs). While needle exchange and opiate substitution programmes attend to reducing the harm from injection drug use, condom distribution addresses the sexual risks that drugs users may face. Such harm reduction strategies are typically directed by health services organisations. However, as Drumm, McBride, Metsch, Neugeld, and Sawatsky (2005) claim, “using existing strengths of drug users is an effective treatment approach […] more work needs to be done to understand health care skills that users may already possess” (p. 609). Such self-directed harm reduction strategies can offer another tool on which public health practitioners may capitalise. Unfortunately, there is only a small body of research that identifies self-directed harm reduction strategies among substance users.

Existing research has mainly focused on the self-directed harm reduction strategies of ecstasy users. According to Shewan, Dalgarno, and Reith (2000), ecstasy users in their study were aware of the adverse effects of their use and planned their use accordingly. In particular, monitoring their mindset and selecting an appropriate context for using ecstasy (i.e., “set and setting”) played a substantial role in managing risks associated with use. Hansen, Maycock, and Lower (2001) identified a number of ‘risk reduction techniques’ such as rationing one's use, peer monitoring (for physical or psychological effects), and choosing to use drugs only during positive mood states. Similar findings were offered from a more recent study by Panagopoulos and Ricciardelli (2005) who found that ecstasy users in their study implemented psychological, drug-specific, behavioural, and peer-related strategies to manage the risk of their use. Psychological strategies included limiting use when in a psychologically vulnerable state (e.g., depressed), while drug-specific strategies involved careful pacing of use, prohibiting poly drug use, inspecting ecstasy tablets before use, and purchasing from known and ‘trusted’ dealers. Specific behavioural and peer-related strategies involved the consumption of water or other non-alcoholic beverages to hydrate the body, or the use of ecstasy only with ‘experienced’ users. Jacinto, Duterte, Sales and Murphy (2008) found similar results regarding users’ reliance on ‘trusted’ dealers.

Similar findings have been found across a (limited) range of study populations. Drumm et al. (2005) found that street involved drug users “do not passively accept the health consequences of use, but rather actively engage in behaviours that attempt to ameliorate damage to their health as well as behaviours specifically designed to improve their health” (p. 608). So-called ‘self-care strategies’ included improving nutrition, increasing physical activity, addressing medical concerns (e.g., over the counter treatments, home remedies, etc.), substance use regulation, and reducing sexual risk. Drumm et al. argued that these strategies indicated substance users’ “substantial knowledge about health issues and considerable commitment to manage health risks while at the same time continuing to be chronic drug users” (p. 622). Preliminary data suggested that pregnant women may also implement self-care practices for their drug use (Baker and Carson, 1999, Flavin, 2002). Interestingly, harm reduction practices of gay men are not well addressed in the literature. Only one of the aforementioned studies on self-directed harm reduction practices reported the inclusion of gay men in their sample.

Some research has explored the drug use practices of gay men in Sydney, Australia and found that lay expertise, shared among peers and ‘network nannies’, produced a community folk pharmacology (e.g., Southgate & Hopwood, 2001). Dowsett, Keys and Wain (2005) identified gay community norms that encourage acceptable, controlled drug use and argue that they be harnessed for harm reduction purposes. However, none of these studies reported the inclusion of participants or users from specific ethno-racial backgrounds. This is particularly problematic given the reported prevalence of substance use among gay and bisexual men from various racialized groups, and its associated health risks. The present study addresses this gap.

In this article, we identify the self-directed harm reduction strategies of substance-using gay and bisexual men from ethno-racially diverse backgrounds. All participants in our study identified as either gay or bisexual and that is the terminology we use in this article. Our study contributes to a broader understanding of substance use among ethno-racially diverse gay and bisexual men in two ways. First, it challenges the popular notion of substance users (and specifically non-white substance users) as weak in constitution, lacking self-control, and needing a higher form of rationality (see, Lupton, 1995). Instead, it views substance users as knowledgeable about their use, aware of the risks involved, and keen or able to make informed decisions and choices when given the opportunity. Second, it contributes to the growing body of literature that suggests harm reduction (self-directed or otherwise) is a viable option for public health intervention (Myers, Aggleton, & Kippax, 2004). This affords us the opportunity to make recommendations for the content of education and prevention materials and programming and provides context for dissemination and outreach.