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Drug Alcohol Depend. Author manuscript; available in PMC 2017 September 01. Published in final edited form as: Drug Alcohol Depend. 2016 September 1; 166: 226–234. doi:10.1016/j.drugalcdep.2016.07.017.
The Role of Discrimination in Alcohol-related Problems in Samples of Heavy Drinking HIV-Negative and Positive Men who have Sex with Men (MSM) Tyler B. Wray1, David W. Pantalone2,3, Christopher W. Kahler1, Peter M. Monti1, and Kenneth H. Mayer3,4
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1Center
for Alcohol and Addictions Studies, Brown University School of Public Health, Providence, RI
2Department 3The
of Psychology, University of Massachusetts Boston, Boston, MA
Fenway Institute, Fenway Health, Boston, MA
4Beth
Israel Deaconess Medical Center/Harvard Medical School, Boston, MA
Abstract
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Background—Heavy drinking is a major public health concern among men who have sex with men (MSM), as it is in many other populations. However, the consequences of heavy drinking among MSM may be particularly severe, especially for sexual risk behavior, due to the relatively high prevalence of HIV. Minority stress models suggest that, among members of marginalized groups, discrimination may be associated with heavier alcohol use as these individuals increasingly drink to cope with such experiences. Past studies have provided some support for this association. However, they have not explored the role other drinking motives play, how these relationships might differ across MSM who are HIV-positive versus HIV-negative, or how this relationship extends to alcohol-related problems. Methods—In this study, we used path modeling to explore associations between perceived discrimination experiences, drinking motives, alcohol use, and alcohol-related problems in samples of heavy drinking MSM with and without HIV.
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Correspondence regarding this article may be sent to: Tyler B. Wray, Center for Alcohol and Addictions Studies, Brown University School of Public Health, 121 South Main Street, Providence, RI 02912, Phone: 401-863-6659, Fax: 401-863-6697, [email protected]. Contributors Dr. Wray oversaw data collection for Study 1, conducted the analyses, and prepared initial drafts of the manuscript. Dr. Pantalone oversaw data collection for Study 2, and prepared initial drafts of the manuscript. Dr. Kahler oversaw data collection for Study 2, helped conduct analyses, and revised drafts of the manuscript. Drs. Monti and Mayer provided guidance during data collection, prepared sections of the manuscript, revised drafts, and aided in interpretation of results. Conflict of Interest The authors have no conflicts of interest to disclose. Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Results—In both HIV-negative and positive MSM, perceived discrimination was significantly positively associated with alcohol problems. Drinking to cope appears to play an important role in this relationship in both samples. Reporting more discrimination experiences was associated with drinking more frequently for sexual reasons among both groups. While the total effect of drinking to facilitate sex was positively associated with alcohol-related problems, sex motives did not mediate associations between discrimination and either drinking outcome. Conclusion—These results suggest that interventions addressing discrimination and specific drinking motivations may be useful in helping reduce alcohol use of heavy drinking MSM. Keywords Alcohol; alcohol problems; MSM; gay/bisexual men; discrimination; drinking motives
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1. INTRODUCTION Heavy drinking and alcohol-related problems are major public health concerns among gay, bisexual, and other men who have sex with men (MSM), as they are in many populations. While there is little compelling evidence that rates of heavy drinking or alcohol-related disorders are higher among MSM than heterosexual men (Drabble et al., 2005, 2008), there is strong evidence that MSM experience specific alcohol-related problems that are particularly severe. For example, given the higher rates of HIV and some other sexuallytransmitted infections (STIs, e.g., syphilis) among MSM (Beyrer et al., 2012a, 2012b; Centers for Disease Control and Prevention, 2013; Parsons et al., 2012), alcohol-involved sexual risk behavior may be more likely to result in STI/HIV compared with men who have sex with only women.
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Studies have shown that rates of alcohol use and heavy drinking appear to be elevated among MSM who are living with HIV. Specifically, one multi-site study found that HIVpositive MSM had higher rates of binge drinking (5+ drinks on a single occasion) when compared with women and heterosexual men (Vellozzi et al., 2009). Another study showed that approximately 20% of HIV-positive MSM “binge drank” at least once a week (Skeer et al., 2012). These findings are significant, since people living with HIV also experience a number of unique health problems as a result of heavy drinking, including higher risk for liver toxicity (Puoti et al., 2000; Salmon-Ceron et al., 2005), poor response to antiretroviral therapy (Braithwaite et al., 2005; Cook et al., 2001), and increased cognitive difficulties (Devlin et al., 2012). Together, these studies suggest that heavy drinking may have particularly harmful health consequences for MSM. Despite these effects, little research has been devoted to understanding factors that uniquely contribute to heavy drinking and alcohol-related problems among MSM. 1.1 Health Effects of Discrimination Past research has shown that experiencing discrimination has negative health consequences. For example, several reviews have highlighted that experiencing discrimination in one’s life is a key risk factor for mental health problems later in life (Brown et al., 2000; Kessler et al., 1999; Pascoe and Smart-Richman, 2009). Among racial and ethnic minority individuals,
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perceived discrimination is associated with a variety of poor health outcomes, including obesity, hypertension, and pain (Pascoe and Smart-Richman, 2009; Williams and Mohammed, 2009). Moreover, for MSM of color living with HIV, experiencing racial discrimination is negatively associated with CD4 counts and antiretroviral therapy adherence, and positively associated with having a detectable viral load (Bogart et al., 2013, 2010).
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Several studies suggest that perceived discrimination is also associated with higher levels of alcohol and other drug use. For example, experiencing racial discrimination is directly associated with higher levels of alcohol use among racial/ethnic minority individuals (Gerrard et al., 2012; Martin et al., 2003; Sanders-Phillips et al., 2009). Discrimination based on sexual orientation has received less attention in the literature to date, but crosssectional studies similarly show associations between discrimination and alcohol use and problems among sexual and gender minority (lesbian, gay, bisexual, and transgender; LGBT) individuals (McCabe et al., 2010; McKirnan and Peterson, 1989). MSM who are living with HIV experience yet another layer of discrimination based on their HIV status (Boarts et al., 2008; Bogart et al., 2010). Few studies have yet explored the possibility that unfair treatment based on particular aspects of sexual orientation and/or HIV status could be associated with alcohol use and problems in MSM. 1.2 Motivations for Drinking in Alcohol Use and Problems
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While past research has established strong evidence for an association between discrimination and alcohol use/problems in general, recent reviews highlight that an important next step involves elucidating the mechanisms involved in this risk (Paradies, 2006; Williams and Mohammed, 2009). What are the ways that different kinds of discrimination can lead to heavy drinking and increase the likelihood of experiencing alcohol-related problems? One possible explanation is that experiencing discrimination leads individuals to drink for specific reasons that, in turn, increase risk. For example, a large body of past research suggests that drinking to cope—that is, drinking specifically in order to escape or avoid negative emotions—directly places individuals at risk for alcohol-related problems (Carey and Correia, 1997; Cooper et al., 1995; Kuntsche et al., 2005; Read et al., 2003). Thus, one intuitive possibility is that experiencing discrimination—based on any aspect of one’s identity or behavior—may lead individuals to drink in order to cope with these experiences which, in turn, increases the risk for alcohol-related problems. Hatzenbuehler and colleagues (2011) explored this possibility and found that, among LGB individuals, experiencing discrimination based on sexual orientation was associated with alcohol-related problems through coping motives. This process may be particularly relevant specifically among HIV-positive MSM who experience dual forms of discrimination (based on both their sexual orientation and their HIV status). Previously published studies have shown that individuals report many motivations for drinking, not just coping, and that these motives may also provide important pathways whereby discrimination is linked with alcohol use and problems. For example, the tendency to drink specifically to increase positive affect (i.e., enhancement motives) is often associated with increased alcohol-related problems through heavier drinking patterns
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(Cooper et al., 1995; Kuntsche et al., 2005; Read et al., 2003). That is, those who report drinking in order to have more fun often report drinking more heavily, which in turn increases their likelihood of experiencing alcohol-related problems. Although social facilitation motives are another common reason for drinking, findings rarely suggest an association with problems and, overall, have been mixed about their association with use (Cooper, 1994; Kahler et al., 2015; Magid et al., 2007).
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A measure of sexual motives for drinking has recently been developed, and drinking specifically to enable or enhance sex could play an important role in the relations between types of discrimination and alcohol use/problems (Kahler et al., 2015). Experiencing ostracism or ridicule because of one’s sexual orientation may be associated with feeling the need to drink in order to approach potential sexual partners which, in turn, could lead to heavier use. Similarly, experiencing discrimination on the basis of HIV status may lead those living with HIV to drink more frequently to facilitate sex, because they believe the “courage” provided by alcohol is needed to approach potential partners. However, HIVpositive MSM experience multiple forms of discrimination that are relevant to sexuality (i.e., from both their sexual orientation and HIV-status), so it is possible that sexual motives for drinking play a more prominent role in alcohol use for HIV-positive MSM. In a psychometric study involving MSM living with HIV, Kahler and colleagues (2015) found that endorsing sexual motives for drinking was not directly associated with experiencing alcohol-related problems. However, this study did not explore associations between sexual motives for drinking and alcohol use, or whether these motives could be indirectly associated with problems through heavier drinking. They also did not explore these associations specifically among MSM who were HIV-negative.
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1.3 The Current Study
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This study uses path modeling to explore associations between perceived discrimination, drinking motives, alcohol use, and alcohol-related problems in two samples of heavy drinking MSM: MSM without HIV (Study 1), and MSM living with HIV (Study 2). Using similar analyses, we explored whether experiencing discrimination (based on sexual orientation in Study 1 or sexual orientation/HIV status in Study 2) was associated with the tendency to report drinking for any of four specific reasons: coping, enhancement, social, and sexual motives. With this approach, we also explored whether these specific motives were differentially associated with heavier patterns of drinking and alcohol-related problems. Given published findings, we hypothesized that experiencing discrimination would be positively associated with the frequency of drinking to cope which would, in turn, be associated with an increased likelihood of alcohol-related problems. We also expected that discrimination would be associated with drinking more often to experience positive affect, but that those endorsing these enhancement motives would be at higher risk for alcohol-related problems primarily as a result of their heavier drinking. Finally, we expected that those who experienced discrimination would report drinking more often for sexual reasons, particularly among HIV-positive MSM, and that these men would be at risk for alcohol-related problems through greater alcohol use. Given the lack of past research, we did not specify a priori hypotheses about the role of social motives, but included them in the analyses for exploratory purposes.
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2. STUDY 1 METHODS 2.1 Participants Participants were 183 MSM who were recruited for an experimental study on alcohol intoxication’s effects on sexual decision-making. All participants were recruited from the northeastern United States via online advertisements (on social media, classified websites), flyers, and outreach at local LGBT-oriented events. Eligible participants reported (1) being at least 21 years of age (actual range: 21–50), (2) endorsing condomless anal sex (CAS) with a man in the past year, (3) being HIV-negative (based on self-report), (4) not being in an exclusive romantic relationship of longer than three months, and (5) drinking an average of > 14 drinks per week or drinking five or more drinks on at least one occasion per month. See Table 1 for Study 1 participant demographic characteristics.
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2.2 Measures 2.2.1—Perceived discrimination based on sexual orientation was assessed using the Multiple Discrimination Scale (MDS; Bogart et al., 2013, 2011). The MDS asks participants to rate (1 = yes, 0 = no) whether they have experienced 10 different types of discrimination in the past 6 months, because “someone thought [they] were gay.” Items assess verbal or physical violence, being ridiculed or made fun of, and being excluded or avoided, among other experiences. Example items include, “Were you denied a job or did you lose a job because someone thought that you were gay?” Past research supports the construct validity of the MDS (Bogart et al., 2013, 2010, 2011), and internal consistency in this sample was acceptable (α=0.83). Scores were summed and standardized (such that M=0 and SD=1) for the full analysis.
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2.2.2—Drinking motives were assessed using the Drinking Motives Questionnaire (DMQ; Cooper et al., 1992). This 15-item scale asks participants to rate how often they drink for a variety of reasons on a scale from 0 (almost never) to 5 (almost always/always). Five items assessed each of the following types of reasons: Coping (e.g., “To forget your worries”), enhancement (e.g., “Because you like the feeling”), and social facilitation (e.g., “To be sociable”). The DMQ has strong psychometric properties (Cooper et al., 1995) and has been used extensively in past research (Kuntsche et al., 2005). All subscales showed good internal consistency (coping: α=0.85. enhancement: α=0.84. social: α=0.83) and items for each were summed and standardized for use in the full analysis.
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2.2.3—Sexual motives for drinking were assessed using a 5-item scale (Kahler et al., 2015). Items are rated on the same scale as other motives; 0 (almost never) to 5 (almost always/ always). Example items include “because it helps you enjoy sex more, to be more confident in approaching sex partners,” and “to make you feel horny.” This measure showed strong reliability (α=0.83) and has demonstrated validity in past studies (Kahler et al., 2015). Items were summed and standardized for use in the full models. 2.2.4—Alcohol use level in the past 30 days was assessed using 3 items reflecting participants’ typical frequency and quantity of drinking. Standard drinks were defined (1 drink = 12 oz. beer, 5 oz. wine, or 0.5 oz. liquor), and participants rated (1) how many days a
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month they typically drank and (2) how many drinks they typically consumed when they drank. Participants also indicated (3) how many days on which they binge drank each month. These items were summed before being standardized for use in the full model. 2.2.5—Alcohol-related problems in the past six months were assessed using the Short Michigan Alcoholism Screening Test (SMAST; Selzer et al., 1975). The SMAST consists of 13 yes/no items which assess a variety of alcohol-related problems, including feeling guilty, getting in trouble at work, or being in a hospital because of drinking. The SMAST has been used extensively in past research and has demonstrated strong validity (Hays et al., 1995; Shields et al., 2007). Internal consistency in this sample was acceptable (α=0.71). 2.3 Procedure
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Interested participants were initially screened online, and eligible participants went on to complete all study measures via a linked online survey. Participants were not compensated for this portion of the study. All study procedures were approved by the Brown University Institutional Review Board. 2.4 Data Analysis Plan
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To explore hypothesized associations among discrimination, drinking motives, alcohol use, and problems, we estimated path models in Mplus 7.0 (Muthen and Muthen, 2007). In these models, participants’ total scores for sexual orientation-based discrimination were specified as an exogenous variable, with paths specified to each type of drinking motive (social, enhancement, coping, and sexual). In turn, paths were first specified from each motive type to alcohol use level. In initial models, we assumed that alcohol use level would mediate the associations between each motive and alcohol-related problems. However, given past research, one exception is that, initially, we also specified a direct path from coping motives to alcohol-related problems. We inspected modification indices after initial models were run, and any paths >10 (which suggests that model fit might be improved) were subsequently freed and the model re-estimated. Model fit was evaluated using reference values for fit indices reported in Hu and Bentler (1999; TLI=0.95, CFI=0.95, RMSEA=0.06, SRMR=0.08). However, some flexibility in interpreting these reference values is warranted, given that values of fit indices are often affected by factors other than misspecification, such as the number of variables included, the model df, sample size, and non-normality (Barrett, 2007; Hayduk et al., 2007; Kenny et al., 2014). Drinking motive types were allowed to covary in all models. Given evidence of positive skew in the alcohol problems variable, we specified a negative binomial distribution for all models and used maximum likelihood with robust standard errors as an estimator. All indirect effects were estimated using biascorrected, bootstrapped confidence intervals (MacKinnon et al., 2004).
3. STUDY 1 RESULTS See Table 1 for Study 1 sample demographic characteristics and descriptive statistics. Twelve participants did not complete the online survey and, thus, were dropped from the full analysis, resulting in an analytic sample of 171. Seventy-six percent of participants reported experiencing at least one type of discrimination based on their sexual orientation in the past
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six months. The most common experiences involved being insulted or made fun of (62.7%), being treated with hostility or coldness (49.4%), and being ignored, excluded or avoided by someone close to them (36.8%) because of their sexual orientation. Participants reported drinking an average of 3 days a week (SD = 1.76), and drank an average of 4.1 drinks per drinking day (SD = 1.88). They reported drinking five or more drinks on a single occasion an average of 2.9 times per month (SD = 1.76). Participants endorsed an average of 3.1 (SD = 1.50) alcohol-related problems in the past month. The most common were having felt guilty about drinking (25.2%), having problems with a spouse, parent, or relative because of drinking (22.8%), and having a spouse, parent, or relative worry about their drinking (17.5%). 3.1 Path Model
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In the initial model, all possible paths from the discrimination to motives were specified, as were all possible paths from motives to alcohol use. We specified a direct path between coping motives and problems, but all other motives were hypothesized to be associated with problems primarily through alcohol use. This initial model fit well, χ2(6) = 10.12, p = .120, CFI = 0.98, TLI= 0.94, RMSEA = 0.08, SRMR = 0.03. No modification indices exceeded the minimum threshold value.
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See Figure 1 for the full path model. Reporting more perceived discrimination based on sexual orientation was positively associated with frequently drinking to cope with negative emotions, to enhance mood, and to facilitate sex. Drinking to enhance mood, in turn, was positively associated with alcohol use level. Only alcohol use and coping motives were positively associated with alcohol-related problems. Additionally, the indirect effect of perceived discrimination on alcohol problems through coping motives was significant, while associations between discrimination and alcohol problems through enhancement motives and alcohol use were not significant. However, enhancement motives were significantly indirectly associated with alcohol problems through alcohol use in this sample. See Table 3 for all model indirect effects.
4. STUDY 1 DISCUSSION
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The results of Study 1 suggest that heavy drinking, HIV-negative MSM who report more discrimination experiences based on their sexual orientation also report drinking more often for a wide variety of the reasons we assessed: to enhance their mood, to facilitate sex, and to cope with negative emotions. In turn, those who reported more frequent drinking to cope with negative emotions were directly at risk for experiencing alcohol-related problems, overand-above their level of alcohol use. This finding mirrors results reported in past studies that drinking specifically to escape or avoid negative feelings uniquely increases the risk for a variety of alcohol problems (Cooper et al., 1995; Magid et al., 2007; Read et al., 2003). Our findings also add further support to a past study showing that, among LGB men and women, experiencing discrimination was associated with more frequent drinking to cope and that this, in turn, increased the risk for alcohol-related problems (Hatzenbuehler et al., 2011). While participants reporting more discrimination also reported more frequently drinking to enhance a positive mood, this pathway was not significantly associated with heavier
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drinking patterns or more alcohol-related problems. Similar to findings in the literature for other populations (e.g., college students; Read et al., 2003), however, frequently drinking to enhance positive emotions in general was associated with higher levels of use which, in turn, increased the risk for the development of alcohol problems—suggesting that MSM are also similarly vulnerable to heavy drinking and problems when they drink for enhancement reasons. Experiencing more sexual orientation-based discrimination was not associated with drinking more frequently to facilitate social interactions. Drinking for social and sexual reasons was also not associated with heavier patterns of drinking nor alcohol problems, either directly or through use. Overall, these results suggest that, for HIV-negative MSM, drinking to cope with negative emotions may be one pathway whereby experiencing discrimination based on sexual orientation could lead to alcohol-related problems. Drinking to enhance positive mood, on the other hand, may result in heavier levels of use which results in increased risk for problems irrespective of discrimination experiences.
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5. STUDY 2 METHODS 5.1 Participants
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Participants were 185 heavy drinking, HIV-positive MSM who were enrolled in a randomized controlled trial testing a brief intervention for heavy drinking. Participants were recruited from an urban community health center in the northeast with a focus on sexual and gender minority health. This center cares for more than 2,000 MSM who are living with HIV. Analyses in this section were conducted on baseline (pre-randomization) data. Participants eligible for the larger trial (1) were at least 18 years old (Actual range: 20–66), (2) typically drank > 14 drinks per week or drank > 5 drinks on a single occasion at least once in a typical month, (3) were diagnosed with HIV, (4) identified as a man who had engaged in sex (oral or anal) with a male partner in the last 12 months, or identified as gay/ bisexual in terms of sexual orientation. Participants were ineligible if they (1) reported current intravenous drug use, (2) were currently psychotic, suicidal, or manic, (3) had been or were being treated for an HIV-related opportunistic infection in the past three months, or (4) were currently receiving treatment for an alcohol or drug problem. See Table 1 for Study 2 participant demographic characteristics. 5.2 Measures
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Overall, the same constructs were assessed in both studies. However, while the specific measures used to assess discrimination experiences (both sexual orientation-based and HIVrelated; α=0.81), drinking motives (coping: α=0.89, enhancement: α=0.82, social: α=0.86), and sexual motives for drinking (α=0.91) were the same in both studies, measures of alcohol use and alcohol problems were different in this study compared to Study 1. 5.2.1—Alcohol use over the past 30 days was assessed using a Timeline Followback interview (Sobell, 1980). The TLFB uses a calendar to cue memory and facilitate recall. For each day, participants were asked by an interviewer to indicate the number of standard drinks they consumed (standard drinks were defined in the same way as for Study 1). For each participant, we extracted the frequency of drinking, the average number of drinks consumed when drinking, and binge drinking frequency (days on which 5 or more drinks
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were consumed). We summed and standardized these variables as in Study 1 to arrive at a composite alcohol use variable (calculated in the same way as for Study 1). The TLFB has demonstrated excellent reliability and validity for assessing alcohol use (Sobell and Sobell, 1980; Sobell et al., 1979). 5.2.2—Alcohol problems were assessed using the Short Inventory of Problems (SIP; (Miller et al., 1995). The SIP assesses 15 negative consequences of alcohol use over the chosen time period (in this case, 3 months) and has been found to have strong psychometric properties (Miller et al., 1995; Tonigan and Miller, 1993). Internal consistency in this sample was excellent (α=0.95). 5.3 Procedure
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Interested participants completed a brief screening interview either in-person or by phone. Those who screened as eligible were invited to participate in an in-person baseline visit, where they provided informed consent and completed a baseline assessment. Measures used for this study were collected by a trained interviewer or through audio computer assisted self-interview (ACASI). All procedures for this study were approved by Brown University Institutional Review Boards. 5.4 Data Analysis Plan Data for Study 2 were analyzed in the same way as Study 1, with the same a priori model specified, using the same approaches to evaluating fit and freeing/constraining paths.
6. STUDY 2 RESULTS Author Manuscript
See Table 1 for Study 2 sample demographic characteristics and descriptive statistics. Fifty percent of all participants reported experiencing discrimination based on their HIV-status. The most common experiences involved being rejected by a potential sexual or romantic partner (46%), being ignored, excluded, being insulted or made fun of (44%), and being treated with hostility or coldness by strangers (38%). Finally, 65% of participants reported at least one experience with discrimination based on their HIV status or sexual orientation.
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As in Study 1, we specified all possible paths from both discrimination variables to motives, and from motives to drinking. However, we initially constrained all paths from motives to problems to zero, except the direct path specified between coping motives to alcohol-related problems. This initial model was of mediocre fit, χ2(5) = 14.38, p < .01, CFI = 0.97, TLI=0.86, RMSEA = 0.10, SRMR = 0.03. Modification indices suggested freeing the path from social motives directly to alcohol-related problems, so this path was estimated in the subsequent model. The fit of this model was good, χ2(4) = 6.30, p = .178, CFI = 0.99, TLI=0.96, RMSEA = 0.06, SRMR = 0.03. A Satorra-Bentler Chi-square difference test also showed that this significantly improved model fit compared with the initial model, χ2(1) = 7.49, p = .006. See Figure 2 for the full Study 2 path model. As in Study 1 and past studies, reporting more discrimination was associated with drinking more often to cope, however, it was also associated with drinking more often to facilitate sex. Both drinking to enhance positive Drug Alcohol Depend. Author manuscript; available in PMC 2017 September 01.
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emotions and to facilitate sex were associated with heavier patterns of alcohol use. Not surprisingly, heavier patterns of alcohol use were in turn associated with experiencing more alcohol-related problems. Also, as in Study 1, drinking to cope was directly associated with experiencing more alcohol-related problems, and the indirect association between discrimination and alcohol-related problems through coping motives was significant. However, this was the only significant indirect path from discrimination to alcohol-related problems. Several interesting relationships emerged between each type of drinking motive and alcohol use and problems. For example, both drinking to enhance positive mood and to facilitate sex were both associated with alcohol-related problems through alcohol use. Unexpectedly, frequently drinking for social reasons was directly and negatively associated with alcohol-related problems.
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The results of Study 2 were largely consistent with those of Study 1 and similar past studies. Most strikingly, reporting more discrimination experiences based on either HIV status or sexual orientation was associated with drinking more frequently to cope with negative emotions which was, in turn, directly associated with problems, as in Study 1 and past studies (Hatzenbuehler et al., 2011). Those reporting more discrimination experiences also reported drinking more frequently for sexual reasons in this study as in Study 1, but it was not associated with drinking to enhance positive mood as it was in Study 1. Social motives were also directly negatively associated with alcohol-related problems (but not alcohol use) among MSM living with HIV in Study 2, whereas social motives were not associated with drinking or problems in Study 1. While this could suggest that those HIV-positive MSM who drink for social reasons were actually at lower risk for alcohol-related problems, we believe it is more likely that this unexpected association emerged due to multicollinearity, specifically between social and enhancement motives. We were able to reproduce this “flip” in sign by conducting a follow-up stepwise linear regression, which showed that social motives were positively associated with alcohol use unless enhancement motives were included in the model. This explanation is also supported by bivariate scatterplots and correlations, showing a weak but positive association between social motives and use.
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Interestingly, specifically for heavy drinking MSM living with HIV, frequently drinking for sexual reasons was generally associated with heavier drinking and, in turn, alcohol-related problems. This finding is important, since it suggests that, for HIV-positive MSM, drinking to facilitate or enhance sex may be one risk factor that leads to heavier drinking and health problems due to alcohol use. This finding was also reported in one earlier manuscript that involved many of the same participants reported here (Kahler et al., 2015) but contrasts with the HIV-negative MSM in Study 1. One possible explanation for this difference is that HIVpositive MSM who drink to facilitate sex may feel the need to drink more heavily to ease inhibitions or self-consciousness about potential rejection or ridicule from sex partners they might approach. Alternatively, these men may generally feel more anxiety about approaching partners—given concerns about potential rejection due to their HIV-positive status—and may use alcohol to ease that tension, placing them at increased risk for alcoholrelated problems. Finally, another possible interpretation is that this process is relevant to older MSM or MSM with heavier drinking patterns. That is, in addition to HIV status, Drug Alcohol Depend. Author manuscript; available in PMC 2017 September 01.
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participants in Study 2 were also substantially older and drank more heavily than participants in Study 1.
8. GENERAL DISCUSSION
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The results of both of these studies suggest that, among heavy drinking MSM, experiencing more discrimination on the basis of sexual orientation or HIV-status (among those living with HIV) was generally associated with reporting more alcohol-related problems, suggesting that discrimination may be an important risk factor for problem drinking among these individuals. These results are consistent with several past studies suggesting that discrimination is associated with heavier substance use (McCabe et al., 2010; McKirnan and Peterson, 1989). Our findings also support results from similar past studies (Hatzenbuehler et al., 2011) showing that specific drinking motives may represent important mechanisms whereby discrimination can lead to problem drinking. In particular, drinking to cope with negative emotions mediated the relationship between discrimination and alcohol-related problems in both studies. In both studies, no other indirect effects from discrimination to alcohol use or problems were identified, suggesting that this pathway could be among the more important mechanisms through which discrimination can lead to alcohol problems among heavy drinking MSM. As such, these findings indicate that alcohol interventions tailored for MSM might benefit from addressing the role of discrimination in problematic drinking, as well as healthier strategies for coping with discrimination.
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Our findings also suggest that other drinking motives are important risk factors for heavy drinking and alcohol-related problems, and that some of these motives show common and unique associations across HIV-negative and HIV-positive MSM. As seen in other populations (Carey and Correia, 1997; Cooper et al., 1995; Kuntsche et al., 2005; Read et al., 2003), drinking to “have a better time” was associated with more alcohol-related problems through heavier patterns of use in both samples. However, indirect associations between discrimination and alcohol outcomes through enhancement motives were not significant in either study, suggesting that, like other groups, MSM who drink specifically to enhance positive mood are at higher risk for alcohol-related problems via drinking more heavily. As such, interventions developed for other populations that incorporate content addressing the tendency to “drink to party” or “have a good time” (Canale et al., 2015; Fried and Dunn, 2012; Lau-Barraco and Dunn, 2008) might help MSM reduce their drinking.
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Our results also highlight the potentially unique importance of sexual motives for drinking in HIV-positive MSM. Specifically, our findings suggest that drinking to facilitate sex may increase risk for alcohol-related problems through heavier patterns of use in MSM living with HIV. That is, HIV-positive MSM who drink specifically to ease inhibitions around sex, to increase their confidence in approaching potential sex partners, or to feel less inhibited sexually may drink more heavily which, in turn, increases their risk for alcohol-related problems. Thus, another key component of alcohol interventions designed specifically for HIV-positive MSM could be content designed to modify recipients’ beliefs about the role of alcohol in sex, and to build skills and self-confidence for approaching potential romantic partners when alcohol is not involved.
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8.1 Limitations
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Several limitations are important to note. First, while this study explored associations between discrimination based on both sexual orientation and HIV-status (in Study 2), the small proportion of racial/ethnic minority participants in both studies precluded us from exploring the role of racial discrimination among these individuals. Examining these associations should be a priority for future research, given the reliable findings about racial discrimination’s associations with negative outcomes among Black and Latino HIV-positive MSM (Bogart et al., 2013). Second, for most constructs used in these analyses, the same measures were used across both samples to facilitate comparisons in pathways between the two samples. However, assessments of alcohol use patterns and drinking problems were unique to each study. As such, some of the highlighted differences in paths across HIVnegative and HIV-positive samples of MSM may be due to differences in the instruments used. Similarly, in addition to HIV status, the two samples were also substantially different in terms of both age and drinking behavior; those in Study 2 (the HIV-positive sample) were substantially older (Age M = 42.2 vs. M = 27.8 in Study 1) and drank more heavily (e.g., Number of binge drinking days in past 30 M = 7.6 vs. M = 3.3 in Study 1). As such, the observed differences in associations across studies could also be due to these variables, as well. Still, it is important to note that, while we cannot definitively attribute differences in associations observed across the two samples specifically to HIV-status itself, past studies have shown similar differences in age and drinking patterns across HIV-negative and positive MSM (Galvan et al., 2002; Koblin et al., 2006; Kurtz et al., 2012; Lauby et al., 2008; Skeer et al., 2012). Thus, the differences in demographic characteristics observed across these two studies could reflect that HIV-positive MSM are on average older and may drink more heavily compared with HIV-negative MSM.
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Both samples consisted of heavy drinking MSM, so the results reported here may not generalize to MSM with more moderate drinking patterns. Associations between the predictors and alcohol use may have been diminished among these heavy drinkers due to the restricted range in the alcohol use variable. Similarly, while both samples specifically recruited heavy drinking MSM, Study 2 explicitly recruited participants for a study on a brief intervention for drinking. As such, the results reported here may not generalize to MSM with more moderate drinking patterns, and different findings across the two studies may reflect differences between those willing to receive a drinking intervention and those who were not. Finally, the results reported here are cross-sectional and, as such, we cannot make inferences regarding the role of discrimination in causing changes in drinking motives, alcohol use patterns, or alcohol-related problems. Longitudinal studies of discrimination experienced in adolescence and young adulthood as a predictor of later drinking motives and drinking problems would be highly valuable. 8.2. Conclusions In sum, these studies suggest that perceived discrimination is an important risk factor for alcohol-related problems among heavy drinking MSM, and that drinking to cope with negative emotions may be an important mechanism for this effect. As such, alcohol interventions tailored for MSM may be improved by incorporating content on healthier ways of coping with discrimination. Results also suggest that interventions challenging drinking
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motivations that lead to heavy alcohol use and problems in other populations may likely be effective with heavy drinking MSM. Moreover, specifically challenging the tendency to drink to facilitate or enhance sex may also be an effective addition to alcohol interventions designed for HIV-positive MSM.
Acknowledgments This manuscript was supported by the National Institute on Alcohol Abuse and Alcoholism [grant numbers P01AA019072, T32AA007459, and L30AA023336].
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Highlights
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Path models explored associations between discrimination and alcohol outcomes
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Reporting more discrimination events was positively associated with alcohol problems
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Drinking to cope mediated this relationship in both HIV-negative and positive MSM
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Drinking for sexual reasons was positively associated with alcohol problems
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Interventions could address discrimination and specific drinking motives
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Figure 1.
Final model of discrimination on drinking motives, alcohol use, and alcohol-related problems among heavy drinking HIV-negative MSM (Study 1) Note. χ2(5) = 10.6, p = .098, CFI = 0.94, RMSEA = 0.84, SRMR = 0.03. Model coefficients are standardized; unstandardized are reported in parentheses when appropriate. †p
Drug Alcohol Depend. Author manuscript; available in PMC 2017 September 01. Published in final edited form as: Drug Alcohol Depend. 2016 September 1; 166: 226–234. doi:10.1016/j.drugalcdep.2016.07.017.
The Role of Discrimination in Alcohol-related Problems in Samples of Heavy Drinking HIV-Negative and Positive Men who have Sex with Men (MSM) Tyler B. Wray1, David W. Pantalone2,3, Christopher W. Kahler1, Peter M. Monti1, and Kenneth H. Mayer3,4
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1Center
for Alcohol and Addictions Studies, Brown University School of Public Health, Providence, RI
2Department 3The
of Psychology, University of Massachusetts Boston, Boston, MA
Fenway Institute, Fenway Health, Boston, MA
4Beth
Israel Deaconess Medical Center/Harvard Medical School, Boston, MA
Abstract
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Background—Heavy drinking is a major public health concern among men who have sex with men (MSM), as it is in many other populations. However, the consequences of heavy drinking among MSM may be particularly severe, especially for sexual risk behavior, due to the relatively high prevalence of HIV. Minority stress models suggest that, among members of marginalized groups, discrimination may be associated with heavier alcohol use as these individuals increasingly drink to cope with such experiences. Past studies have provided some support for this association. However, they have not explored the role other drinking motives play, how these relationships might differ across MSM who are HIV-positive versus HIV-negative, or how this relationship extends to alcohol-related problems. Methods—In this study, we used path modeling to explore associations between perceived discrimination experiences, drinking motives, alcohol use, and alcohol-related problems in samples of heavy drinking MSM with and without HIV.
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Correspondence regarding this article may be sent to: Tyler B. Wray, Center for Alcohol and Addictions Studies, Brown University School of Public Health, 121 South Main Street, Providence, RI 02912, Phone: 401-863-6659, Fax: 401-863-6697, [email protected]. Contributors Dr. Wray oversaw data collection for Study 1, conducted the analyses, and prepared initial drafts of the manuscript. Dr. Pantalone oversaw data collection for Study 2, and prepared initial drafts of the manuscript. Dr. Kahler oversaw data collection for Study 2, helped conduct analyses, and revised drafts of the manuscript. Drs. Monti and Mayer provided guidance during data collection, prepared sections of the manuscript, revised drafts, and aided in interpretation of results. Conflict of Interest The authors have no conflicts of interest to disclose. Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Results—In both HIV-negative and positive MSM, perceived discrimination was significantly positively associated with alcohol problems. Drinking to cope appears to play an important role in this relationship in both samples. Reporting more discrimination experiences was associated with drinking more frequently for sexual reasons among both groups. While the total effect of drinking to facilitate sex was positively associated with alcohol-related problems, sex motives did not mediate associations between discrimination and either drinking outcome. Conclusion—These results suggest that interventions addressing discrimination and specific drinking motivations may be useful in helping reduce alcohol use of heavy drinking MSM. Keywords Alcohol; alcohol problems; MSM; gay/bisexual men; discrimination; drinking motives
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1. INTRODUCTION Heavy drinking and alcohol-related problems are major public health concerns among gay, bisexual, and other men who have sex with men (MSM), as they are in many populations. While there is little compelling evidence that rates of heavy drinking or alcohol-related disorders are higher among MSM than heterosexual men (Drabble et al., 2005, 2008), there is strong evidence that MSM experience specific alcohol-related problems that are particularly severe. For example, given the higher rates of HIV and some other sexuallytransmitted infections (STIs, e.g., syphilis) among MSM (Beyrer et al., 2012a, 2012b; Centers for Disease Control and Prevention, 2013; Parsons et al., 2012), alcohol-involved sexual risk behavior may be more likely to result in STI/HIV compared with men who have sex with only women.
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Studies have shown that rates of alcohol use and heavy drinking appear to be elevated among MSM who are living with HIV. Specifically, one multi-site study found that HIVpositive MSM had higher rates of binge drinking (5+ drinks on a single occasion) when compared with women and heterosexual men (Vellozzi et al., 2009). Another study showed that approximately 20% of HIV-positive MSM “binge drank” at least once a week (Skeer et al., 2012). These findings are significant, since people living with HIV also experience a number of unique health problems as a result of heavy drinking, including higher risk for liver toxicity (Puoti et al., 2000; Salmon-Ceron et al., 2005), poor response to antiretroviral therapy (Braithwaite et al., 2005; Cook et al., 2001), and increased cognitive difficulties (Devlin et al., 2012). Together, these studies suggest that heavy drinking may have particularly harmful health consequences for MSM. Despite these effects, little research has been devoted to understanding factors that uniquely contribute to heavy drinking and alcohol-related problems among MSM. 1.1 Health Effects of Discrimination Past research has shown that experiencing discrimination has negative health consequences. For example, several reviews have highlighted that experiencing discrimination in one’s life is a key risk factor for mental health problems later in life (Brown et al., 2000; Kessler et al., 1999; Pascoe and Smart-Richman, 2009). Among racial and ethnic minority individuals,
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perceived discrimination is associated with a variety of poor health outcomes, including obesity, hypertension, and pain (Pascoe and Smart-Richman, 2009; Williams and Mohammed, 2009). Moreover, for MSM of color living with HIV, experiencing racial discrimination is negatively associated with CD4 counts and antiretroviral therapy adherence, and positively associated with having a detectable viral load (Bogart et al., 2013, 2010).
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Several studies suggest that perceived discrimination is also associated with higher levels of alcohol and other drug use. For example, experiencing racial discrimination is directly associated with higher levels of alcohol use among racial/ethnic minority individuals (Gerrard et al., 2012; Martin et al., 2003; Sanders-Phillips et al., 2009). Discrimination based on sexual orientation has received less attention in the literature to date, but crosssectional studies similarly show associations between discrimination and alcohol use and problems among sexual and gender minority (lesbian, gay, bisexual, and transgender; LGBT) individuals (McCabe et al., 2010; McKirnan and Peterson, 1989). MSM who are living with HIV experience yet another layer of discrimination based on their HIV status (Boarts et al., 2008; Bogart et al., 2010). Few studies have yet explored the possibility that unfair treatment based on particular aspects of sexual orientation and/or HIV status could be associated with alcohol use and problems in MSM. 1.2 Motivations for Drinking in Alcohol Use and Problems
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While past research has established strong evidence for an association between discrimination and alcohol use/problems in general, recent reviews highlight that an important next step involves elucidating the mechanisms involved in this risk (Paradies, 2006; Williams and Mohammed, 2009). What are the ways that different kinds of discrimination can lead to heavy drinking and increase the likelihood of experiencing alcohol-related problems? One possible explanation is that experiencing discrimination leads individuals to drink for specific reasons that, in turn, increase risk. For example, a large body of past research suggests that drinking to cope—that is, drinking specifically in order to escape or avoid negative emotions—directly places individuals at risk for alcohol-related problems (Carey and Correia, 1997; Cooper et al., 1995; Kuntsche et al., 2005; Read et al., 2003). Thus, one intuitive possibility is that experiencing discrimination—based on any aspect of one’s identity or behavior—may lead individuals to drink in order to cope with these experiences which, in turn, increases the risk for alcohol-related problems. Hatzenbuehler and colleagues (2011) explored this possibility and found that, among LGB individuals, experiencing discrimination based on sexual orientation was associated with alcohol-related problems through coping motives. This process may be particularly relevant specifically among HIV-positive MSM who experience dual forms of discrimination (based on both their sexual orientation and their HIV status). Previously published studies have shown that individuals report many motivations for drinking, not just coping, and that these motives may also provide important pathways whereby discrimination is linked with alcohol use and problems. For example, the tendency to drink specifically to increase positive affect (i.e., enhancement motives) is often associated with increased alcohol-related problems through heavier drinking patterns
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(Cooper et al., 1995; Kuntsche et al., 2005; Read et al., 2003). That is, those who report drinking in order to have more fun often report drinking more heavily, which in turn increases their likelihood of experiencing alcohol-related problems. Although social facilitation motives are another common reason for drinking, findings rarely suggest an association with problems and, overall, have been mixed about their association with use (Cooper, 1994; Kahler et al., 2015; Magid et al., 2007).
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A measure of sexual motives for drinking has recently been developed, and drinking specifically to enable or enhance sex could play an important role in the relations between types of discrimination and alcohol use/problems (Kahler et al., 2015). Experiencing ostracism or ridicule because of one’s sexual orientation may be associated with feeling the need to drink in order to approach potential sexual partners which, in turn, could lead to heavier use. Similarly, experiencing discrimination on the basis of HIV status may lead those living with HIV to drink more frequently to facilitate sex, because they believe the “courage” provided by alcohol is needed to approach potential partners. However, HIVpositive MSM experience multiple forms of discrimination that are relevant to sexuality (i.e., from both their sexual orientation and HIV-status), so it is possible that sexual motives for drinking play a more prominent role in alcohol use for HIV-positive MSM. In a psychometric study involving MSM living with HIV, Kahler and colleagues (2015) found that endorsing sexual motives for drinking was not directly associated with experiencing alcohol-related problems. However, this study did not explore associations between sexual motives for drinking and alcohol use, or whether these motives could be indirectly associated with problems through heavier drinking. They also did not explore these associations specifically among MSM who were HIV-negative.
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1.3 The Current Study
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This study uses path modeling to explore associations between perceived discrimination, drinking motives, alcohol use, and alcohol-related problems in two samples of heavy drinking MSM: MSM without HIV (Study 1), and MSM living with HIV (Study 2). Using similar analyses, we explored whether experiencing discrimination (based on sexual orientation in Study 1 or sexual orientation/HIV status in Study 2) was associated with the tendency to report drinking for any of four specific reasons: coping, enhancement, social, and sexual motives. With this approach, we also explored whether these specific motives were differentially associated with heavier patterns of drinking and alcohol-related problems. Given published findings, we hypothesized that experiencing discrimination would be positively associated with the frequency of drinking to cope which would, in turn, be associated with an increased likelihood of alcohol-related problems. We also expected that discrimination would be associated with drinking more often to experience positive affect, but that those endorsing these enhancement motives would be at higher risk for alcohol-related problems primarily as a result of their heavier drinking. Finally, we expected that those who experienced discrimination would report drinking more often for sexual reasons, particularly among HIV-positive MSM, and that these men would be at risk for alcohol-related problems through greater alcohol use. Given the lack of past research, we did not specify a priori hypotheses about the role of social motives, but included them in the analyses for exploratory purposes.
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2. STUDY 1 METHODS 2.1 Participants Participants were 183 MSM who were recruited for an experimental study on alcohol intoxication’s effects on sexual decision-making. All participants were recruited from the northeastern United States via online advertisements (on social media, classified websites), flyers, and outreach at local LGBT-oriented events. Eligible participants reported (1) being at least 21 years of age (actual range: 21–50), (2) endorsing condomless anal sex (CAS) with a man in the past year, (3) being HIV-negative (based on self-report), (4) not being in an exclusive romantic relationship of longer than three months, and (5) drinking an average of > 14 drinks per week or drinking five or more drinks on at least one occasion per month. See Table 1 for Study 1 participant demographic characteristics.
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2.2 Measures 2.2.1—Perceived discrimination based on sexual orientation was assessed using the Multiple Discrimination Scale (MDS; Bogart et al., 2013, 2011). The MDS asks participants to rate (1 = yes, 0 = no) whether they have experienced 10 different types of discrimination in the past 6 months, because “someone thought [they] were gay.” Items assess verbal or physical violence, being ridiculed or made fun of, and being excluded or avoided, among other experiences. Example items include, “Were you denied a job or did you lose a job because someone thought that you were gay?” Past research supports the construct validity of the MDS (Bogart et al., 2013, 2010, 2011), and internal consistency in this sample was acceptable (α=0.83). Scores were summed and standardized (such that M=0 and SD=1) for the full analysis.
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2.2.2—Drinking motives were assessed using the Drinking Motives Questionnaire (DMQ; Cooper et al., 1992). This 15-item scale asks participants to rate how often they drink for a variety of reasons on a scale from 0 (almost never) to 5 (almost always/always). Five items assessed each of the following types of reasons: Coping (e.g., “To forget your worries”), enhancement (e.g., “Because you like the feeling”), and social facilitation (e.g., “To be sociable”). The DMQ has strong psychometric properties (Cooper et al., 1995) and has been used extensively in past research (Kuntsche et al., 2005). All subscales showed good internal consistency (coping: α=0.85. enhancement: α=0.84. social: α=0.83) and items for each were summed and standardized for use in the full analysis.
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2.2.3—Sexual motives for drinking were assessed using a 5-item scale (Kahler et al., 2015). Items are rated on the same scale as other motives; 0 (almost never) to 5 (almost always/ always). Example items include “because it helps you enjoy sex more, to be more confident in approaching sex partners,” and “to make you feel horny.” This measure showed strong reliability (α=0.83) and has demonstrated validity in past studies (Kahler et al., 2015). Items were summed and standardized for use in the full models. 2.2.4—Alcohol use level in the past 30 days was assessed using 3 items reflecting participants’ typical frequency and quantity of drinking. Standard drinks were defined (1 drink = 12 oz. beer, 5 oz. wine, or 0.5 oz. liquor), and participants rated (1) how many days a
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month they typically drank and (2) how many drinks they typically consumed when they drank. Participants also indicated (3) how many days on which they binge drank each month. These items were summed before being standardized for use in the full model. 2.2.5—Alcohol-related problems in the past six months were assessed using the Short Michigan Alcoholism Screening Test (SMAST; Selzer et al., 1975). The SMAST consists of 13 yes/no items which assess a variety of alcohol-related problems, including feeling guilty, getting in trouble at work, or being in a hospital because of drinking. The SMAST has been used extensively in past research and has demonstrated strong validity (Hays et al., 1995; Shields et al., 2007). Internal consistency in this sample was acceptable (α=0.71). 2.3 Procedure
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Interested participants were initially screened online, and eligible participants went on to complete all study measures via a linked online survey. Participants were not compensated for this portion of the study. All study procedures were approved by the Brown University Institutional Review Board. 2.4 Data Analysis Plan
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To explore hypothesized associations among discrimination, drinking motives, alcohol use, and problems, we estimated path models in Mplus 7.0 (Muthen and Muthen, 2007). In these models, participants’ total scores for sexual orientation-based discrimination were specified as an exogenous variable, with paths specified to each type of drinking motive (social, enhancement, coping, and sexual). In turn, paths were first specified from each motive type to alcohol use level. In initial models, we assumed that alcohol use level would mediate the associations between each motive and alcohol-related problems. However, given past research, one exception is that, initially, we also specified a direct path from coping motives to alcohol-related problems. We inspected modification indices after initial models were run, and any paths >10 (which suggests that model fit might be improved) were subsequently freed and the model re-estimated. Model fit was evaluated using reference values for fit indices reported in Hu and Bentler (1999; TLI=0.95, CFI=0.95, RMSEA=0.06, SRMR=0.08). However, some flexibility in interpreting these reference values is warranted, given that values of fit indices are often affected by factors other than misspecification, such as the number of variables included, the model df, sample size, and non-normality (Barrett, 2007; Hayduk et al., 2007; Kenny et al., 2014). Drinking motive types were allowed to covary in all models. Given evidence of positive skew in the alcohol problems variable, we specified a negative binomial distribution for all models and used maximum likelihood with robust standard errors as an estimator. All indirect effects were estimated using biascorrected, bootstrapped confidence intervals (MacKinnon et al., 2004).
3. STUDY 1 RESULTS See Table 1 for Study 1 sample demographic characteristics and descriptive statistics. Twelve participants did not complete the online survey and, thus, were dropped from the full analysis, resulting in an analytic sample of 171. Seventy-six percent of participants reported experiencing at least one type of discrimination based on their sexual orientation in the past
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six months. The most common experiences involved being insulted or made fun of (62.7%), being treated with hostility or coldness (49.4%), and being ignored, excluded or avoided by someone close to them (36.8%) because of their sexual orientation. Participants reported drinking an average of 3 days a week (SD = 1.76), and drank an average of 4.1 drinks per drinking day (SD = 1.88). They reported drinking five or more drinks on a single occasion an average of 2.9 times per month (SD = 1.76). Participants endorsed an average of 3.1 (SD = 1.50) alcohol-related problems in the past month. The most common were having felt guilty about drinking (25.2%), having problems with a spouse, parent, or relative because of drinking (22.8%), and having a spouse, parent, or relative worry about their drinking (17.5%). 3.1 Path Model
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In the initial model, all possible paths from the discrimination to motives were specified, as were all possible paths from motives to alcohol use. We specified a direct path between coping motives and problems, but all other motives were hypothesized to be associated with problems primarily through alcohol use. This initial model fit well, χ2(6) = 10.12, p = .120, CFI = 0.98, TLI= 0.94, RMSEA = 0.08, SRMR = 0.03. No modification indices exceeded the minimum threshold value.
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See Figure 1 for the full path model. Reporting more perceived discrimination based on sexual orientation was positively associated with frequently drinking to cope with negative emotions, to enhance mood, and to facilitate sex. Drinking to enhance mood, in turn, was positively associated with alcohol use level. Only alcohol use and coping motives were positively associated with alcohol-related problems. Additionally, the indirect effect of perceived discrimination on alcohol problems through coping motives was significant, while associations between discrimination and alcohol problems through enhancement motives and alcohol use were not significant. However, enhancement motives were significantly indirectly associated with alcohol problems through alcohol use in this sample. See Table 3 for all model indirect effects.
4. STUDY 1 DISCUSSION
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The results of Study 1 suggest that heavy drinking, HIV-negative MSM who report more discrimination experiences based on their sexual orientation also report drinking more often for a wide variety of the reasons we assessed: to enhance their mood, to facilitate sex, and to cope with negative emotions. In turn, those who reported more frequent drinking to cope with negative emotions were directly at risk for experiencing alcohol-related problems, overand-above their level of alcohol use. This finding mirrors results reported in past studies that drinking specifically to escape or avoid negative feelings uniquely increases the risk for a variety of alcohol problems (Cooper et al., 1995; Magid et al., 2007; Read et al., 2003). Our findings also add further support to a past study showing that, among LGB men and women, experiencing discrimination was associated with more frequent drinking to cope and that this, in turn, increased the risk for alcohol-related problems (Hatzenbuehler et al., 2011). While participants reporting more discrimination also reported more frequently drinking to enhance a positive mood, this pathway was not significantly associated with heavier
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drinking patterns or more alcohol-related problems. Similar to findings in the literature for other populations (e.g., college students; Read et al., 2003), however, frequently drinking to enhance positive emotions in general was associated with higher levels of use which, in turn, increased the risk for the development of alcohol problems—suggesting that MSM are also similarly vulnerable to heavy drinking and problems when they drink for enhancement reasons. Experiencing more sexual orientation-based discrimination was not associated with drinking more frequently to facilitate social interactions. Drinking for social and sexual reasons was also not associated with heavier patterns of drinking nor alcohol problems, either directly or through use. Overall, these results suggest that, for HIV-negative MSM, drinking to cope with negative emotions may be one pathway whereby experiencing discrimination based on sexual orientation could lead to alcohol-related problems. Drinking to enhance positive mood, on the other hand, may result in heavier levels of use which results in increased risk for problems irrespective of discrimination experiences.
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5. STUDY 2 METHODS 5.1 Participants
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Participants were 185 heavy drinking, HIV-positive MSM who were enrolled in a randomized controlled trial testing a brief intervention for heavy drinking. Participants were recruited from an urban community health center in the northeast with a focus on sexual and gender minority health. This center cares for more than 2,000 MSM who are living with HIV. Analyses in this section were conducted on baseline (pre-randomization) data. Participants eligible for the larger trial (1) were at least 18 years old (Actual range: 20–66), (2) typically drank > 14 drinks per week or drank > 5 drinks on a single occasion at least once in a typical month, (3) were diagnosed with HIV, (4) identified as a man who had engaged in sex (oral or anal) with a male partner in the last 12 months, or identified as gay/ bisexual in terms of sexual orientation. Participants were ineligible if they (1) reported current intravenous drug use, (2) were currently psychotic, suicidal, or manic, (3) had been or were being treated for an HIV-related opportunistic infection in the past three months, or (4) were currently receiving treatment for an alcohol or drug problem. See Table 1 for Study 2 participant demographic characteristics. 5.2 Measures
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Overall, the same constructs were assessed in both studies. However, while the specific measures used to assess discrimination experiences (both sexual orientation-based and HIVrelated; α=0.81), drinking motives (coping: α=0.89, enhancement: α=0.82, social: α=0.86), and sexual motives for drinking (α=0.91) were the same in both studies, measures of alcohol use and alcohol problems were different in this study compared to Study 1. 5.2.1—Alcohol use over the past 30 days was assessed using a Timeline Followback interview (Sobell, 1980). The TLFB uses a calendar to cue memory and facilitate recall. For each day, participants were asked by an interviewer to indicate the number of standard drinks they consumed (standard drinks were defined in the same way as for Study 1). For each participant, we extracted the frequency of drinking, the average number of drinks consumed when drinking, and binge drinking frequency (days on which 5 or more drinks
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were consumed). We summed and standardized these variables as in Study 1 to arrive at a composite alcohol use variable (calculated in the same way as for Study 1). The TLFB has demonstrated excellent reliability and validity for assessing alcohol use (Sobell and Sobell, 1980; Sobell et al., 1979). 5.2.2—Alcohol problems were assessed using the Short Inventory of Problems (SIP; (Miller et al., 1995). The SIP assesses 15 negative consequences of alcohol use over the chosen time period (in this case, 3 months) and has been found to have strong psychometric properties (Miller et al., 1995; Tonigan and Miller, 1993). Internal consistency in this sample was excellent (α=0.95). 5.3 Procedure
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Interested participants completed a brief screening interview either in-person or by phone. Those who screened as eligible were invited to participate in an in-person baseline visit, where they provided informed consent and completed a baseline assessment. Measures used for this study were collected by a trained interviewer or through audio computer assisted self-interview (ACASI). All procedures for this study were approved by Brown University Institutional Review Boards. 5.4 Data Analysis Plan Data for Study 2 were analyzed in the same way as Study 1, with the same a priori model specified, using the same approaches to evaluating fit and freeing/constraining paths.
6. STUDY 2 RESULTS Author Manuscript
See Table 1 for Study 2 sample demographic characteristics and descriptive statistics. Fifty percent of all participants reported experiencing discrimination based on their HIV-status. The most common experiences involved being rejected by a potential sexual or romantic partner (46%), being ignored, excluded, being insulted or made fun of (44%), and being treated with hostility or coldness by strangers (38%). Finally, 65% of participants reported at least one experience with discrimination based on their HIV status or sexual orientation.
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As in Study 1, we specified all possible paths from both discrimination variables to motives, and from motives to drinking. However, we initially constrained all paths from motives to problems to zero, except the direct path specified between coping motives to alcohol-related problems. This initial model was of mediocre fit, χ2(5) = 14.38, p < .01, CFI = 0.97, TLI=0.86, RMSEA = 0.10, SRMR = 0.03. Modification indices suggested freeing the path from social motives directly to alcohol-related problems, so this path was estimated in the subsequent model. The fit of this model was good, χ2(4) = 6.30, p = .178, CFI = 0.99, TLI=0.96, RMSEA = 0.06, SRMR = 0.03. A Satorra-Bentler Chi-square difference test also showed that this significantly improved model fit compared with the initial model, χ2(1) = 7.49, p = .006. See Figure 2 for the full Study 2 path model. As in Study 1 and past studies, reporting more discrimination was associated with drinking more often to cope, however, it was also associated with drinking more often to facilitate sex. Both drinking to enhance positive Drug Alcohol Depend. Author manuscript; available in PMC 2017 September 01.
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emotions and to facilitate sex were associated with heavier patterns of alcohol use. Not surprisingly, heavier patterns of alcohol use were in turn associated with experiencing more alcohol-related problems. Also, as in Study 1, drinking to cope was directly associated with experiencing more alcohol-related problems, and the indirect association between discrimination and alcohol-related problems through coping motives was significant. However, this was the only significant indirect path from discrimination to alcohol-related problems. Several interesting relationships emerged between each type of drinking motive and alcohol use and problems. For example, both drinking to enhance positive mood and to facilitate sex were both associated with alcohol-related problems through alcohol use. Unexpectedly, frequently drinking for social reasons was directly and negatively associated with alcohol-related problems.
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The results of Study 2 were largely consistent with those of Study 1 and similar past studies. Most strikingly, reporting more discrimination experiences based on either HIV status or sexual orientation was associated with drinking more frequently to cope with negative emotions which was, in turn, directly associated with problems, as in Study 1 and past studies (Hatzenbuehler et al., 2011). Those reporting more discrimination experiences also reported drinking more frequently for sexual reasons in this study as in Study 1, but it was not associated with drinking to enhance positive mood as it was in Study 1. Social motives were also directly negatively associated with alcohol-related problems (but not alcohol use) among MSM living with HIV in Study 2, whereas social motives were not associated with drinking or problems in Study 1. While this could suggest that those HIV-positive MSM who drink for social reasons were actually at lower risk for alcohol-related problems, we believe it is more likely that this unexpected association emerged due to multicollinearity, specifically between social and enhancement motives. We were able to reproduce this “flip” in sign by conducting a follow-up stepwise linear regression, which showed that social motives were positively associated with alcohol use unless enhancement motives were included in the model. This explanation is also supported by bivariate scatterplots and correlations, showing a weak but positive association between social motives and use.
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Interestingly, specifically for heavy drinking MSM living with HIV, frequently drinking for sexual reasons was generally associated with heavier drinking and, in turn, alcohol-related problems. This finding is important, since it suggests that, for HIV-positive MSM, drinking to facilitate or enhance sex may be one risk factor that leads to heavier drinking and health problems due to alcohol use. This finding was also reported in one earlier manuscript that involved many of the same participants reported here (Kahler et al., 2015) but contrasts with the HIV-negative MSM in Study 1. One possible explanation for this difference is that HIVpositive MSM who drink to facilitate sex may feel the need to drink more heavily to ease inhibitions or self-consciousness about potential rejection or ridicule from sex partners they might approach. Alternatively, these men may generally feel more anxiety about approaching partners—given concerns about potential rejection due to their HIV-positive status—and may use alcohol to ease that tension, placing them at increased risk for alcoholrelated problems. Finally, another possible interpretation is that this process is relevant to older MSM or MSM with heavier drinking patterns. That is, in addition to HIV status, Drug Alcohol Depend. Author manuscript; available in PMC 2017 September 01.
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participants in Study 2 were also substantially older and drank more heavily than participants in Study 1.
8. GENERAL DISCUSSION
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The results of both of these studies suggest that, among heavy drinking MSM, experiencing more discrimination on the basis of sexual orientation or HIV-status (among those living with HIV) was generally associated with reporting more alcohol-related problems, suggesting that discrimination may be an important risk factor for problem drinking among these individuals. These results are consistent with several past studies suggesting that discrimination is associated with heavier substance use (McCabe et al., 2010; McKirnan and Peterson, 1989). Our findings also support results from similar past studies (Hatzenbuehler et al., 2011) showing that specific drinking motives may represent important mechanisms whereby discrimination can lead to problem drinking. In particular, drinking to cope with negative emotions mediated the relationship between discrimination and alcohol-related problems in both studies. In both studies, no other indirect effects from discrimination to alcohol use or problems were identified, suggesting that this pathway could be among the more important mechanisms through which discrimination can lead to alcohol problems among heavy drinking MSM. As such, these findings indicate that alcohol interventions tailored for MSM might benefit from addressing the role of discrimination in problematic drinking, as well as healthier strategies for coping with discrimination.
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Our findings also suggest that other drinking motives are important risk factors for heavy drinking and alcohol-related problems, and that some of these motives show common and unique associations across HIV-negative and HIV-positive MSM. As seen in other populations (Carey and Correia, 1997; Cooper et al., 1995; Kuntsche et al., 2005; Read et al., 2003), drinking to “have a better time” was associated with more alcohol-related problems through heavier patterns of use in both samples. However, indirect associations between discrimination and alcohol outcomes through enhancement motives were not significant in either study, suggesting that, like other groups, MSM who drink specifically to enhance positive mood are at higher risk for alcohol-related problems via drinking more heavily. As such, interventions developed for other populations that incorporate content addressing the tendency to “drink to party” or “have a good time” (Canale et al., 2015; Fried and Dunn, 2012; Lau-Barraco and Dunn, 2008) might help MSM reduce their drinking.
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Our results also highlight the potentially unique importance of sexual motives for drinking in HIV-positive MSM. Specifically, our findings suggest that drinking to facilitate sex may increase risk for alcohol-related problems through heavier patterns of use in MSM living with HIV. That is, HIV-positive MSM who drink specifically to ease inhibitions around sex, to increase their confidence in approaching potential sex partners, or to feel less inhibited sexually may drink more heavily which, in turn, increases their risk for alcohol-related problems. Thus, another key component of alcohol interventions designed specifically for HIV-positive MSM could be content designed to modify recipients’ beliefs about the role of alcohol in sex, and to build skills and self-confidence for approaching potential romantic partners when alcohol is not involved.
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8.1 Limitations
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Several limitations are important to note. First, while this study explored associations between discrimination based on both sexual orientation and HIV-status (in Study 2), the small proportion of racial/ethnic minority participants in both studies precluded us from exploring the role of racial discrimination among these individuals. Examining these associations should be a priority for future research, given the reliable findings about racial discrimination’s associations with negative outcomes among Black and Latino HIV-positive MSM (Bogart et al., 2013). Second, for most constructs used in these analyses, the same measures were used across both samples to facilitate comparisons in pathways between the two samples. However, assessments of alcohol use patterns and drinking problems were unique to each study. As such, some of the highlighted differences in paths across HIVnegative and HIV-positive samples of MSM may be due to differences in the instruments used. Similarly, in addition to HIV status, the two samples were also substantially different in terms of both age and drinking behavior; those in Study 2 (the HIV-positive sample) were substantially older (Age M = 42.2 vs. M = 27.8 in Study 1) and drank more heavily (e.g., Number of binge drinking days in past 30 M = 7.6 vs. M = 3.3 in Study 1). As such, the observed differences in associations across studies could also be due to these variables, as well. Still, it is important to note that, while we cannot definitively attribute differences in associations observed across the two samples specifically to HIV-status itself, past studies have shown similar differences in age and drinking patterns across HIV-negative and positive MSM (Galvan et al., 2002; Koblin et al., 2006; Kurtz et al., 2012; Lauby et al., 2008; Skeer et al., 2012). Thus, the differences in demographic characteristics observed across these two studies could reflect that HIV-positive MSM are on average older and may drink more heavily compared with HIV-negative MSM.
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Both samples consisted of heavy drinking MSM, so the results reported here may not generalize to MSM with more moderate drinking patterns. Associations between the predictors and alcohol use may have been diminished among these heavy drinkers due to the restricted range in the alcohol use variable. Similarly, while both samples specifically recruited heavy drinking MSM, Study 2 explicitly recruited participants for a study on a brief intervention for drinking. As such, the results reported here may not generalize to MSM with more moderate drinking patterns, and different findings across the two studies may reflect differences between those willing to receive a drinking intervention and those who were not. Finally, the results reported here are cross-sectional and, as such, we cannot make inferences regarding the role of discrimination in causing changes in drinking motives, alcohol use patterns, or alcohol-related problems. Longitudinal studies of discrimination experienced in adolescence and young adulthood as a predictor of later drinking motives and drinking problems would be highly valuable. 8.2. Conclusions In sum, these studies suggest that perceived discrimination is an important risk factor for alcohol-related problems among heavy drinking MSM, and that drinking to cope with negative emotions may be an important mechanism for this effect. As such, alcohol interventions tailored for MSM may be improved by incorporating content on healthier ways of coping with discrimination. Results also suggest that interventions challenging drinking
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motivations that lead to heavy alcohol use and problems in other populations may likely be effective with heavy drinking MSM. Moreover, specifically challenging the tendency to drink to facilitate or enhance sex may also be an effective addition to alcohol interventions designed for HIV-positive MSM.
Acknowledgments This manuscript was supported by the National Institute on Alcohol Abuse and Alcoholism [grant numbers P01AA019072, T32AA007459, and L30AA023336].
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Highlights
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Path models explored associations between discrimination and alcohol outcomes
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Reporting more discrimination events was positively associated with alcohol problems
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Drinking to cope mediated this relationship in both HIV-negative and positive MSM
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Drinking for sexual reasons was positively associated with alcohol problems
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Interventions could address discrimination and specific drinking motives
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Figure 1.
Final model of discrimination on drinking motives, alcohol use, and alcohol-related problems among heavy drinking HIV-negative MSM (Study 1) Note. χ2(5) = 10.6, p = .098, CFI = 0.94, RMSEA = 0.84, SRMR = 0.03. Model coefficients are standardized; unstandardized are reported in parentheses when appropriate. †p
