F A Guide toOAIDSCResearch andU CounselingS Volume 13 Number 4 March 1998

methamphetamine, cocaine, crack An Tale of Two Epidemics: cocaine, and heroin—regional differences in these drug use patterns, and a whole HIV and Stimulant Use range of demographic data. In the eastern Michael Gorman, PhD, MSW and upper middle western United States, and in parts of the U.S. South, the typical drug use-related AIDS case is likely to be The words “heroin” and “injection drug a heterosexual individual—increasingly a use” have come to be equated with HIV woman or a person of color or both— transmission. But, other drugs are injected, who has used heroin, crack, or cocaine. and other attributes of these drugs, includ- In the western United States, the profile ing sex-enhancing properties and impaired is significantly different. In California, judgment, may increase sexual risk-taking Oregon, and Washington, for example, a and HIV infection. Chief among these near majority of people with AIDS who “other” drugs are the stimulants: amphet- have injection drug use histories have been amines, methamphetamines, and cocaine. gay and bisexual men (although this pro- This article looks at stimulants and their portion appears to be decreasing). In the relation to the HIV epidemic of the 1990s. West, the drugs of choice associated with First, it reviews recent HIV surveillance HIV disease appear to be stimulants, espe- data about the shape of the drug use epi- cially methamphetamines, but also demic in United States. Second, it offers cocaine, with heroin being less common an overview of the stimulant epidemic in this population. Seroprevalence among in particular. Finally, it describes two case people entering methadone maintenance in that offer insights into the lives of seropos- western Washington, for example, hovers itive individuals who use stimulants. at about 2 percent, versus 60 percent in comparable populations in New York City.* The Epidemiology of Drug Use and HIV A great deal of HIV transmission in the The Class of Stimulants United States is attributable to the role The class of drugs called stimulants substance use plays in unsafe sexual refers to widely disparate kinds of sub- behavior. This is especially likely to be stances, which have in common the ability the case with stimulants such as metham- *Surveillance data to increase activity in the central and from the Centers phetamine and cocaine. While nearly 60 autonomic nervous systems. The primary for Disease Control percent of the adults with AIDS and injec- stimulant drugs associated with HIV dis- and Prevention tion drug use histories are heterosexual ease in the United States are cocaine, (CDC) have not pro- men and 21 percent are women, 20 per- vided extensive data crack cocaine, and methamphetamines. on drug of choice cent are men who have sex with men. Cocaine probably represents the oldest for people with Among people with AIDS younger than 25 drug in this class, having been used by AIDS. But another years old, these proportions are even more South American Indians for more than CDC initiative, dramatic: nearly one-third of those cases the Supplemental 1300 years. Cocaine is derived from the HIV/AIDS Surveillance are among young women, one-third among leaf of the coca plant (Erythroxylon coca) (SHAS), should fill heterosexual men, and almost another and was originally chewed to deliver its in this gap, by includ- third among men who have sex with men. effect. Cocaine induces a general state of ing information on Analyses of drug use have generally euphoria, depresses appetite, and increas- drug history, primary drug of choice, and ignored drug-specific patterns and subcul- es endurance. Crack is a free base form of other factors. tures of drug use—for example, among cocaine. Cocaine can be ingested, snorted, these groups are so significant Editorial: The Individual Described for HIV prevention. Michael Robert Marks, Editor Siever adds to this complexity by discussing in his article the effects of individual differences The speed and crack epidem- use methamphetamine and on a culturally competent, client- ics are not news, nor is their highlights geographical differ- centered clinical approach. connection to HIV. Stimulants ences among these user popula- For providers, all of this infor- lead to “disinhibition,” a stiff tions. Two articles abstracted mation is crucial to approach and formal word that describes in the Recent Reports—one some of the most stereotyped actions that are anything but by Gorman and one by Cathy groups in our society. The arti- controlled and often risky. Reback—relying on ethnographic cles here clarify not only the While this effect may be in- methods also detail the traits of extent and severity of the inter- herent to stimulant abuse, the specific subpopulations of speed twined epidemics of HIV and profiles of people who use stim- users in Seattle and Los Angeles. stimulant use, but also the ulants vary across a broad array magnitude of difference among of populations. This issue of A Mantra for a Complex World clients who may look the same. FOCUS concentrates on metham- All of these reports help to This perspective, like the phetamine use, one of the key flesh out the speed epidemic and two epidemics, is not news. But areas of discourse at a confer- the challenges of delivering HIV perhaps, in the face of so many ence on HIV and substance prevention messages to groups pressures to homogenize our among men who have sex with that seem to be similar but are, perceptions, it must be repeated men last September in Seattle. in reality, vastly different. Most over and over; a mantra neces- Michael Gorman, one of the compelling, is the fact that there sary to overcome the natural conference’s organizers, des- are so many distinct groups of impulse, even among the most cribes the range of demographic users and that what may appear skilled therapist, to simplify a characteristics of people who to be subtle differences among too, too complex world.

smoked (as is often the case with crack), anorexia, hyperreflexia (over-responsive and injected. Cocaine mixed with heroin is reflexes), restlessness, talkativeness, and References called “speedball.” In addition to stimulant insomnia. At high dosages or prolonged properties, cocaine has local anesthetic continuous use, effects may also include Abramowitz AG, Meredith L. properties that can lead to convulsions hypervigilance and paranoia with halluci- Stimulant Abuse as well as respiratory distress. nations, with tendencies to violence. in San Francisco: Amphetamines were first synthesized While not a new problem, metham- Status Reports by a German pharmacologist in 1887. The phetamine use has undergone a recent on Cocaine and Methamphetamine related compound methamphetamine, resurgence and continues to attract consid- Problems. Community currently referred to as “speed”, “crank,” erable national attention. Methampheta- Substance Abuse or “ice” was synthesized in 1919. Amphet- mines currently rank among the most Services, San amines, including methamphetamines, are widely used synthetic drugs in the United Francisco Department of Public Health, currently the most widely abused synthet- States, according to the Drug Abuse 1996. ic drugs in the United States and the Warning Network, the CDC, the Drug Pacific Rim. Amphetamines and metham- Enforcement Agency, and the Office Battjes RJ, Sloboda phetamines—which may be drunk, eaten, of National Drug Control Policy. Z, Grace WC. smoked, injected, or absorbed through the Between 1991 and 1996, methampheta- A Contextual Perspective on rectum—cause the release of the neuro- mine-related deaths in the United States HIV Risk. National transmitters norepinephrine, dopamine, tripled, and almost all involved metham- Institute on Drug and serotonin. With a half-life of approxi- phetamines in combination with at least Abuse Research mately 24 hours, the action of these drugs one other drug. Emergency room-related Monograph Series. 1994; 143: 1-4. may be quite prolonged. Their therapeutic methamphetamine episodes also tripled effects include treatment of narcolepsy (a since the early 1990s, with the largest Diaz T, Chu SY, Byers sleep disorder), attention deficit disorder increases occurring in the western United RH, et al. Types of (ADD), and in some cases, depression. States, especially in Phoenix, San Diego, drugs used by injec- The toxic effects of amphetamines San Francisco, Los Angeles, Denver, and tion drug users with HIV/AIDS in a multi- and methamphetamines may include Seattle. By the mid-1990s, the metham- site surveillance headache, hypertension, pallor, palpi- phetamine epidemic had penetrated project: Implications tation, and the constriction of veins (vaso- the Midwest and parts of the southern for intervention. constriction). In low to moderate doses, United States. American Journal of Public Health. 1994; these drugs may lead to signs of central In all western and many midwestern 84: 1971-1975. nervous system intoxication, including states, methamphetamine has similarly 2 FOCUS March 1998 increased as the primary drug Two years later, burnt-out with his gruel- related to admissions to pub- ing school and work schedule, Robert In Washington, licly funded drug treatment decided to “live a little and do drugs all programs. Washington state summer.” After two months of water-inject- admissions for admissions have increased six- ing crystal, he lost his job, quit his intern- fold since 1992 and in some ship, and dropped out of college. He was treatment for quarters have equaled or even evicted from his apartment, losing all of speed use have exceeded the number of people his personal belongings. Robert considers being treated for heroin use. himself a crystal addict: “I mean, crystal is increased six- Demographically, methampheta- the type of drug that you’re doing around mine users tend to resemble the the clock.” Today, reflecting on his losses, fold, in some population characteristics of the he says, “I wish I’d never done crystal.” regions in which they live, that places even is, predominantly White, but Roxy: Going to Heaven increasingly Latino and Native Roxy, a 36-year-old, seropositive, Black, exceeding the American. Data collected by the transgendered female began shooting number treated San Francisco Department of speed when she was 19. She remembers Public Health for an HIV vaccine her first time fondly: “It was like dying and for heroin use. feasibility study found that 24 going to heaven.” Her primary motivation percent of the gay and bisexual was for energy to dance. In 1983, Roxy was men recruited through the city’s living in San Francisco and beginning sexually transmitted disease hormone replacement therapy. When doc- clinics, bars, and clubs had used speed tors told her that crystal would interfere during the previous year. with her male-to-female process, she The rise of methamphetamines notwith- stopped for two years, choosing to inject standing, cocaine still remains a tremen- cocaine instead. After almost dying of a dously popular drug. Since it shares with cocaine overdose, she went back to crystal. methamphetamines some of the same After she completed her transition from pharmacological attributes, cocaine puts male to female, Roxy began sex work in people at risk for HIV disease in similar San Francisco’s Tenderloin District. She ways: through needle sharing, sharing of regularly engaged in unsafe sex. She even- other drug paraphernalia, or sexual disinhi- tually began stealing money to support bition. It may be helpful to consider the her habit and going on crystal binges cases of two seropositive individuals who that sometimes lasted as long as 18 days. use stimulants. Both individuals were iden- Ultimately she decided that she had to tified through the Seattle Methamphetamine stop prostituting and using crystal, so she Study at the University of Washington. moved to Seattle with one of her “johns.” She remained clean from crystal for two Robert: Burning Out years. During a trip to San Francisco to Gorman EM, Barr BD, Robert is a 28-year-old, gay White man visit friends, the reality of her HIV status Hansen A, et al. who is staying with a friend while looking hit her, and she began shooting crystal Speed, sex, gay men for a job and a new apartment. He is and HIV: Ecological again. Roxy states, “HIV will really depress and community unsure of his HIV status; he tested negative the shit out of you. Especially when you perspectives. Medical three years ago, but occasionally engages know somebody that’s really sick.” Anthropology in unsafe sex. Robert “water-injects” crystal Roxy still uses crystal—alone while Quarterly. 1997; methamphetamine (shooting a crystal 11(4): 505-515. masturbating to pornographic videos. She solution into the anus). He says he has is well-connected to medical and social Jacobs M, Fehr KO, never shot crystal intravenously. Robert services in Seattle and regularly volun- Cox T, et al. Drugs says he initially used crystal to increase teers time at local AIDS organizations. and Drug Abuse: sexual pleasure and energy for dancing. A Reference Text. Today, he say he uses it as an escape from Conclusion Addiction Research Foundation, Toronto, homelessness and unemployment. Robert and Roxy represent two points 1987. Raised a Mormon in Utah, he moved to on the spectrum of people who use stimu- Seattle at age 21 to take a job for which he’d lants. Each began using speed for one National Institute been recruited. He also began a law office reason and saw these reasons change over on Drug Abuse. internship and continued his undergradu- Epidemiologic Trends time; nonetheless, the fact of addiction in Drug Abuse, 1992- ate studies. He held a 3.9 grade point aver- remained prominent. The epidemiological 1997. Community age and maintained a focus on his career data discussed in this article offer a per- Epidemiology Work goals. Robert says he first experienced spective on the surprising number of Group, Public Health crystal while in San Francisco when he was different stimulant epidemics; stories like Service, National Institutes of Health, 23. “It wasn’t all that pleasant,” he says. “It those of Robert and Roxy suggest the Rockville, Md, 1998. was way too intense, lasted way too long.” texture of each of these epidemics. 3 FOCUS March 1998 may emerge frankly paranoid delusions and Stimulant Abuse Treatment and HIV visual and auditory hallucinations that Michael D. Siever, PhD closely resemble paranoid schizophrenia. With continued use, amphetamine users The use of mind-altering substances is often develop a pattern of confused and commonplace in our society. We use alco- disorganized behavior, including compul- hol and other drugs for many reasons: to sive repetition of meaningless acts some- ease tension, to relax, to deal with unpleas- times referred to as “tweaking.” Other ant emotions, to escape the difficult reali- negative effects include profound physical ties of life, to seek thrills. Unfortunately, and emotional depression as the drug is for many people, the recreational use of metabolized and the positive effects wear alcohol and other drugs becomes problem- off. Although not a direct effect of the drug, atic and, for some, leads to addiction. In amphetamine users often suffer the conse- the last two decades, the potential negative quences of going for days without eating, 1 consequences of substance use have drinking, or sleeping. increased significantly due to HIV disease. There is mounting evidence that meth- This article discusses HIV and stimulants, amphetamine in high doses or with pro- specifically cocaine and amphetamine, longed use can produce long-term 2 the context of stimulant use, and clinical changes in brain chemistry. This may approaches that can help clients. explain the persistence for months, even years after drug cessation of drug craving, Effects of Drug Use paranoia, and sometimes even psychotic Both cocaine and amphetamine can ele- behavior, including hallucinations. In vate mood, induce euphoria, increase alert- addition, many speed users, upon relapse, ness, reduce fatigue, increase energy, resume the often elaborate paranoid delu- decrease appetite, increase motor and sions at what seems to be exact point speech activity, and provide a sense of where they left off the last time they used. increased personal power and prowess. The most important difference between These positive effects often lead, either crack and speed is the cost and duration of Authors slowly or swiftly, to addiction. Both can the high: speed is less expensive and pro- duces a much longer lasting high with a Michael Gorman, PhD, be ingested in a variety of ways including MSW is a research snorting, smoking, and injecting. Cocaine half-life that is 12 to 13 times that of scientist and clinical today is most commonly taken in the form cocaine.2 Although crack is relatively social worker with of “crack” which is smoked. Methampheta- cheap, around $10 per “rock,” and the the Alcohol and effect is intense, the brief high necessitates Drug Abuse Institute mine, known as “crystal,” “crank,” “meth,” of the University or “speed,” is most often snorted, but frequent purchases. Methamphetamine, of Washington in increasingly is either smoked or injected.1 on the other hand, is relatively cheap with Seattle. His current Side effects for both cocaine and amphet- a high that lasts for four to six hours at focus is methamphet- a minimum; costing about $30, a quarter- amine dependency, amine include increased blood pressure particularly among and heart rate, sweating, anxiety, irritabili- gram of crystal may keep the low frequen- sexual minority ty, insomnia, and paranoia. At high doses cy user high for several days. populations. or with prolonged use, the irritability and Differences in the cultural context anxiety can become heightened and there of crack and speed use are particularly

crack users: Diffusion of innovations Clearinghouse: Stimulants and HIV and HIV risk behaviors. Substance Use and Misuse. 1997; 32(5): 635-651. Elwood WN, Williams ML, Bell DC, et al. References Ellison BJ, Downey AB, Duesberg P. HIV Powerlessness and HIV prevention Bowen AM, Trotter RT II. HIV risk in as a surrogate marker for drug use: A among people who trade sex for drugs re-analysis of the San Francisco men’s intravenous drug users and crack (‘strawberries’). AIDS Care. 1997; 9(3): health study. Genetica. 1995; 95(1-3): cocaine smokers: Predicting stages 273-284. 165-171. of change for condom use. Journal Falck RS, Wang J, Carlson RG, et al. of Consulting and Clinical Psychology. Elwood WN. Lipstick, needle, and Factors influencing condom use among 1995; 63(2): 238-248. company: A case study of the structure heterosexual users of injection drugs of a bridge group in Houston, Texas. Connors MM. The politics of marginal- and crack cocaine. Sexually Transmitted Connections. 1995; 18(1): 46-57. Diseases. 1997; 24(4): 204-210. ization: The appropriation of AIDS prevention messages among injection Elwood WN, Ataabadi AN. Influence Frosch D, Shoptaw S, Huber A, et al. drug users. Culture, Medicine, and of interpersonal and mass-mediated Sexual HIV risk among gay and bisexu- Psychiatry. 1995; 19(4): 425-452. interventions on injection drug and al male methamphetamine abusers.

4 FOCUS March 1998 important in dealing with HIV risk. While aspects of drug use is crucial in develop- crack, usually smoked, poses little risk ing an effective relationship with clients. of HIV transmission, metham- A good illustration of a culturally com- phetamine is often injected. petent approach is the treatment of meth- With crack, HIV risk is most amphetamine abuse in gay and bisexual Many crystal often associated with unsafe men. Since pharmacological treatments for sex in the context of a “sex-for- methamphetamine dependency have not addicts are self- drugs” exchange.3 Metham- yet been developed, care must focus on phetamine also has a psychosocial and behavioral treatment.2 medicating an component of sexual risk, The context of drug use in this population particularly among gay and is influenced by the centrality of sexuality undiagnosed bisexual men for whom sex to a gay or bisexual identity, the emotional is often an integral part of the impact of AIDS on the gay and bisexual attention deficit drug experience.4 Crystal can communities, and the marginalization act as an aphrodisiac, leading of gay and bisexual men. hyperactivity to disinhibition and enabling For many gay and bisexual men, drug prolonged, intense sex, includ- use and sexuality are closely intertwined. disorder. ing sexual marathons with Many report never having had sex while numerous partners and not under the influence of some sub- risky activities. stance. Consequently, feeling “horny” becomes a trigger for drug use and is the The Context of Use most frequent reason for relapse. In addi- References Working successfully with drug users tion, in a community that celebrates casu- 1. Julien RM. A Primer requires taking into account the type and al sex, many gay and bisexual men have of Drug Action: A extent of drug use and its cultural context. unresolved issues around sexual versus Concise, Nontechnical Guide to the Actions, And while substance abuse treatment may emotional intimacy. Finally, in a communi- Uses, and Side Effects be a necessary adjunct to HIV prevention ty in which beauty is highly prized and of Psychoactive Drugs. and care, it is important to realize that not sexual objectification common, many use 6th ed. New York: W. all drug use constitutes abuse or addic- speed as a method of weight control. H. Freeman, 1992. tion, but may nonetheless affect HIV risk. Within gay and bisexual communities, 2. Substance Abuse To provide culturally competent ser- substance use occurs in the context of and Mental Health vices to drug users, a client-centered massive loss and grief. Regardless of a Services Administra- approach is essential. The clinician must tion, Center for person’s serostatus, the illness and death Substance Abuse seek to understand each client as an indi- of so many loved ones has complicated Treatment. Proceed- vidual, including the social context in bereavement and produced widespread ings of the National which the client uses, his or her pattern depression. In addition to its reputation Consensus Meeting of drug use and reasons for using, and the on the Use, Abuse, as the most effective antidepressant avail- and Sequelae of relationship between sex and drugs. When able on the street, methamphetamine is Abuse with Metham- dealing with such highly stigmatized known to combat the physical effects of phetamine with behaviors, it is especially important that HIV disease such as fatigue. Implications for health care workers create a safe, non- Prevention, Research, One of the most frequent reasons given and Treatment. (DHHS judgmental environment. Acknowledging for substance abuse among gay and bisexu- Publication No. SMA the positive as well as the negative al men is the desire to numb oneself, to not

Journal of Substance Abuse Treatment. use of condoms among midwestern Contacts 1996; 13(6): 483-486. users of injection drugs and crack Michael Gorman, PhD, MSW, University cocaine. Sexually Transmitted Diseases. of Washington, 3937 Fifteenth Avenue, Iguchi MY, Bux DA Jr. Reduced proba- 1996; 23(4): 277-282. bility of HIV infection among crack NE, NL-15, Seattle, WA 98105, 206-543- cocaine-using injection drug users. Word CO, Bowser B. Background to 8962. American Journal of Public Health. crack cocaine addiction and HIV high- Michael Siever, PhD, Stonewall Project, 1997; 87(6): 1008-1012. risk behavior: The next epidemic. 3180 18th Street, Suite 205, UC Box American Journal of Drug and Alcohol 1336, San Francisco, CA 94110, 415- Koester S, Booth RE, Zhang Y. The preva- Abuse. 1997; 23(1): 67-77. lence of additional injection-related HIV 255-7803. risk behaviors among injection drug Zanis DA, Cohen E, Meyers K, et al. HIV users, Journal of Acquired Immune risks among homeless men differentiated Deficiency Syndromes and Human by cocaine use and psychiatric distress. Retrovirology. 1996; 12(2): 202-207. Addictive Behaviors. 1997; 22(2): 287-92. Siegal HA, Falck RS, Wang J, et al. Methamphetamine abuse increases. History of sexually transmitted disease DAWN Briefings. Drug Abuse Warning infection, drug-use behaviors, and the Network. December 1996: 1-2. See also references cited in articles in this issue.

5 FOCUS March 1998 feel, to not think. This desire for escape sex techniques while high are among the combined with the current “safe sex initial goals to which clients might agree. fatigue” felt by some gay and bisexual men, Motivational interviewing is especially 96-8013.) Washington, enables them to engage in unsafe sexual useful in ascertaining a client’s desire for D.C.: U.S. Government activity without acknowledging the conse- change and for reinforcing whatever desire Printing Office, 1997. quences. Additionally, in the gay communi- for change exists.5 For the client who wants ty, recreational substance use is considered to quit, cognitive-behavioral techniques 3. Carlson RG, Siegal HA. The crack life: normative, not deviant. Ironically, despite such as relapse prevention may be An ethnographic this, gay and bisexual injection drug users helpful.6 Using relapse prevention, coun- overview of crack use may still experience significant stigmatiza- selors and clients identify the environmen- and sexual behavior tion from within their community. tal and psychological cues that trigger the among African- Americans in a mid- As is true in other stigmatized communi- desire to use and develop effective coping west metropolitan ties, many gay and bisexual men, having skills to minimize these triggers. In addi- city. Journal of experienced insensitivity, homophobia, and tion, in order to avoid relapse, providers Psychoactive Drugs. even outright discrimination from health and clients may need to manage difficult 1991; 23(1): 11-20. care providers, may therefore distrust the emotional issues that the client had suc- 4. Reback CJ. The health care system. Many also resist Twelve cessfully avoided through drug use. For Social Construction of Step groups in which the focus is on com- some, a substance abuse treatment pro- a Gay Drug: Metham- monality and on minimizing difference, a gram is appropriate; for others, peer sup- phetamine Use among Gay and Bisexual perspective that may counter a gay or bisex- port such as Crystal Meth Anonymous, a Males in Los Angeles. ual man’s experience of feeling “different” rapidly growing, West Coast, Twelve Step Los Angeles: City of because of his sexual orientation. Similarly, group may be sufficient. It is also impor- Los Angeles, 1997. many gay and bisexual men may have diffi- tant to remember that many people deal effectively with their substance abuse 5. Miller WR, Rollnick culty with the Twelve Step emphasis on SR. Motivational Inter- spirituality, given the condemnation most problems without any professional help. viewing: Preparing religions express toward homosexuality. People to Change All of these issues are magnified for gay Conclusion Addictive Behavior. and bisexual men of color. Many of these Overcoming methamphetamine abuse New York: Guilford Press, 1991. clients have experienced not only societal and addiction is an arduous and lengthy stigmatization, but also homophobia from process. Patience is required both of the 6. Marlatt GA, their ethnic communities and racism from counselor and the client. Relapse is often Gordon JR. Relapse the gay and bisexual communities. part of the recovery process and should Prevention: Maintenance not be viewed by the counselor or client Strategies in Treatment Considerations as failure. This is especially true in terms the Treatment of In addition to cultural context, it is of methamphetamine addiction because Addictive Behaviors. important to understand the individual drug craving and negative side effects New York: Guilford Press, 1985. histories of stimulant abusing gay and may persist long after drug use cessation. bisexual men whose past may include The very nature of addiction is that the Authors sexual abuse and exploitation, physical immediate payoff of using seems to out- Michael D. Siever, and emotional abuse, and other factors weigh the long-term benefits of abstain- PhD, is Director that may contribute to pre-existing mental ing. The clinician’s most important role of the Stonewall health issues and predispose them to may be in helping the client at each step Project—a harm substance use and other high-risk behav- to cope with the length of this process, reduction program for gay and bisexual iors. One common clinical observation is continually assisting him or her in remem- men dealing with that many who are addicted to metham- bering the long-term benefits of recovery. methamphetamine phetamine are self-medicating an undiag- use—of the UCSF nosed attention deficit hyperactivity Division of Substance Abuse and Addiction disorder, while others were diagnosed and Medicine at San prescribed Ritalin as children and became Comments and Submissions Francisco General addicted to this amphetamine analog. We invite readers to send letters Hospital. He is also When working with gay and bisexual Community Co-Chair responding to articles published in of the Treatment on methamphetamine users, as with any other FOCUS or dealing with current AIDS Demand Substance substance users, it is essential to gauge the research and counseling issues. We Abuse Planning client’s motivation for change. Many clients also encourage readers to submit arti- Council for the City may have no desire to cease their speed and County of San cle proposals, including a summary of Francisco, a staff use or are ambivalent at best about making the idea and a detailed outline of the member of an NIMH- any changes. For these clients, harm reduc- article. Send correspondence to: funded research tion approaches, especially in terms of HIV project on HIV pre- risk, may be more useful than trying to Editor, FOCUS vention at UCSF AIDS impose abstinence. Reducing frequency UCSF AIDS Health Project, Box 0884 Health Project, and a licensed psychologist and amount of use, switching from inject- San Francisco, CA 94143-0884 in private practice. ing to snorting or smoking, or using safer 6 FOCUS March 1998 HIV-infected as nonusing gay men. Recent Reports According to the researchers, there are several explanations for this association, Speed and Risky Sex among Non-Injectors which was independent of the use of other drugs. First, users were more than twice Molitor F, Truax SR, Ruiz JD, et al. Association of methamphetamine use during sex with risky sexual as likely as nonusers to have exchanged behaviors and HIV infection among non-injection money or drugs for sex. Second, people drug users. Western Journal of Medicine. 1998; who use methamphetamines may be risk 168(2): 93-97. (California Department of Health takers by nature. Third, because metham- Services, Office of AIDS.) phetamines reduce social inhibitions and A study of clients tested at about 850 heighten sexual pleasure, users may be state-funded antibody test sites in more likely to seek sexual gratification California found that snorting and smoking from numerous partners. Fourth, metham- methamphetamines is associated with phetamines can cloud a user’s judgment risky sexual behaviors and HIV infection. about unsafe sexual practices. Researchers gathered data from 370,000 The researchers advise health educators clients tested between July 1, 1994 and to address the perceived positive aspects of December 31, 1995. They excluded data methamphetamine use, for example, elevat- from injection drug users, people who ed sexual experience and performance, reported no sexual relations, and women when formulating HIV-prevention messages. who only had sex with women, and divid- ed the remaining Methamphetamine Use and Gay Identity 250,000 clients into Reback CJ. The Social Construction of a Gay Drug: four categories—gay Methamphetamine Use among Gay and Bisexual men, bisexual men, Males in Los Angeles. Los Angeles: City of Los There was a strong Angeles, 1997. heterosexual men, and relationship between heterosexual women— Methamphetamine use in the gay com- and each category into munity has increased so dramatically in gay identity and methamphetamine recent years that for many men, it has users and nonusers. become an integral part of their gay identi- drug use: speed About 4 percent of ty—a surprising result suggested by an facilitated social and the 250,000 subjects ethnographic survey of gay and bisexual reported using metham- men in Los Angeles. Interventions for sexual interactions, phetamines during sex. substance use must therefore address Methamphetamine use gay identity and the meaning of gay sex. interrupted negative during sex was related Researchers interviewed 63 methamphet- to risky behavior amine users who used the drug at least once internal messages regardless of sex, age, a month during the previous six months and race or ethnicity, or at least once in the previous 30 days. Parti- about being gay, or sexual orientation, and cipants self-identified as gay or bisexual was independent of men, heterosexual men who have sex with became positively other drug use (alcohol, men, or male-to-female transgendered indi- associated with sex cocaine, and marijuana). viduals. Research methods included obser- Those reporting meth- vational fieldwork, unstructured interviews, and sexual identity. amphetamine use had and focus group discussions in five popula- significantly more sexual tions: former methamphetamine users, partners than nonusers youth, men of color, predominantly street- —and were more likely using HIV-positive men, and predominantly than non-users to have engaged in anal middle-class and upper-middle-class intercourse. Regardless of type of inter- seropositive professionals. course—vaginal, anal-receptive, or anal- Of the sample, 49 percent were White, insertive—methamphetamine users were 22 percent were Hispanic, 19 percent were less likely than nonusers to use condoms African American, 7 percent were Native and were more likely than nonusers to have American and 3 percent were Asian/Paci- acquired a sexually transmitted disease. fic Islander. Participants’ ages ranged from Users were more than twice as likely to 17 to 51 years. Nearly all had been tested have had sex with a sex worker or to have for HIV and were aware of their HIV exchanged money or drugs for sex; they status; 42 percent were seropositive. were more than four times as likely to Participants identified themselves in have had sex with an injection drug user. terms of three primary characteristics, all Gay men who reported methampheta- of which are associated with social stigma: mine use were almost twice as likely to be sexuality, methamphetamine use, and HIV 7 FOCUS March 1998 status. Many participants used methamphet- said that when they tried methampheta- amines as a positive coping mechanism for mines, they became hooked. Subgroups dealing with physical or emotional pain, of methamphetamine users included: men negative internal messages arising from involved in “circuit parties,” men whose their sexual orientation, or fears of trans- activities focused on gay baths and sex F mitting HIV. Most distanced themselves clubs, transgendered or transsexual peo- A Guide toOCUAIDS Research and CounselingS from the self-concept of drug user by con- ple, young adults connected with street Executive Editor; Director, sidering themselves “functional” and there- scenes, HIV-infected men who used meth- AIDS Health Project fore exceptional among users: 64 percent amphetamines to self-medicate, middle James W. Dilley, MD viewed their crystal use as controlled but class “weekend users,” and men who lived Editor often described the crystal use of friends as in the suburbs but socialized in the city. Robert Marks unmanageable. Crystal use also freed many Mental health providers reported that Staff Writers subjects from guilt associated with their HIV some people with HIV disease used meth- Susan LaCroix John Tighe status and unsafe sex. amphetamines to help manage symptoms Subjects indicated a strong relationship of depression. Research subjects them- Founding Editor; Advisor Michael Helquist between gay identity and drug use; meth- selves reported they used the drugs for amphetamines facilitated social interac- their aphrodisiac qualities and some Medical Advisor Stephen Follansbee, MD tions and sexual encounters, interrupted transgendered individuals used them negative internal messages about being to assist in the transition to their Design Saul Rosenfield gay, or in some way had become positive- feminine personae. ly associated with sex and sexual identity. Other studies have found that the Production In terms of social interactions, crystal disinhibiting effect of speed can lead Andrew Tavoni Shauna O’Donnell use was described as an “equalizer,” to increased number of sexual partners, enabling clients to cross social bound- unsafe sexual behaviors, condom break- Circulation Shauna O’Donnell aries. It also formed separate social group- age, and needle sharing. One study found ings around injectors, who were afforded that methamphetamine-using men who Interns Gloria Chung less social status by non-injectors, and have sex with men engage in unprotected Jesse Ritvo “club kids,” youth for whom crystal use is anal intercourse 2.9 times more often than associated with dancing rather than with nonusers; another found that the strongest FOCUS is a monthly pub- sex. Youth who lived with a parent or relative hazard for HIV seroconversion lication of the AIDS Health Project, affiliated guardian primarily used crystal for danc- was consistent methamphetamine use. with the University of ing; those who did not tended to support California San Francisco. themselves through sex work and used Twelve issues of FOCUS crystal primarily for sex. are $36 for U.S. residents, $24 for those with limited Next Month incomes, $48 for individu- An Ethnographic View of Speed and Sex als in other countries, $90 Gorman EM, Barr B, Hansen A, et al. Speed, sex, HIV disease has always had a for U.S. institutions, and gay men, and HIV: Ecological and community tremendous effect on interpersonal $110 for institutions in other countries. Make perspectives. Medical Anthropology Quarterly. relationships, in particular, intimate checks payable to “UC 1997; 11(4): 505-515. (University of Washington.) ones and most dramatically in commit- Regents.” Address sub- ted relationships. In couples—both scription requests and cor- The recent rise in methamphetamine respondence to: FOCUS, use presents one of the most serious mixed serostatus ones and couples UCSF AIDS Health hazards for HIV seroconversion among where both partners have HIV—the Project, Box 0884, San unexpected recovery of one partner is Francisco, CA 94143- men who have sex with men, according 0884. Back issues are $3 to preliminary data from a Seattle ethno- bound to have an effect on the couple’s each: for a list, write to the graphic study. dynamic. In the April issue of FOCUS, above address or call Robert H. Remien, PhD, a Research (415) 476-6430. Researchers recruited 30 subjects using Scientist/Clinical Psychologist at To ensure uninterrupted referrals from participating agencies and delivery, send your new individuals. Approximately 80 percent Columbia University, details the effects address four weeks before were White, and a majority identified of successful antiviral treatment on you move. themselves as gay or bisexual. All partici- a couple, discussing issues such as Printed on recycled paper. pants were either still using methamphet- changes in roles, expectations, and sex- ©1998 UC Regents: All amines or had recently stopped, and ual activity. rights reserved. nearly half reported injection as their Also in the March issue, Norman M. ISSN 1047-0719 primary method of use. The study relied Sohn, PhD, LCSW, a psychotherapist on ethnographic research methods such and a member of the clinical faculty of as unobtrusive community observations, the University of California San focus group interviews with both service Francisco Department of Psychiatry, providers and community leaders, and a reviews the theoretical underpinnings variety of types of individual interview. of couples counseling, applying a con- A majority of those interviewed had trol-mastery approach. extensive histories of polydrug use; all

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