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Journal of Homosexuality Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wjhm20
Social Responsibility, Substance Use, and Sexual Risk Behavior in Men Who Have Sex With Men a
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Aaron M. Martin MS , Eric G. Benotsch PhD , Anna Cejka MA & Diana Luckman MA
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Department of Psychology , Virginia Commonwealth University , Richmond , Virginia , USA b
Department of Psychology , University of Colorado Denver , Denver , Colorado , USA c
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University of Northern Colorado , Greeley , Colorado , USA Accepted author version posted online: 12 Sep 2013.Published online: 02 Jan 2014.
To cite this article: Aaron M. Martin MS , Eric G. Benotsch PhD , Anna Cejka MA & Diana Luckman MA (2014) Social Responsibility, Substance Use, and Sexual Risk Behavior in Men Who Have Sex With Men, Journal of Homosexuality, 61:2, 251-269, DOI: 10.1080/00918369.2013.839908 To link to this article: http://dx.doi.org/10.1080/00918369.2013.839908
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Journal of Homosexuality, 61:251–269, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 0091-8369 print/1540-3602 online DOI: 10.1080/00918369.2013.839908
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Social Responsibility, Substance Use, and Sexual Risk Behavior in Men Who Have Sex With Men AARON M. MARTIN, MS and ERIC G. BENOTSCH, PhD Department of Psychology, Virginia Commonwealth University, Richmond, Virginia, USA
ANNA CEJKA, MA Department of Psychology, University of Colorado Denver, Denver, Colorado, USA
DIANA LUCKMAN, MA University of Northern Colorado, Greeley, Colorado, USA
Considerable public health literature focuses on relationships between problematic human characteristics (e.g., psychopathology) and unhealthy behaviors. A recent movement termed positive psychology emphasizes the advantages of assessing relationships between human strengths (e.g., altruism) and beneficial health behaviors. The present study assessed social responsibility, an orientation to help or protect others even when there is nothing to be gained as an individual, and its relationship to HIV-relevant behaviors. In our sample of 350 men who have sex with men (MSM), social responsibility was negatively correlated with substance use and HIV risk behaviors. Men who had been tested for HIV and knew their HIV status—a behavior that helps men protect their partners but does not protect themselves from the virus—also scored higher in social responsibility. Interventions designed to reduce HIV risk behavior in MSM may benefit from efforts to promote human strengths. KEYWORDS social responsibility, sexual behavior, men who have sex with men, substance use, altruism
Address correspondence to Eric G. Benotsch, Department of Psychology, P.O. Box 842018, Virginia Commonwealth University, Richmond, VA 23284, USA. E-mail: [email protected] 251
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The spread of infectious disease, particularly HIV, is a public health concern that reverberates from the individual to the global level. While medical breakthroughs have increased the average lifespan of those individuals living with HIV, these advances have also increased the number of individuals who could transmit the virus (Centers for Disease Control and Prevention, 2008). As such, it is important to direct interventions toward curbing those behaviors that increase the probability of HIV transmission. This is especially important for at-risk populations, such as men who have sex with men (MSM). Fortunately, some interventions have demonstrated success at decreasing unprotected anal intercourse and number of sexual partners, as well as increasing condom use (Herbst et al., 2005; Kalichman et al., 2005). However, most of these interventions do not focus on enriching those human strengths that might be associated with a decrease in sexual risk behavior and behavioral correlates of sexual risk (e.g., substance use; Benotsch, Seeley, et al., 2006; NIDA, 2006). The introduction of strength-based approaches to risk-reduction interventions may be warranted, as some MSM continue to engage in transmission risk behaviors despite widespread knowledge regarding these risks (Crepaz & Marks, 2002).
A POSITIVE INFLUENCE: SOCIAL RESPONSIBILITY The field of positive psychology offers several psychosocial constructs that have yet to be explored as possible protective factors for engaging in behaviors that pose health risks. One such construct, social responsibility, has been conceptualized as an orientation to help or protect others as part of a society or community even when there is nothing to be gained and includes an awareness of the problems and difficulties that affect a society or communities on a daily basis (Berkowitz & Lutterman, 1968; Peterson & Seligman, 2004). Individuals high in social responsibility may be concerned with the ethical and moral dilemmas that affect a community and may have a strong sense of justice when it comes to these issues (Peterson & Seligman, 2004). Although most health behaviors are investigated and understood from a selfcentered perspective that takes into account only an individual’s own health (e.g., Health Belief Model; Rosenstock, Strecher, & Becker, 1994), there is evidence that moral motives that drive societal-oriented prevention behaviors overlap with those motives associated with personal prevention (e.g., perceptions of personal risk; Kals & Montada, 2001). Identity with a social group implies a valuing of the social bond with others from this group (Peterson & Seligman, 2004), meaning that socially responsible behavior should manifest itself toward others in these social groups, while social exclusion will result in a reduction in pro-social behaviors (Twenge, Baumeister, DeWall, Ciarocco, & Bartels, 2007). Indeed, inclusion and connectedness has been associated with a greater likelihood
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to serve the common good of a community (Batson, Ahmad, & Tsang, 2002; Flanagan, 2004). This suggests that the heightened awareness of one’s own disenfranchised group coupled with a felt obligation to protect this group may be reflected by socially responsible behavior that is relevant to preventing sexually transmitted infections in MSM. Indeed, stronger gay identity has been associated with higher rates of condom use among MSM (Chng & Geliga-Vargas, 2000; Newcomb & Mustanski, 2011; Seibt et al., 1995).
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SOCIAL RESPONSIBILITY’S ROLE IN TRANSMISSION RISK To date, studies that have approximated this sense of societal level obligation have done so narrowly, closely focusing on a sense of personal responsibility to individual sexual partners (Bogart et al., 2006; Wolitski, Bailey, O’Leary, Gómez, & Parsons, 2003). For instance, HIV “prevention altruism” (Nimmons, 1998) has been described as a personal responsibility including the values, motivations, and practices involved in preventing the transmission of HIV to sexual partners (O’Dell, Rosser, Miner, & Jacoby; 2008; Wolitski et al., 2003). The majority of the literature dealing with altruism and similarly defined variations of personal responsibility has focused on at-risk groups such as MSM and injection drug users (IDU; O’Leary & Wolitski, 2009). Being higher in a sense of personal responsibility is associated with decreased likelihood of anal intercourse and increased likelihood of HIV status disclosure among HIV-positive MSM (Parsons, Halkitis, Wolitski, & Gómez, 2003; Wolitski, Flores, O’Leary, Bimbi, & Gómez, 2007). Failure to enhance personal responsibility for protecting partners has been cited as a reason that interventions did not significantly decrease unprotected insertive anal intercourse (O’Leary et al., 2005). It is important to highlight that HIV-positive individuals who perceive their sexual partners to be HIV-negative are more likely to assume personal responsibility for partner protection by engaging in fewer unprotected sex acts (Hong, Goldstein, Rotheram-Borus, Wong, & Gore-Felton, 2006). Unfortunately, this same body of research indicates that HIV-positive MSM may be more likely to perceive their partners as HIV-positive, compared to the perceptions of heterosexual men and women. In a primarily heterosexual (79%) sample of HIV-positive IDU, Latka and colleagues (2007) found that personal responsibility for limiting the sexual transmission of HIV was associated with greater HIV knowledge, self-efficacy for using condoms, having fewer sexual partners, and lower odds for unprotected sex. It is likely that those individuals who feel a personal responsibility to their individual partners may also experience a heightened sense of social responsibility, but this has yet to be explored. Content analysis of popular gay discussion boards on the issues of high-risk sexual activity, such a “barebacking” (anal sex in which condoms are intentionally not used), found that social responsibility was a primary reason cited against the practice
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(Carballo-Diéguez & Bauermeister, 2004). In particular, individuals described the gay community as a “family” when citing this reason.
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SOCIAL RESPONSIBILITY’S ROLE IN SUBSTANCE ABUSE As might be expected, the probability of engaging in sexual risk behaviors often increases with the use of recreational drugs and alcohol, as has been demonstrated in young heterosexual adults across a variety of drug classes (Bailey, Fleming, Henson, Catalano, & Haggerty, 2008; Howard & Wang, 2004; Morrison-Beedy, Carey, Feng, & Tu, 2008; Yan, Chiu, Stoesen, & Wang, 2007). Several studies have also found these associations in MSM populations. In samples of MSM, excessive alcohol use and drug use has been positively associated with unprotected anal sex, but negatively associated with disclosure of HIV status (Benotsch et al., 2007; Heath, Lanoye, & Maisto, 2012). Several studies have also examined the use of methamphetamine in this population and found use to be associated with sexual risk behavior and HIV transmission (Halkitis, Green, & Carragher, 2006; Halkitis, Mukherjee, & Palamar, 2009; Plankey et al., 2007). The recreational use of prescription drugs intended to treat sexual dysfunction (e.g., Viagra) has also been associated with increased risk behavior among MSM (Nettles, Benotsch, & Uban, 2009; Benotsch, Seeley, et al., 2006). Given the relation between social responsibility and sexual risk behaviors, and the exacerbating nature of substance abuse in conjunction with sexual activity, it may be reasonable to suspect those high in social responsibility will also be less inclined to engage in excessive alcohol use or illicit drug use, particularly when it comes to combining these inclinations with sexual activity. The toll that drugs and alcohol have on society, in economic and social terms, is a message many are familiar with, but it may particularly play in the minds of socially responsible individuals (Basu, Paltiel, & Pollack, 2008; Birnbaum et al., 2011). Social responsibility at college age has been related to lower levels of marijuana and tobacco consumption later in life (Roberts & Bogg, 2004). Additionally, social responsibility may be associated with addiction recovery, as members of Alcoholics Anonymous have been found to be higher on these interpersonal measures compared to nonalcoholic controls (Mellor, Conroy, & Masteller, 1986). Interestingly, among IDU who are HIV-positive, those who indicated feeling personal responsibility for preventing transmission during sex did not subsequently engage in safer injection practices (Latka et al., 2007), suggesting a disconnect in feelings of responsibility based on mode of transmission. The purpose of the current study is to broaden the research examining the positive psychology constructs associated with decreased sexual risk behavior and illicit substance use by determining the relevance of the global construct of social responsibility. The construct of social responsibility
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applies more broadly to an awareness of those hardships which plague society and specific communities, not other individuals per se. This makes the contribution of work regarding constructs that tap into responsible community membership and corresponding behaviors unique. Understanding the relation between social responsibility and health-related risk behaviors may improve both individual and group level interventions aimed at decreasing HIV-transmission in MSM. Given the prior findings on the relation between personal responsibility, substance use, and sexual risk behavior, the authors hypothesize that social responsibility will be negatively correlated with both substance use and sexual risk behavior, but positively associated with engaging in protective behaviors such as being tested for HIV and finding out the HIV status of their sexual partners.
METHOD Participants, Setting, and Procedures To investigate the association between social responsibility and sexual risk behavior, 400 people attending a gay pride festival in a large city in the Rocky Mountain region were recruited to complete anonymous, selfadministered surveys. Data analyses were limited to the 350 participants (87.5%) who were men who reported either a gay/bisexual orientation or who reported sex with other men. Data were collected on a single day in June 2009.
Participants Among the 350 participants, the mean age was 33.0 years (SD = 13.8; range = 18 to 78), and the average years of education was 14.0 (SD = 2.4). Eighty percent of participants (n = 280) self-identified as gay, 18% (n = 64) self-identified as bisexual, and 2% (n = 6) self-identified as heterosexual but were retained in the sample because they reported sex with a man in the past three months. The majority of the sample was White (65%; n = 227), with the remainder being Latino (14%; n = 49), African American (8%; n = 29), Native American (3%; n = 11), Asian American (1%; n = 5), or other/mixed ethnic heritage (7%; n = 26). Three men (0.8%) did not report their race/ethnicity. Thirty-two percent of participants (n = 113) had annual incomes below $16,000, 22% (n = 78) had incomes between $16,000– $30,000, 19% (n = 66) had annual incomes between $31,000–$45,000, 25% (n = 88) had incomes above $45,000, and five individuals (1.4%) did not indicate their income. The majority (84%; n = 293) reported having been tested for HIV: of those, 89.4% tested HIV-negative, 8.2% HIV-positive, and 2.4% did not know their test results.
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Procedure A convenience sample of participants were asked to complete an 8-page survey concerning HIV and AIDS as they walked through the festival grounds where retail venders and community organizations occupied display booths, one of which was rented for the purposes of this study. Participants were told that the survey was about sexual relationships, contained personal questions about their sexual history and substance use, was anonymous, and required approximately 15 minutes to complete. Participants’ names were not collected at any time. Participants were offered $2 for completing the survey, and an additional $2 donation was made to an HIV/AIDS charity. All research procedures were approved by the Institutional Review Board of the University of Colorado Denver. Recruitment methods such as these have been used extensively in prior research and have yielded samples that are roughly representative of samples that use more sophisticated sampling procedures (Gore-Felton et al., 2006; Grov, Parsons, & Bimbi, 2007; Halkitis & Parsons, 2002). This festival was chosen as the site for the survey because of the over 250,000 people who attend this annual event (The Center, 2010). Previous research has reported that men who attend gay pride festivals report significant rates of high-risk sexual behaviors (Kalichman, Gore-Felton, Benotsch, Cage, & Rompa, 2004). Almost 60% of all AIDS cases in Colorado have been reported in Denver County and more than 70% of Colorado’s HIV infections have occurred among men who have sex with men (Colorado Department of Public Health and Environment, 2010).
Measures Participants completed self-administered anonymous surveys that included measures of demographic information, gay acculturation, social responsibility, HIV altruism, substance use, perceptions of risk, and sexual practices.
DEMOGRAPHICS Participants were asked their age, years of education, income, race/ ethnicity, whether they self-identified as gay, bisexual, or heterosexual, whether they had been tested for HIV antibodies, and if so, the results of their most recent HIV test. Participants were also asked how many people with HIV/AIDS they have known.
GAY
ACCULTURATION
Participants were asked to indicate how often in the past year they engaged in gay cultural activities (e.g., “Gone out to gay bars,” “Read gay newspapers
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or magazines”). Responses were anchored on a 4-point scale from 1 (never) to 4 (often). This 5-item measure has shown utility in previous research (Benotsch, Kalichman, & Cage, 2002). Internal consistency of this measure was acceptable within this sample (α = .81) and comparable to the internal consistency in prior work (α = .73; Benotsch et al., 2002).
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SOCIAL
RESPONSIBILITY
This construct was assessed with a 5-item version of the Responsibility of People scale (Starrett, 1996). Scores on this measure have been previously related to prosocial activities including hours spent volunteering and charitable contributions (Starrett, 1996). Sample items included “Every person should give some of his time for the good of his town or community” and “I have made many commitments to many different kinds of people, groups, and activities in my life.” Items were rated on a 5-point Likert-type scale ranging from 1 (strongly disagree) to 5 (strongly agree). Internal consistency of this measure was acceptable in the present sample (α = .77) and comparable to the internal consistency of the original scale (α = .74; Starrett, 1996).
HIV
ALTRUISM
The original version of the HIV altruism scale was written specifically for HIV-positive persons and has been related to lower HIV transmission risk behaviors (O’Dell et al., 2008). We modified the scale to make questions applicable to both HIV-positive and HIV-negative individuals by eliminating two of the original seven items. Sample items included “Having safer sex shows that I care about my partner” and “By having safer sex, I am setting an example for others.” Items were rated on a 5-point Likert-type scale ranging from 1 (strongly disagree) to 5 (strongly agree). Internal consistency of this measure was acceptable in the present sample (α = .88) and comparable to the original scale (α = .83; O’Dell et al., 2008).
SUBSTANCE
USE
Participants were asked questions concerning the use of alcohol, marijuana, nitrite inhalants (poppers), cocaine, methamphetamine, ecstasy, heroin, ketamine, GHB, and Rohypnol in the previous 3 months. Street names were included for many of the substances. The frequency of use was measured using a 4-point Likert scale (1–none to 4–at least once a week). Participants were asked similar questions about the use of Viagra and other erectileenhancing drugs. Participants were also asked the number of times they had sex after having “too much” to drink, and the number of times they had sex
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after using drugs in the previous 3 months. This measure is similar to measures employed in prior research (Benotsch, et al., 2011; Nettles et al., 2009) and has been related to both other forms of substance use—for example, the non-medical use of prescription drugs (Benotsch, Martin, Koester, Cejka, & Luckman, 2011) and sexual risk behavior (Benotsch, Snipes, Martin, & Bull, 2013).
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SEXUAL
PRACTICES
Sexual behavior was assessed by asking participants to report the number of times they had engaged in unprotected anal intercourse, as the insertive and receptive partner, in the past 3 months. Participants also recorded the number of sexual partners with whom they had engaged in each behavior. Participants also responded to items assessing if they use condoms when they get into a new relationship and if they find out their partners’ HIV status prior to having sex. Consistent with our prior work, open response formats were used for the sexual behavior measures to reduce response bias and to minimize measurement error (Benotsch, Mikytuck, et al., 2006). Measures similar to these have been found to be reliable in self-reported sexual behavior assessments and to yield aggregate indices of HIV risk that are comparable to those obtained by finer-grained partner-by-partner sexual behavior assessments (Napper, Fisher, Reynolds, & Johnson, 2010; Pinkerton, Benotsch, & Mikytuck, 2007).
ESTIMATES
OF RISK
Participants responded to items that asked them to estimate the risk of HIV transmission in two scenarios. In both scenarios, an HIV-positive man and an HIV-negative man engaged in a single act of unprotected anal sex with ejaculation. In the first scenario, the HIV-positive man was the insertive partner; in the second scenario, the HIV-negative man was the insertive partner. Participants were asked to estimate the likelihood that the HIV-negative man would contract HIV based on his sexual activities described in the scenario (insertive or receptive partner). For both scenarios, response choices were less than 1%, 1–5%, 6–10%, 11–20%, and greater than 20%. This measure has shown utility in prior research (Nettles et al., 2009).
DATA
QUALITY ASSURANCES AND STATISTICAL ANALYSES
All surveys were examined for inconsistencies and invalid responses. Missing data were omitted from analyses, resulting in slightly different ns for various statistical tests. Because distributions of sexual behavior and substance use
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were highly skewed, nonparametric analyses (Spearman rank order correlations and logistic regressions) were used for analyses of these variables as recommended by Hollander and Wolfe (1999). Two-tailed significance levels were used for all tests.
RESULTS
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Social Responsibility Results showed a full range of scores on the social responsibility scale (range = 5 to 25), with a mean of 18.93 (SD = 3.92). White participants scored significantly higher (M = 19.30, SD = 3.68) than non-White participants (M = 18.23, SD = 4.29), t (342) = 2.41, p < .01. Social responsibility was associated with years of formal education (r = 0.23, p < .01), but it was unrelated to age, employment status, income, or HIV status. Men who self-identified as gay had higher social responsibility scores (M = 19.25, SD = 3.61) than men who self-identified as bisexual (M = 17.67, SD = 4.47), t (333) = 2.98, p < .01). Consistent with this finding, social responsibility scores were correlated with scores on the gay acculturation measure (r = 0.25, p < .001). Scores on the social responsibility measure were also significantly correlated with the number of persons with HIV/AIDS participants knew (r s = 0.22, p < .001).
Social Responsibility and HIV Altruism As would be expected, social responsibility scores were correlated with scores on the HIV altruism scale (r = 0.15, p < .01). This degree of association suggests a general concordance between these constructs, but it is not so high that they could be considered identical.
Social Responsibility and Substance Use In general, social responsibility was negatively associated with substance use. As shown in Table 1, social responsibility scores were negatively correlated with the use of ecstasy, cocaine, ketamine, Rohypnol, GHB, and heroin over the past 3 months. Similarly, social responsibility was negatively correlated with the use of phosphodiesterase type-5 inhibitors (Viagra and related medications) that are taken recreationally by some MSM and associated with HIV risk behavior (Nettles et al., 2009; Sherr et al., 2000). Social responsibility scores were unrelated to the use of alcohol, marijuana, methamphetamine, and poppers.
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− .23∗∗ .16∗∗ .14∗∗ .04 .16∗∗ .10 −.02 −.03 .00 .06
− .05 −.03 −.12∗ .01 −.08 −.15∗∗ −.14∗∗ −.21∗∗∗ −.16∗∗ −.11∗ −.11∗ − .36∗∗∗ .18∗∗ .20∗∗ .30∗∗∗ .15∗∗ .06 .12∗ .04 .07
3.
− .16∗∗ .13∗ .34∗∗∗ .43∗∗∗ .37∗∗∗ .13∗ .26∗∗∗ .07
4.
Note. N s range from 340–344. Numbers represent Spearman correlation values. PDE-5 Inhibitors = phosphodiesterase type-5 inhibitors (Viagra, Cialis, Levitra) ∗ p < .05; ∗∗ p < .01; ∗∗∗ p < .001.
1. Social Responsibility 2. Alcohol 3. Marijuana 4. Ecstasy 5. Poppers 6. Methamphetamine 7. Cocaine 8. Ketamine 9. Rohypnol 10. GHB 11. Heroin 12. PDE-5 Inhibitors
2.
1.
− .30∗∗∗ .16∗∗ .28∗∗∗ .29∗∗∗ .20∗∗∗ .18∗∗ .33∗∗∗
5.
− .39∗∗∗ .28∗∗∗ .40∗∗∗ .53∗∗∗ .33∗∗∗ .23∗∗∗
6.
− .29∗∗∗ .39∗∗∗ .19∗∗ .34∗∗∗ .12∗
7.
TABLE 1 Correlation matrix showing relationships between social responsibility and substance use
− .63∗∗∗ .41∗∗∗ .36∗∗∗ .14∗∗
8.
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− .43∗∗∗ .50∗∗∗ .30∗∗∗
9.
− .27∗∗∗ .14∗
10.
− .20∗∗∗
11.
−
12.
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Social Responsibility and HIV Testing The majority of the sample (84%) indicated they had been tested for HIV. Those who had been tested scored significantly higher on social responsibility (M = 19.15, SD = 3.85) than individuals who had never been tested for HIV (M = 17.75, SD = 4.09), t (344) = 2.48, p < .05. Seventy-five percent of participants (n = 264) indicated that they find out about their sex partners’ HIV status before having sex and 73% (n = 256) reported that they use condoms when they get into a relationship. Individuals who indicated they discuss HIV with sexual partners before initiating sexual activity had significantly higher social responsibility scores (M = 19.26, SD = 3.61) than individuals who reported that they do not have this type of discussion (M = 17.79, SD = 4.52), t (333) = 2.90, p < .01. Individuals who reported using condoms when they get into a relationship did not differ in their social responsibility scores from those who did not.
Social Responsibility and Perceptions of Risk Social responsibility scores were associated with greater perceived risk associated with unprotected sex. Social responsibility scores were associated with perceptions of a greater likelihood of HIV transmission when the HIVpositive person is the insertive partner (r = 0.33, p < .001) and when the HIV-positive person is the receptive partner (r = 0.12, p < .05).
HIV Risk Behavior and Social Responsibility In the present study, 71% of the respondents (n = 250) were sexually active in the previous three months. Of the men reporting sexual activity, 63% (n = 158) reported unprotected anal intercourse. In the portion of the sample reporting unprotected sex, 57% (n = 87) indicated that they had only 1 sexual partner and 43% (n = 67) reported sexual activity with 2 or more partners in the last three months. Social responsibility was associated with some HIV risk behaviors. Social responsibility was associated with lower rates of drug use in conjunction with sexual activity (r s = -0.15, p < .01) and was marginally associated with lower rates of having sex after having “too much” to drink (r s = −0.10, p < .10). Social responsibility was also negatively associated with the number of partners with whom participants had engaged in unprotected receptive anal sex, the highest risk behavior for HIV, (r s = −0.15, p < .01). Social responsibility scores were not associated with total unprotected anal sex acts or the number of insertive anal sex partners. Given prior research that suggests multiple factors influence high-risk sexual behavior, we performed a sequential (hierarchical) logistic regression analysis in order to determine the independent relationship between
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social responsibility and risk, after controlling for demographic factors, gay acculturation, HIV altruism, and substance use. The logistic regression analysis predicted membership in one of two groups: those who reported unprotected receptive anal sex with multiple partners in the previous three months (n = 25) and those who did not (n = 278). Results are shown in Table 2. Demographic variables were entered on the first step and significantly predicted this behavior, relative to a constant only model, χ 2 (4, N = 303) = 9.90, p < .05. As seen in Table 2, education was a significant protective factor. Gay acculturation and HIV altruism were entered on the second step and significantly added to the predictive utility of the model, χ 2 (2, N = 303) = 9.99, p < .01. Gay acculturation was a significant risk factor and HIV altruism was a significant protective factor for having multiple partners with whom the participants had engaged in unprotected receptive anal sex. The four substances most commonly used by participants in the previous 3 months (alcohol, marijuana, poppers, ecstasy) were entered on the third step and increased the predictive utility of the model, χ 2 (4, N = 303) = 13.52, p < .01. As shown in Table 2, after accounting for other factors, alcohol and ecstasy were significant risk factors. Social responsibility was entered on the final step and significantly improved the model, χ 2 (1, N = 303) = 4.06, p < .05, indicating that social responsibility was a protective factor for having multiple unprotected receptive anal sex partners, after accounting for the influence of age, education, income, race, gay acculturation, HIV altruism, and the use of alcohol, marijuana, poppers, and ecstasy.
DISCUSSION In the present study, social responsibility was related to both sexual risk behavior and substance use, such that individuals higher in social TABLE 2 Sequential logistical regression analysis predicting multiple receptive anal sex partners, past 3 months Variable and Step
OR
CI
B
1. Age Education Income Race (Reference category = White) 2. Gay Acculturation HIV Altruism 3. Alcohol use Marijuana use Poppers use Ecstasy use 4. Social Responsibility
0.98 0.74 1.42 1.14
(0.94, 1.02) (0.60, 0.92) (0.97, 2.08) (0.47, 2.75)
−.020 −.298 .352 .128
.020 .112 .194 .451
ns
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Social Responsibility, Substance Use, and Sexual Risk Behavior in Men Who Have Sex With Men a
a
b
Aaron M. Martin MS , Eric G. Benotsch PhD , Anna Cejka MA & Diana Luckman MA
c
a
Department of Psychology , Virginia Commonwealth University , Richmond , Virginia , USA b
Department of Psychology , University of Colorado Denver , Denver , Colorado , USA c
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University of Northern Colorado , Greeley , Colorado , USA Accepted author version posted online: 12 Sep 2013.Published online: 02 Jan 2014.
To cite this article: Aaron M. Martin MS , Eric G. Benotsch PhD , Anna Cejka MA & Diana Luckman MA (2014) Social Responsibility, Substance Use, and Sexual Risk Behavior in Men Who Have Sex With Men, Journal of Homosexuality, 61:2, 251-269, DOI: 10.1080/00918369.2013.839908 To link to this article: http://dx.doi.org/10.1080/00918369.2013.839908
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Journal of Homosexuality, 61:251–269, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 0091-8369 print/1540-3602 online DOI: 10.1080/00918369.2013.839908
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Social Responsibility, Substance Use, and Sexual Risk Behavior in Men Who Have Sex With Men AARON M. MARTIN, MS and ERIC G. BENOTSCH, PhD Department of Psychology, Virginia Commonwealth University, Richmond, Virginia, USA
ANNA CEJKA, MA Department of Psychology, University of Colorado Denver, Denver, Colorado, USA
DIANA LUCKMAN, MA University of Northern Colorado, Greeley, Colorado, USA
Considerable public health literature focuses on relationships between problematic human characteristics (e.g., psychopathology) and unhealthy behaviors. A recent movement termed positive psychology emphasizes the advantages of assessing relationships between human strengths (e.g., altruism) and beneficial health behaviors. The present study assessed social responsibility, an orientation to help or protect others even when there is nothing to be gained as an individual, and its relationship to HIV-relevant behaviors. In our sample of 350 men who have sex with men (MSM), social responsibility was negatively correlated with substance use and HIV risk behaviors. Men who had been tested for HIV and knew their HIV status—a behavior that helps men protect their partners but does not protect themselves from the virus—also scored higher in social responsibility. Interventions designed to reduce HIV risk behavior in MSM may benefit from efforts to promote human strengths. KEYWORDS social responsibility, sexual behavior, men who have sex with men, substance use, altruism
Address correspondence to Eric G. Benotsch, Department of Psychology, P.O. Box 842018, Virginia Commonwealth University, Richmond, VA 23284, USA. E-mail: [email protected] 251
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The spread of infectious disease, particularly HIV, is a public health concern that reverberates from the individual to the global level. While medical breakthroughs have increased the average lifespan of those individuals living with HIV, these advances have also increased the number of individuals who could transmit the virus (Centers for Disease Control and Prevention, 2008). As such, it is important to direct interventions toward curbing those behaviors that increase the probability of HIV transmission. This is especially important for at-risk populations, such as men who have sex with men (MSM). Fortunately, some interventions have demonstrated success at decreasing unprotected anal intercourse and number of sexual partners, as well as increasing condom use (Herbst et al., 2005; Kalichman et al., 2005). However, most of these interventions do not focus on enriching those human strengths that might be associated with a decrease in sexual risk behavior and behavioral correlates of sexual risk (e.g., substance use; Benotsch, Seeley, et al., 2006; NIDA, 2006). The introduction of strength-based approaches to risk-reduction interventions may be warranted, as some MSM continue to engage in transmission risk behaviors despite widespread knowledge regarding these risks (Crepaz & Marks, 2002).
A POSITIVE INFLUENCE: SOCIAL RESPONSIBILITY The field of positive psychology offers several psychosocial constructs that have yet to be explored as possible protective factors for engaging in behaviors that pose health risks. One such construct, social responsibility, has been conceptualized as an orientation to help or protect others as part of a society or community even when there is nothing to be gained and includes an awareness of the problems and difficulties that affect a society or communities on a daily basis (Berkowitz & Lutterman, 1968; Peterson & Seligman, 2004). Individuals high in social responsibility may be concerned with the ethical and moral dilemmas that affect a community and may have a strong sense of justice when it comes to these issues (Peterson & Seligman, 2004). Although most health behaviors are investigated and understood from a selfcentered perspective that takes into account only an individual’s own health (e.g., Health Belief Model; Rosenstock, Strecher, & Becker, 1994), there is evidence that moral motives that drive societal-oriented prevention behaviors overlap with those motives associated with personal prevention (e.g., perceptions of personal risk; Kals & Montada, 2001). Identity with a social group implies a valuing of the social bond with others from this group (Peterson & Seligman, 2004), meaning that socially responsible behavior should manifest itself toward others in these social groups, while social exclusion will result in a reduction in pro-social behaviors (Twenge, Baumeister, DeWall, Ciarocco, & Bartels, 2007). Indeed, inclusion and connectedness has been associated with a greater likelihood
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to serve the common good of a community (Batson, Ahmad, & Tsang, 2002; Flanagan, 2004). This suggests that the heightened awareness of one’s own disenfranchised group coupled with a felt obligation to protect this group may be reflected by socially responsible behavior that is relevant to preventing sexually transmitted infections in MSM. Indeed, stronger gay identity has been associated with higher rates of condom use among MSM (Chng & Geliga-Vargas, 2000; Newcomb & Mustanski, 2011; Seibt et al., 1995).
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SOCIAL RESPONSIBILITY’S ROLE IN TRANSMISSION RISK To date, studies that have approximated this sense of societal level obligation have done so narrowly, closely focusing on a sense of personal responsibility to individual sexual partners (Bogart et al., 2006; Wolitski, Bailey, O’Leary, Gómez, & Parsons, 2003). For instance, HIV “prevention altruism” (Nimmons, 1998) has been described as a personal responsibility including the values, motivations, and practices involved in preventing the transmission of HIV to sexual partners (O’Dell, Rosser, Miner, & Jacoby; 2008; Wolitski et al., 2003). The majority of the literature dealing with altruism and similarly defined variations of personal responsibility has focused on at-risk groups such as MSM and injection drug users (IDU; O’Leary & Wolitski, 2009). Being higher in a sense of personal responsibility is associated with decreased likelihood of anal intercourse and increased likelihood of HIV status disclosure among HIV-positive MSM (Parsons, Halkitis, Wolitski, & Gómez, 2003; Wolitski, Flores, O’Leary, Bimbi, & Gómez, 2007). Failure to enhance personal responsibility for protecting partners has been cited as a reason that interventions did not significantly decrease unprotected insertive anal intercourse (O’Leary et al., 2005). It is important to highlight that HIV-positive individuals who perceive their sexual partners to be HIV-negative are more likely to assume personal responsibility for partner protection by engaging in fewer unprotected sex acts (Hong, Goldstein, Rotheram-Borus, Wong, & Gore-Felton, 2006). Unfortunately, this same body of research indicates that HIV-positive MSM may be more likely to perceive their partners as HIV-positive, compared to the perceptions of heterosexual men and women. In a primarily heterosexual (79%) sample of HIV-positive IDU, Latka and colleagues (2007) found that personal responsibility for limiting the sexual transmission of HIV was associated with greater HIV knowledge, self-efficacy for using condoms, having fewer sexual partners, and lower odds for unprotected sex. It is likely that those individuals who feel a personal responsibility to their individual partners may also experience a heightened sense of social responsibility, but this has yet to be explored. Content analysis of popular gay discussion boards on the issues of high-risk sexual activity, such a “barebacking” (anal sex in which condoms are intentionally not used), found that social responsibility was a primary reason cited against the practice
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(Carballo-Diéguez & Bauermeister, 2004). In particular, individuals described the gay community as a “family” when citing this reason.
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SOCIAL RESPONSIBILITY’S ROLE IN SUBSTANCE ABUSE As might be expected, the probability of engaging in sexual risk behaviors often increases with the use of recreational drugs and alcohol, as has been demonstrated in young heterosexual adults across a variety of drug classes (Bailey, Fleming, Henson, Catalano, & Haggerty, 2008; Howard & Wang, 2004; Morrison-Beedy, Carey, Feng, & Tu, 2008; Yan, Chiu, Stoesen, & Wang, 2007). Several studies have also found these associations in MSM populations. In samples of MSM, excessive alcohol use and drug use has been positively associated with unprotected anal sex, but negatively associated with disclosure of HIV status (Benotsch et al., 2007; Heath, Lanoye, & Maisto, 2012). Several studies have also examined the use of methamphetamine in this population and found use to be associated with sexual risk behavior and HIV transmission (Halkitis, Green, & Carragher, 2006; Halkitis, Mukherjee, & Palamar, 2009; Plankey et al., 2007). The recreational use of prescription drugs intended to treat sexual dysfunction (e.g., Viagra) has also been associated with increased risk behavior among MSM (Nettles, Benotsch, & Uban, 2009; Benotsch, Seeley, et al., 2006). Given the relation between social responsibility and sexual risk behaviors, and the exacerbating nature of substance abuse in conjunction with sexual activity, it may be reasonable to suspect those high in social responsibility will also be less inclined to engage in excessive alcohol use or illicit drug use, particularly when it comes to combining these inclinations with sexual activity. The toll that drugs and alcohol have on society, in economic and social terms, is a message many are familiar with, but it may particularly play in the minds of socially responsible individuals (Basu, Paltiel, & Pollack, 2008; Birnbaum et al., 2011). Social responsibility at college age has been related to lower levels of marijuana and tobacco consumption later in life (Roberts & Bogg, 2004). Additionally, social responsibility may be associated with addiction recovery, as members of Alcoholics Anonymous have been found to be higher on these interpersonal measures compared to nonalcoholic controls (Mellor, Conroy, & Masteller, 1986). Interestingly, among IDU who are HIV-positive, those who indicated feeling personal responsibility for preventing transmission during sex did not subsequently engage in safer injection practices (Latka et al., 2007), suggesting a disconnect in feelings of responsibility based on mode of transmission. The purpose of the current study is to broaden the research examining the positive psychology constructs associated with decreased sexual risk behavior and illicit substance use by determining the relevance of the global construct of social responsibility. The construct of social responsibility
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applies more broadly to an awareness of those hardships which plague society and specific communities, not other individuals per se. This makes the contribution of work regarding constructs that tap into responsible community membership and corresponding behaviors unique. Understanding the relation between social responsibility and health-related risk behaviors may improve both individual and group level interventions aimed at decreasing HIV-transmission in MSM. Given the prior findings on the relation between personal responsibility, substance use, and sexual risk behavior, the authors hypothesize that social responsibility will be negatively correlated with both substance use and sexual risk behavior, but positively associated with engaging in protective behaviors such as being tested for HIV and finding out the HIV status of their sexual partners.
METHOD Participants, Setting, and Procedures To investigate the association between social responsibility and sexual risk behavior, 400 people attending a gay pride festival in a large city in the Rocky Mountain region were recruited to complete anonymous, selfadministered surveys. Data analyses were limited to the 350 participants (87.5%) who were men who reported either a gay/bisexual orientation or who reported sex with other men. Data were collected on a single day in June 2009.
Participants Among the 350 participants, the mean age was 33.0 years (SD = 13.8; range = 18 to 78), and the average years of education was 14.0 (SD = 2.4). Eighty percent of participants (n = 280) self-identified as gay, 18% (n = 64) self-identified as bisexual, and 2% (n = 6) self-identified as heterosexual but were retained in the sample because they reported sex with a man in the past three months. The majority of the sample was White (65%; n = 227), with the remainder being Latino (14%; n = 49), African American (8%; n = 29), Native American (3%; n = 11), Asian American (1%; n = 5), or other/mixed ethnic heritage (7%; n = 26). Three men (0.8%) did not report their race/ethnicity. Thirty-two percent of participants (n = 113) had annual incomes below $16,000, 22% (n = 78) had incomes between $16,000– $30,000, 19% (n = 66) had annual incomes between $31,000–$45,000, 25% (n = 88) had incomes above $45,000, and five individuals (1.4%) did not indicate their income. The majority (84%; n = 293) reported having been tested for HIV: of those, 89.4% tested HIV-negative, 8.2% HIV-positive, and 2.4% did not know their test results.
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Procedure A convenience sample of participants were asked to complete an 8-page survey concerning HIV and AIDS as they walked through the festival grounds where retail venders and community organizations occupied display booths, one of which was rented for the purposes of this study. Participants were told that the survey was about sexual relationships, contained personal questions about their sexual history and substance use, was anonymous, and required approximately 15 minutes to complete. Participants’ names were not collected at any time. Participants were offered $2 for completing the survey, and an additional $2 donation was made to an HIV/AIDS charity. All research procedures were approved by the Institutional Review Board of the University of Colorado Denver. Recruitment methods such as these have been used extensively in prior research and have yielded samples that are roughly representative of samples that use more sophisticated sampling procedures (Gore-Felton et al., 2006; Grov, Parsons, & Bimbi, 2007; Halkitis & Parsons, 2002). This festival was chosen as the site for the survey because of the over 250,000 people who attend this annual event (The Center, 2010). Previous research has reported that men who attend gay pride festivals report significant rates of high-risk sexual behaviors (Kalichman, Gore-Felton, Benotsch, Cage, & Rompa, 2004). Almost 60% of all AIDS cases in Colorado have been reported in Denver County and more than 70% of Colorado’s HIV infections have occurred among men who have sex with men (Colorado Department of Public Health and Environment, 2010).
Measures Participants completed self-administered anonymous surveys that included measures of demographic information, gay acculturation, social responsibility, HIV altruism, substance use, perceptions of risk, and sexual practices.
DEMOGRAPHICS Participants were asked their age, years of education, income, race/ ethnicity, whether they self-identified as gay, bisexual, or heterosexual, whether they had been tested for HIV antibodies, and if so, the results of their most recent HIV test. Participants were also asked how many people with HIV/AIDS they have known.
GAY
ACCULTURATION
Participants were asked to indicate how often in the past year they engaged in gay cultural activities (e.g., “Gone out to gay bars,” “Read gay newspapers
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or magazines”). Responses were anchored on a 4-point scale from 1 (never) to 4 (often). This 5-item measure has shown utility in previous research (Benotsch, Kalichman, & Cage, 2002). Internal consistency of this measure was acceptable within this sample (α = .81) and comparable to the internal consistency in prior work (α = .73; Benotsch et al., 2002).
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SOCIAL
RESPONSIBILITY
This construct was assessed with a 5-item version of the Responsibility of People scale (Starrett, 1996). Scores on this measure have been previously related to prosocial activities including hours spent volunteering and charitable contributions (Starrett, 1996). Sample items included “Every person should give some of his time for the good of his town or community” and “I have made many commitments to many different kinds of people, groups, and activities in my life.” Items were rated on a 5-point Likert-type scale ranging from 1 (strongly disagree) to 5 (strongly agree). Internal consistency of this measure was acceptable in the present sample (α = .77) and comparable to the internal consistency of the original scale (α = .74; Starrett, 1996).
HIV
ALTRUISM
The original version of the HIV altruism scale was written specifically for HIV-positive persons and has been related to lower HIV transmission risk behaviors (O’Dell et al., 2008). We modified the scale to make questions applicable to both HIV-positive and HIV-negative individuals by eliminating two of the original seven items. Sample items included “Having safer sex shows that I care about my partner” and “By having safer sex, I am setting an example for others.” Items were rated on a 5-point Likert-type scale ranging from 1 (strongly disagree) to 5 (strongly agree). Internal consistency of this measure was acceptable in the present sample (α = .88) and comparable to the original scale (α = .83; O’Dell et al., 2008).
SUBSTANCE
USE
Participants were asked questions concerning the use of alcohol, marijuana, nitrite inhalants (poppers), cocaine, methamphetamine, ecstasy, heroin, ketamine, GHB, and Rohypnol in the previous 3 months. Street names were included for many of the substances. The frequency of use was measured using a 4-point Likert scale (1–none to 4–at least once a week). Participants were asked similar questions about the use of Viagra and other erectileenhancing drugs. Participants were also asked the number of times they had sex after having “too much” to drink, and the number of times they had sex
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after using drugs in the previous 3 months. This measure is similar to measures employed in prior research (Benotsch, et al., 2011; Nettles et al., 2009) and has been related to both other forms of substance use—for example, the non-medical use of prescription drugs (Benotsch, Martin, Koester, Cejka, & Luckman, 2011) and sexual risk behavior (Benotsch, Snipes, Martin, & Bull, 2013).
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SEXUAL
PRACTICES
Sexual behavior was assessed by asking participants to report the number of times they had engaged in unprotected anal intercourse, as the insertive and receptive partner, in the past 3 months. Participants also recorded the number of sexual partners with whom they had engaged in each behavior. Participants also responded to items assessing if they use condoms when they get into a new relationship and if they find out their partners’ HIV status prior to having sex. Consistent with our prior work, open response formats were used for the sexual behavior measures to reduce response bias and to minimize measurement error (Benotsch, Mikytuck, et al., 2006). Measures similar to these have been found to be reliable in self-reported sexual behavior assessments and to yield aggregate indices of HIV risk that are comparable to those obtained by finer-grained partner-by-partner sexual behavior assessments (Napper, Fisher, Reynolds, & Johnson, 2010; Pinkerton, Benotsch, & Mikytuck, 2007).
ESTIMATES
OF RISK
Participants responded to items that asked them to estimate the risk of HIV transmission in two scenarios. In both scenarios, an HIV-positive man and an HIV-negative man engaged in a single act of unprotected anal sex with ejaculation. In the first scenario, the HIV-positive man was the insertive partner; in the second scenario, the HIV-negative man was the insertive partner. Participants were asked to estimate the likelihood that the HIV-negative man would contract HIV based on his sexual activities described in the scenario (insertive or receptive partner). For both scenarios, response choices were less than 1%, 1–5%, 6–10%, 11–20%, and greater than 20%. This measure has shown utility in prior research (Nettles et al., 2009).
DATA
QUALITY ASSURANCES AND STATISTICAL ANALYSES
All surveys were examined for inconsistencies and invalid responses. Missing data were omitted from analyses, resulting in slightly different ns for various statistical tests. Because distributions of sexual behavior and substance use
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were highly skewed, nonparametric analyses (Spearman rank order correlations and logistic regressions) were used for analyses of these variables as recommended by Hollander and Wolfe (1999). Two-tailed significance levels were used for all tests.
RESULTS
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Social Responsibility Results showed a full range of scores on the social responsibility scale (range = 5 to 25), with a mean of 18.93 (SD = 3.92). White participants scored significantly higher (M = 19.30, SD = 3.68) than non-White participants (M = 18.23, SD = 4.29), t (342) = 2.41, p < .01. Social responsibility was associated with years of formal education (r = 0.23, p < .01), but it was unrelated to age, employment status, income, or HIV status. Men who self-identified as gay had higher social responsibility scores (M = 19.25, SD = 3.61) than men who self-identified as bisexual (M = 17.67, SD = 4.47), t (333) = 2.98, p < .01). Consistent with this finding, social responsibility scores were correlated with scores on the gay acculturation measure (r = 0.25, p < .001). Scores on the social responsibility measure were also significantly correlated with the number of persons with HIV/AIDS participants knew (r s = 0.22, p < .001).
Social Responsibility and HIV Altruism As would be expected, social responsibility scores were correlated with scores on the HIV altruism scale (r = 0.15, p < .01). This degree of association suggests a general concordance between these constructs, but it is not so high that they could be considered identical.
Social Responsibility and Substance Use In general, social responsibility was negatively associated with substance use. As shown in Table 1, social responsibility scores were negatively correlated with the use of ecstasy, cocaine, ketamine, Rohypnol, GHB, and heroin over the past 3 months. Similarly, social responsibility was negatively correlated with the use of phosphodiesterase type-5 inhibitors (Viagra and related medications) that are taken recreationally by some MSM and associated with HIV risk behavior (Nettles et al., 2009; Sherr et al., 2000). Social responsibility scores were unrelated to the use of alcohol, marijuana, methamphetamine, and poppers.
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− .23∗∗ .16∗∗ .14∗∗ .04 .16∗∗ .10 −.02 −.03 .00 .06
− .05 −.03 −.12∗ .01 −.08 −.15∗∗ −.14∗∗ −.21∗∗∗ −.16∗∗ −.11∗ −.11∗ − .36∗∗∗ .18∗∗ .20∗∗ .30∗∗∗ .15∗∗ .06 .12∗ .04 .07
3.
− .16∗∗ .13∗ .34∗∗∗ .43∗∗∗ .37∗∗∗ .13∗ .26∗∗∗ .07
4.
Note. N s range from 340–344. Numbers represent Spearman correlation values. PDE-5 Inhibitors = phosphodiesterase type-5 inhibitors (Viagra, Cialis, Levitra) ∗ p < .05; ∗∗ p < .01; ∗∗∗ p < .001.
1. Social Responsibility 2. Alcohol 3. Marijuana 4. Ecstasy 5. Poppers 6. Methamphetamine 7. Cocaine 8. Ketamine 9. Rohypnol 10. GHB 11. Heroin 12. PDE-5 Inhibitors
2.
1.
− .30∗∗∗ .16∗∗ .28∗∗∗ .29∗∗∗ .20∗∗∗ .18∗∗ .33∗∗∗
5.
− .39∗∗∗ .28∗∗∗ .40∗∗∗ .53∗∗∗ .33∗∗∗ .23∗∗∗
6.
− .29∗∗∗ .39∗∗∗ .19∗∗ .34∗∗∗ .12∗
7.
TABLE 1 Correlation matrix showing relationships between social responsibility and substance use
− .63∗∗∗ .41∗∗∗ .36∗∗∗ .14∗∗
8.
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− .43∗∗∗ .50∗∗∗ .30∗∗∗
9.
− .27∗∗∗ .14∗
10.
− .20∗∗∗
11.
−
12.
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Social Responsibility and HIV Testing The majority of the sample (84%) indicated they had been tested for HIV. Those who had been tested scored significantly higher on social responsibility (M = 19.15, SD = 3.85) than individuals who had never been tested for HIV (M = 17.75, SD = 4.09), t (344) = 2.48, p < .05. Seventy-five percent of participants (n = 264) indicated that they find out about their sex partners’ HIV status before having sex and 73% (n = 256) reported that they use condoms when they get into a relationship. Individuals who indicated they discuss HIV with sexual partners before initiating sexual activity had significantly higher social responsibility scores (M = 19.26, SD = 3.61) than individuals who reported that they do not have this type of discussion (M = 17.79, SD = 4.52), t (333) = 2.90, p < .01. Individuals who reported using condoms when they get into a relationship did not differ in their social responsibility scores from those who did not.
Social Responsibility and Perceptions of Risk Social responsibility scores were associated with greater perceived risk associated with unprotected sex. Social responsibility scores were associated with perceptions of a greater likelihood of HIV transmission when the HIVpositive person is the insertive partner (r = 0.33, p < .001) and when the HIV-positive person is the receptive partner (r = 0.12, p < .05).
HIV Risk Behavior and Social Responsibility In the present study, 71% of the respondents (n = 250) were sexually active in the previous three months. Of the men reporting sexual activity, 63% (n = 158) reported unprotected anal intercourse. In the portion of the sample reporting unprotected sex, 57% (n = 87) indicated that they had only 1 sexual partner and 43% (n = 67) reported sexual activity with 2 or more partners in the last three months. Social responsibility was associated with some HIV risk behaviors. Social responsibility was associated with lower rates of drug use in conjunction with sexual activity (r s = -0.15, p < .01) and was marginally associated with lower rates of having sex after having “too much” to drink (r s = −0.10, p < .10). Social responsibility was also negatively associated with the number of partners with whom participants had engaged in unprotected receptive anal sex, the highest risk behavior for HIV, (r s = −0.15, p < .01). Social responsibility scores were not associated with total unprotected anal sex acts or the number of insertive anal sex partners. Given prior research that suggests multiple factors influence high-risk sexual behavior, we performed a sequential (hierarchical) logistic regression analysis in order to determine the independent relationship between
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social responsibility and risk, after controlling for demographic factors, gay acculturation, HIV altruism, and substance use. The logistic regression analysis predicted membership in one of two groups: those who reported unprotected receptive anal sex with multiple partners in the previous three months (n = 25) and those who did not (n = 278). Results are shown in Table 2. Demographic variables were entered on the first step and significantly predicted this behavior, relative to a constant only model, χ 2 (4, N = 303) = 9.90, p < .05. As seen in Table 2, education was a significant protective factor. Gay acculturation and HIV altruism were entered on the second step and significantly added to the predictive utility of the model, χ 2 (2, N = 303) = 9.99, p < .01. Gay acculturation was a significant risk factor and HIV altruism was a significant protective factor for having multiple partners with whom the participants had engaged in unprotected receptive anal sex. The four substances most commonly used by participants in the previous 3 months (alcohol, marijuana, poppers, ecstasy) were entered on the third step and increased the predictive utility of the model, χ 2 (4, N = 303) = 13.52, p < .01. As shown in Table 2, after accounting for other factors, alcohol and ecstasy were significant risk factors. Social responsibility was entered on the final step and significantly improved the model, χ 2 (1, N = 303) = 4.06, p < .05, indicating that social responsibility was a protective factor for having multiple unprotected receptive anal sex partners, after accounting for the influence of age, education, income, race, gay acculturation, HIV altruism, and the use of alcohol, marijuana, poppers, and ecstasy.
DISCUSSION In the present study, social responsibility was related to both sexual risk behavior and substance use, such that individuals higher in social TABLE 2 Sequential logistical regression analysis predicting multiple receptive anal sex partners, past 3 months Variable and Step
OR
CI
B
1. Age Education Income Race (Reference category = White) 2. Gay Acculturation HIV Altruism 3. Alcohol use Marijuana use Poppers use Ecstasy use 4. Social Responsibility
0.98 0.74 1.42 1.14
(0.94, 1.02) (0.60, 0.92) (0.97, 2.08) (0.47, 2.75)
−.020 −.298 .352 .128
.020 .112 .194 .451
ns
