Gay, bisexual, and other men who have sex with men (GBMSM) constitute a key population that continues to be disproportionately affected by Human Immunodeficiency Virus (HIV) on a global scale (1). Within communities of GBMSM, young gay, bisexual, and other men who have sex with men (YMSM) experience a greater burden of HIV risk compared to their older counterparts, which may be attributed to a higher incidence of risky sexual behaviors, sexualized substance use, and barriers to health-seeking behaviors (2, 3).
The use of amphetamine-type stimulants (ATS), in particular methamphetamine, has become increasingly prevalent among GBMSM (4). Methamphetamine is a derivative of amphetamine that is often used by GBMSM in sexualized contexts, known colloquially as ‘chemsex’ (5). Other drugs typically associated with chemsex include gamma-hydroxybutyrate/gamma-butyrolactone (GHB/GBL), mephedrone, ecstasy, ketamine, as well as drugs typically prescribed for erectile dysfunction (ED) such as Viagra or Cialis (6) (Citation omitted for double-blinded peer review). Chemsex has been identified in numerous studies as a significant risk factor for HIV among GBMSM due to the interplay between drug use and behaviors that place such individuals at a higher risk of acquiring HIV, including unprotected anal sexual intercourse with an increased number of sex partners, prolonged sexual encounters, and the sharing of sex toys (7, 8).
Globally, the trend of amphetamine-type stimulant use remains high among GBMSM. A 2012 study among GBMSM in 12 countries across Asia reported ATS to be the most widely used types of drugs among the 10,861 participants sampled, with 8.1% reporting to have recently used ecstasy and 4% having used methamphetamine (9). This trend of ATS use is also reflected in non-Asian settings (4, 10, 11). YMSM are also especially vulnerable to substance use disorders and the risks associated with them. A 2014 study conducted among 595 YMSM aged 12 to 24 years old in across eight cities in the United States found that 10.8% of participants surveyed has reported using methamphetamine in the past 90 days (12); other studies have similarly reported greater instances of substance abuse among YMSM relative to older cohorts of GBMSM (13–15).
The use of amyl nitrites, otherwise known as ‘poppers’, in sexual contexts is has been reported to be common as well for GBMSM across various settings largely as a means of sexual enhancement (16–18). Popper use has been found to be associated with HIV seroconversion as well as sexual risk behaviors such as having multiple sex partners and having unprotected anal intercourse (19–21). Demographic and psychosocial correlates for popper use among GBMSM include being older, being HIV-positive, and reporting visiting sex-on-premises venues, licensed lesbian, gay, bisexual, and transgender (LGBT) venues, and using other substances (18, 22).
Apart from the use of typically illicit substances, heavy alcohol use has also been established to be common among GBMSM, especially in developed country settings (23–25). Past studies have also found that individuals who identify with any sexual minority status, including GBMSM, had initiated alcohol use at a younger age, compared to their heterosexual counterparts (26, 27). An early onset of alcohol initiation among GBMSM has been found to be associated with a greater number of lifetime sexual partners, elevated levels of depressive symptoms, and alcohol abuse later in life (28). Heavy alcohol use among GBMSM, and in particular the use of alcohol during or after sex, has also been found to be associated with behaviors associated with HIV acquisition risk, such as unprotected anal intercourse (29–31); however, these findings have been inconsistent due to methodological differences in measuring alcohol use and the lack of experimental study designs (32).
Risk factors for substance use
Risk factors for substance use in general, including the use of ATS among GBMSM, have been well-established in the extant literature. Depression severity is a risk factor that increases individuals’ likelihood of using ATS, with participants reporting that the use of substances help to alleviate the negative effects of such mood disorders (33). Additionally, MSM who experience consistent episodes of neglect or trauma at a young age also report increased susceptibility of eventual methamphetamine use (34). Other studies have qualitatively evaluated that methamphetamine use is perceived to be instrumental in alleviating personal dread of growing old and sickly, or fears of becoming less attractive and unwanted (35). A recent study in Singapore found that GBMSM engaged in chemsex as a means of coping with societal rejection (Citation omitted for double-blinded peer review). Methamphetamine use, especially in the context of chemsex, has also been established as an important means of providing a safe haven from sexual discrimination and isolation among GBMSM living with HIV (36).
Reasons for heavy alcohol use reported by GBMSM in general may include life histories of traumatic experiences such as sexual orientation-based discrimination and childhood sexual abuse (37, 38), while YMSM specifically reported social drinking motivations as a main reason for engaging in heavy alcohol use (39). As for the use of alcohol during sex among GBMSM, reasons included more situational or contextual factors such as the facilitation of cognitive ‘escape’ for the awareness of HIV risk, or the enhancement of sexual pleasure (40, 41).
Situating social capital as risk factors for sexualized substance use
Adequate social support has been credited in various studies as one of the main reasons for the reduction in risky sexual behaviors among GBMSM (42). Specifically, community connectedness plays an instrumental function in the provision of intangible support, especially for GBMSM who may experience difficulties in tapping on their kinship or peer network for social support, or who have repressed their sexuality out of fear of being discriminated (43, 44). However, other studies have reported a positive association between drug use and GBMSM community engagement as well (Wei et al., 2012); findings from studies pertaining to the relationship between of community connectedness and personal forms of social capital on drug use among GBMSM thus remain mixed. These mixed findings may be attributed to the varying ways in which community affiliation or social capital have been measured or conceptualized in various studies, which may span across measures that reflect access to social networks, psychological feelings of affiliation, or even explicit forms of affiliation that presuppose participation in interest groups or activities.
With regard to alcohol use, GBMSM who report a stronger affiliation with gay male culture and who have met sexual partners through entertainment establishments where alcohol use takes place are more likely to have engaged in heavy alcohol use (23, 25). Among YMSM, gay bar attendance, depression, sensation seeking, peer risk behaviors, multiple sexual partners, and a younger age of alcohol initiation were found to be associated with heavier alcohol use patterns (45, 46).
There has been a lack of consensus around the conceptualization, operationalization, and thus measurement of social capital. This has resulted in a large variety of ways, sometimes conflicting, in which measures that constitute social capital have been linked to substance use-related behaviors among GBMSM. Past studies that measure varying forms of social capital and its relationship with substance use among GBMSM have tended to measure only one form or dimension of social capital, or conflate different nuanced aspects of social capital with one another, which have led to conflicting findings in some cases.
Measures of the social cohesion school of social capital, conceptualized as the resources available to members or citizens of a social group or society and as a property that exists at the group level, are relevant to individual health outcomes as an individual may benefit from being embedded or immersed in a given context. These group level attributes may include group-aggregated, contextual measures such as perceptions of trustworthiness and collective socialization (i.e. adults in community and not just parents shape child development) (47). On the other hand, measures of the network theory approach, conceptualized as the resources that are embedded within an individual’s social networks, include both egocentric (i.e. individual-centred) and sociometric (i.e. group-centred) properties. At the egocentric level, these may include measures that reflect the functional nature of ties with others in the community, such as measures of social support and those that reflect the availability of necessary resources, or measures that reflect the structural nature of ties, such as the size of one’s own network or the density of relationships and ties within those networks (48).
In the context of risk factors for substance use among GBMSM, measures of community connectedness, or a psychological feeling of being connected to the wider community, may align more with the social cohesion approach to social capital. On the other hand, measures that reflect an individual’s access to social support from others may reflect the functional nature of ties within a network, whereas one’s access to substances via other substance users may reflect more structural aspects of one’s own network. In this study, we selected several potential measures of social capital that we thought were potentially epidemiologically relevant as risk factors for substance use among YMSM in Singapore, including age of sexual debut (as a proxy for one’s initiation into sexual networks, and thus access to sexualized substance use), bonding social capital, bridging social capital, connectedness to the LGBT community, as well as the extent of sexual orientation disclosure or ‘outness’ to family, to the world, and to religion, as a proxy for being able to access social support, given major barriers such as prevailing stigma and the criminalization of sexual relations between men in the present setting.
Substance use among GBMSM in Singapore
As of 2018, a total of 8,275 incident HIV infections have been notified with the ministry of health in Singapore (MOH). The spread of HIV in Singapore is characterized by its concentration among GBMSM, as well as older, heterosexual men (49). Despite being an established risk factor for HIV and other STI acquisition, few studies have attempted to study patterns of drug use among GBMSM in Singapore, notwithstanding the Asia Internet MSM Sex Survey (AIMSS) that was conducted from 2009 to 2010 among 4,072 GBMSM from Singapore, which found that 12.8% of participants had reported consuming drugs prior to, or during sex in the preceding six months (50). A more recent qualitative study among GBMSM in Singapore found that chemsex was perceived to be common in Singapore, and openly solicited through geosocial networking apps (Citation omitted for double-blinded peer review).
Social capital among GBMSM in Singapore should be interpreted in light of the sociocultural milieu in which they are embedded. Singapore society has largely held negative perceptions of, and attitudes towards lesbian, gay, bisexual, and transgender (LGBT) individuals (51–53), as well as drug users (54). Criminal legislation towards sexual minorities and drug users have corresponded, and arguably, contributed, to these negative attitudes. Section 377A of the Singapore Penal Code criminalizes consensual sexual behaviour between men, with penalties for imprisonment for a term that may extend up to no longer than two years. Drug use and trafficking of drugs are also punished by severe penalties under the Singapore Penal Code. The Misuse of Drugs Act criminalizes the possession and use of drugs with penalties that range from fines of up to S$20,000 to a maximum of ten years in prison, and trafficking of drugs beyond stipulated thresholds with a mandatory death penalty or life imprisonment.
The aims of this study are two-fold. Firstly, given the risks associated with substance use, coupled with preliminary data on the rise in the incidence and prevalence of chemsex among GBMSM in Singapore, we embarked on this study to address the dearth of information on the risk factors associated with chemsex among YMSM in Singapore. Secondly, mixed findings around the relationship between measures of social capital and substance use in general may be attributed to the varying ways in which community affiliation or social capital have been measured or conceptualized in various studies, which may span across measures that reflect access to social networks, psychological feelings of affiliation, or even explicit forms of affiliation that presuppose participation in interest groups or activities. To fill this gap, this study simultaneously explores varying measures of social capital, such as age of sexual debut, bonding social capital, bridging social capital, community connectedness, as well as the extent of sexual orientation disclosure or ‘outness’ to varying social groups, on its association with varying patterns of substance use. Doing so will allow us to draw more nuanced, exploratory claims around the role of social capital and its potential relationship with varying patterns of substance use among YMSM