THE GAY COMMUNITY has a long history of alcohol and drug abuse above the rate that occurs in the heterosexual population. Research suggests that gay men use drugs in specific situations, such as during sex or during visits to specific “homosocial” venues like bars, clubs, sex parties or bathhouses. Thus, for many gay men, a unique aspect of gay culture is that drug use is very often specifically connected to seeking or having sex. When I was a young man in the 1970’s, the heyday of disco, there was something that we referred to as “the five D’s”: drugs, dancing, dick, dishing, and dining, which were all elements in the formation of an individual as well as a communal gay identity. The dance floors of the clubs—including such legendary ones as the Sanctuary, Tenth Floor, the Loft, Twelve West, Paradise Garage, Flamingo, and the Saint in Manhattan, Trocadero in San Francisco, Studio One in LA, the A House in Provincetown, the Ice Palace and Sandpiper on Fire Island, Warsaw in Miami—were venues where thousands of gay men created a celebratory, albeit sometimes self-destructive, tribal atmosphere. This spirit lives on in today’s circuit parties, which are late-night, and often multi-day, dance events attended by thousands of gay men, characterized by a high level of drug use and sexual activity—and a heightened risk of HIV transmission.
As the AIDS epidemic has dragged on, there is less certainty than ever about the role of drugs and alcohol in unprotected anal intercourse and the spread of HIV. Many gay men using the Internet for “cyber cruising” state in their on-line profiles that they’re “chem friendly” and want to “party”—code words for having sex while using one of the currently fashionable “club drugs,” such as methamphetamine, GHB, Ketamine, or Ecstasy (MDMA). One drug, crystal methamphetamine (also known as crystal, meth, Tina, and crank) has become the premium fuel for unsafe sex. Crystal meth has the particular property of inducing its users to abandon caution and take sexual risks that they would otherwise avoid. To a greater extent than poppers (amyl or butyl nitrate), cocaine, or alcohol, crystal meth lowers inhibitions and heightens one’s sensory experience, so it has the qualities of an aphrodisiac. A study by New York psychologist Perry Halkitis confirmed the relationship between crystal meth use and high-risk sexual behavior among men who have sex with men (MSM). Halkitis reported on studies of its use during the early 1990’s that showed it was largely a regional phenomenon affecting parts of the western U.S. But more recent investigations have shown that crystal meth has reached the eastern U.S. as well.
Dr. Thomas Frieden, commissioner of the New York City Department of Health and Mental Hygiene, reports that one in four gay men who are newly diagnosed with HIV in San Francisco had used crystal in the previous six months. Or, to look at it another way, gay meth users are almost twice as likely to be HIV-positive as non-users. And users are more than one third less likely to use a condom during receptive anal intercourse than non-users. But to say that meth use causes risky behavior may be an oversimplification. According to Halkitis (2003):
Whether the relationship between use of the drug (crystal) and sexual risk behavior among gay and bisexual men is a direct one is unclear. What is more likely is that men with certain psychological profiles are attracted to methamphetamine, use it in environments and contexts that are sexually charged, and as a result are situated to engage in sexual risk. Whether men use the drug intentionally as a way to facilitate sexual risk-taking behavior or whether sexual risk-taking is a natural byproduct of methamphetamine use are issues that need to be further disentangled.
What is it about crystal that draws men to take it, and precisely what is the connection between crystal and unprotected anal sex, or “barebacking”? Manhattan psychiatrist Jeffrey Guss offered a succinct answer to this question in the title of a pioneering article: “Sex Like You Could Never Imagine.” In it, Guss writes: “Stimulant drugs, particularly cocaine and methamphetamine, are particularly appealing to gay men in a highly sexualized subculture that exists within the broader gay community.” Guss points out that a major source of the attraction to these drugs lies in their ability to counteract pre-existing anxieties about sex, so that sexual activity for six to twelve hours becomes “realistic and predictable.”
Crystal’s appeal and seductiveness reside in its physiological and psychological effects. The drug intensifies the senses, elevates one’s mood, increases sex drive, and gives the user energy while suppressing appetite and the need for sleep. Some men who use crystal report an increase in sensitivity in their anus, which leads to an increased likelihood of receptive anal intercourse. The psychological effects reported by crystal users include hyper-sexuality, euphoria, lower sexual inhibitions, increased self-esteem, and increased self-confidence. Crystal meth use also reinforces the elements of escapism and adventure that underpin the desire to frequent dance parties, sex clubs, and sex parties.
Of 48 men surveyed by Halkitis in New York, a majority used crystal for sexual encounters because it helped them to achieve a specific sexual objective. For example, one man justified his crystal use by saying: “I want to be penetrated. It enhances that feeling.” Others explained that crystal enabled them to prolong their sexual encounters, often prodigiously, with one describing sexual encounters lasting from eleven to fifteen hours. Guss reports that many men in his practice report that the intensity of sex while on crystal surpasses even the most satisfying sex while not on the drug. Crystal users that I see in my therapy practice have described the sex as “mind blowing,” “phenomenal,” and “awesome.” In one man’s words: “I would say that the only way to explain to someone who has not had sex on crystal is that all of the sex I had while not high on Tina is like watching a black and white television during the 50’s. In comparison, sex on crystal is like watching one of the new, high-definition color televisions with surround sound.” Another man told me that crystal made him feel like a “sexual superman.”
Whether an amphetamine is pharmaceutically produced or illicitly manufactured, as is crystal, the primary effect of this class of drug is to act as a stimulant on the central nervous system. Methamphetamine has been described by the Drug Enforcement Administration as the “most hyperstimulating of the amphetamine analogues.” As Gawin & Ellingwood (1988) state: “This kind of stimulant creates a neurochemical amplification of the pleasure experienced in most activities.” Crystal accomplishes this by affecting neurons that release serotonin, norepinephrine, and dopamine, which produces major changes in a person’s emotional state.
The most common reason given for crystal use by the 48 participants in Halkitis’s study was the drug’s aphrodisiac effects. Those citing this reason were more likely to engage in unprotected anal sex, which is known to be highly correlated with HIV transmission. Halkitis also found that crystal use cuts across all economic and racial groups and is not, contrary to some stereotypes, confined to affluent white men.
In addition to its strictly sexual effects, crystal users also report changes in their psychological state that make social interaction easier and more rewarding. For many, crystal makes cruising for sex and communicating with other men less fraught and simpler, as pre-existing anxieties and inhibitions about sex melt away. Many of the men in Guss’s study reported that other men are more attracted to them when they high on crystal, thus confirming the subjective sense that one is sexier and more attractive. Because crystal meth lowers inhibitions and enables users to prolong sexual encounters, it is also associated with more marginal sexual behaviors such as fisting and group sex. Halkitis argues that the sexual and emotional effects of crystal meth conspire to make it “the quintessential gay drug.”
Michael Siever, director of the Stonewall Project, a San Francisco treatment program targeting gay crystal users, has expressed a similar sentiment: “Crystal is the perfect drug for gay men. What else allows you to party all night long whether you’re dancing or having sex? … at least, at first, before it becomes a problem.” Once the effects of crystal wear off, a user can suffer from severe depression that can last for several days, depending on how long he’s been high. Regular users can become addicted. Long-term use has been linked to acute psychotic episodes characterized by paranoia, withdrawal, flat affect, and auditory, olfactory, visual, and tactile hallucinations. As Howard Grossman, a prominent Manhattan physician and chairman of the Academy of HIV Medicine, has said: “It’s frightening. I’ve seen a huge increase of newly infected gay men that got HIV from unprotected sex during crystal meth binges. Our community is self-destructing with this drug. It just seems to be getting worse and worse and no one is doing anything about it.”
A recurring theme in interviews with crystal users is that the drug is de rigueur at circuit parties, those all-night gay raves that started in the U.S. and have now spread to the Netherlands, the UK, Spain, Greece, Australia, and Canada, typically held in warehouses or other huge venues to accommodate the thousands of men who fly in from all over the world to attend them. It seems globalization has come to gay culture, producing a homogeneous system of clubs, fashions, and values throughout the developed world. And while there’s no evidence to suggest that crystal use is nearly as widespread in other countries as in the U.S., it may be only a matter of time before health care workers in these countries will be facing a similar situation. After all, the use of crystal meth by gay men in the U.S. initially began as a small subculture in southern California and, despite lots of publicity about its dangers in the national and local gay press, it eventually spread across the continent.
Does drug use, particularly crystal, lead to barebacking, or do they simply tend to co-occur? We do know that risky health behaviors, such as smoking and drinking, tend to cluster together. Research by Halkitis and colleagues has found that men who use crystal are exceptionally active sexually. They have identified a class of hypersexual men whose behavior is sometimes characterized by sexual compulsion. What isn’t clear from the research is whether this pattern of hypersexuality existed prior to the use of crystal, which would suggest that such men were attracted to the drug for its purported sexual benefits, or whether they became hypersexual only after beginning to use crystal. What does seem apparent is that many of those who are drawn to crystal exhibit the characteristics of what Zuckerman called “high sensation seekers,” who are defined by “the seeking of varied, novel, complex and intense sensations and experiences, and the willingness to take physical, social, legal and financial risks for the sake of such experiences.” In the gay world, such men are more likely to bareback than men who do not rate high on that scale.
Halkitis adds a cautionary note: “While the most current knowledge points to a strong relationship between drug use and risky sexual behaviors, the emergence of methamphetamine, specifically its influence on sexual behavior, warrants more scrutinized investigation.” Their findings suggest that methamphetamine does not in and of itself induce gay men to take sexual risks, but that certain hypersexual gay men who are already predisposed to risky sex are attracted to crystal.
Crystal meth is a risk factor for contracting HIV for yet another reason that’s unrelated to its psychological effects. In high doses it can make it impossible for some men to obtain a full or even a partial erection. Many users report impaired sexual functioning manifested by temporary erectile dysfunction or delayed ejaculation. This side effect of crystal use is commonly known as “crystal dick.” Gay men who experience erectile dysfunction while on crystal are more likely to be the receptive partner in anal sex, thus increasing their risk of contracting HIV. Some crystal users report that the combination of increased anal sensitivity and crystal dick tends to make them “instant bottoms.” Yet, since Viagra first became available by prescription in the U.S. in 1998, men who use crystal report simultaneously also using one of the drugs used to treat erectile difficulty in order to function as both the insertive as well as receptive partner during anal sex, increasing the possibility of spreading HIV. Dr. Jeffrey Klausner, director of Sexually Transmitted Disease Prevention at the San Francisco Health Department, stated: “Viagra can turn people with chemically induced erectile dysfunction into more effective transmitters of HIV and other STDs.”
Statistics on rates of new HIV infections seem to bear out a possible correlation between the arrival of Viagra (and drugs like it) and elevated rates of HIV transmission among gay men. According to the Centers for Disease Control and Prevention, new diagnoses of HIV in this population have increased by eighteen percent since 1999, a year after Viagra first became commercially available. “For a subset of gay men, Viagra’s definitely found its way into the mix of party drugs,” said Dr. Ken Mayer, a professor of medicine at Brown University and a past board member of the Gay and Lesbian Medical Association. Dr. Mayer is also medical director of research at the Fenway Community Health Center in Boston, one of the premier medical facilities devoted to providing quality medical care to gay, lesbian, bisexual, and transgender people in the U.S. “And in a bathhouse or other setting where there’s an opportunity to have sex with multiple partners, to have a longer-lasting erection can be a prescription for HIV transmission.”
The connection between drug use, particularly crystal meth, and barebacking has been clearly demonstrated. Working one-on-one with clients to help them reduce or eliminate their risky behaviors is all well and good, but barebacking and drug use are two interrelated community-wide problems, and I believe we need a community-wide movement to address the crystal meth problem, which is fueling the barebacking phenomenon. There are several innovative projects going on right now that use the Internet to educate the gay and bisexual male community about the risks of crystal meth and its connection to barebacking. One of these is www.tweaker.org, which offers a variety of educational information about how to make crystal use safer. They have on-line forums specifically dedicated to men who think they contracted HIV while doing crystal and true stories of men who did. A similar website out of Seattle is crystalneon.org.
In response to the rise of both new cases of syphilis and crystal use among gay men in New England who met in Internet chat rooms, Manhunt.net, one of the largest gay male websites in the U.S., began to provide space on the website where gay men could become educated about substance use and treatment programs, as well as other matters related to sexual health. In March 2004, Manhunt revised its site so that members’ profiles could no longer contain PNP (party and play, which signals directly a desire to have sex while under the influence of drugs), and mandated that any profiles that did not delete this would be removed. Manhunt also collaborated with the Fenway Community Health Center in Boston and developed a series of public information messages about crystal that appear as banner advertisements on the site. A button was also added that reads “Need Help,” and when this is clicked, a list of local AIDS service organizations and drug treatment facilities appears. Finally, just before one logs off of Manhunt, the following banner ad appears: “If you use crystal, you are digging your own grave.” These kinds of innovative programs are an important step in reaching men who use crystal and who bareback who otherwise might not be seeking help with education and information.
References
Centers for Disease Control and Prevention. “Increases in HIV Diagnoses: 29 States, 1999–2002.” Morbidity and Mortality Weekly Report, 52, 2003.
Guss, J. “Sex like you can’t even imagine: ‘Crystal,’ crack, and gay men.” Journal of Gay & Lesbian Psychotherapy, 3, 2000.
Gawin, F., and Ellinwood, E. “Cocaine and other stimulants: Action, abuse and treatment.” New England Journal of Medicine, 319, 1988.
Halkitis, P., Parsons, J., and Stirratt, M. “A Double Epidemic: Crystal methamphetamine use and its relation to HIV prevention among gay men.” Journal of Homosexuality, 41, 2001.
Halkitis, P., and Parsons, J. “Recreational drug use and HIV risk sexual behavior among men frequenting urban gay venues.” Journal of Gay & Lesbian Social Services, 14, 2002.
Halkitis, P., Parsons, J. T., and Wilton. L. “Barebacking, among gay and bisexual men in New York City: Explanations for the emergence of intentional unsafe behavior.” Archives of Sexual Behavior, 32 (4), 2003.
Halkitis, P., Parsons, J., and Wilton, L. “An exploratory study of contextual and situational factors related to methamphetamine use among gay and bisexual men in New York City.” Journal of Drug Issues, 33, 2003.
Zuckerman, M. Behavioral Expressions and Biosocial Bases of Sensation Seeking. Cambridge University Press, 1994.
Michael Shernoff, LCSW, a psychotherapist in private practice in Manhattan and adjunct faculty at Columbia University School of Social Work, is the author of the forthcoming Sex Without Condoms: Unprotected Sex, Gay Men and Barebacking.
