Substance Use Among Gay Men Living in Mexico: Perceptions of Well-Being and Implications for Health

Substance use among gay men is an ongoing issue that has relevance for public health, education, and prevention strategies due to the many risks faced by this minority population. Such risks may include sexually transmitted infections (STIs) such as HIV or be a result of oppression; trauma; and violence due to the sociopolitical climate and other forms of societal, institutional, or community-based discrimination (Schroeder et al., 2022). Recent international literature focuses on the harmful effects of substance use related to several sexual risk factors (e.g., HIV, STIs, unprotected anal sex) and adverse outcomes associated with psycho-emotional health due to sexualized drug use, including depression, anxiety, substance use dependence, and suicide ideation (Hibbert et al., 2021; Íncera-Fernández et al., 2021).

Several surveys conducted in 2015 assessed substance use among gay men in Mexico in terms of prevalence, frequency, and types of substances. Results demonstrated that between 74 and 88% of gay male participants actively consumed alcohol, and just under 46% used tobacco (Baruch et al., 2015; Mendoza-Pérez et al., 2015). In contrast, nearly half of gay men in both studies had consumed a substance (apart from alcohol or tobacco) at some time in their lives, with most frequently used substances including (in descending order) marijuana, inhaled nitrites (poppers), cocaine, and methylenedioxymethamphetamine (MDMA, ecstasy) (Baruch et al., 2015; Mendoza-Pérez et al., 2015).

Another study conducted during 2017–2018 among 1850 men who have sex with men (MSM) attending HIV/STI clinics in Mexico City reported that alcohol (76.2%) and tobacco (29.2%) were the most consumed substances in the past month with notable use of marijuana (29.4%), sexual drugs (24.2%), stimulants (13.7%), and depressants (6.3%) (Rodríguez-Bolaños et al., 2022). This is consistent with what was reported about other substance use during the COVID-19 global health pandemic, in which marijuana, poppers, and crystal meth were the three substances most consumed by gay men in Mexico, followed by cocaine, tranquilizers, and MDMA also known as “molly” (Mendoza-Pérez, 2021).

Similar to other studies in this area, most Mexican researchers frame substance use among gay men within a risk paradigm, which includes HIV transmission and condomless anal sex, but also based on certain sociodemographic factors or sociosexual practices while using substances (e.g., serosorting, which is selecting partners with the same HIV status for condomless anal sex) that may have implications for sexual health (Algarin et al., 2023; Caballero-Hoyos et al., 2022; Mendoza-Pérez et al., 2022; Rodríguez-Bolaños et al., 2022). For example, in binational studies of Mexican/US border cities such as Ciudad Juárez and San Diego-Tijuana, MSM who inject drugs (Deiss et al., 2008), use crystal meth (Loza et al., 2020), or use poppers (Pepper et al., 2020) were found to engage in various risk behaviors (e.g., needle sharing, transactional sex for money or drugs, unprotected anal sex) in addition to being at increased risk of STI transmission (e.g., HIV, syphilis, gonorrhea).

The World Health Organization (WHO) maintains that health, “…is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity…”(World Health Organization, 2020, p. 1). As Halbreich (2022) explains, this optimal state of well-being includes physical and emotional health, daily functioning, and interactions with institutions and the broader community, providing an integrative perspective for biopsychosocial health. This offers a view of how to navigate complex physical and sexual risk factors, but it does not delve into relevant key variables (e.g., age, race, sexual orientation) that may help to explain the impact of substance use upon well-being.

In that regard, the model of evaluating substance use environments utilized by gay men in Mexico proposed by Mendoza-Pérez et al. (2023) delves into the biopsychosocial implications of substance use by assessing personal experiences (i.e., motivations, types of substances, forms, and contexts of use) based on changes in consumption patterns and perceived impact upon well-being. The model is not presented as a linear sequence or mutually exclusive environments (i.e., as gay men have different starting points with substances or move through environments differently) but rather by assessing the uniquely lived experiences of these men at various moments in their lives.

This is relevant in that substance use among gay men does not depend solely upon external factors but also on how associated health-disease processes may be a product of genetics, social relationships, and/or cultural processes (Martínez Hernáez, 2007). As Apud and Romaní (2016) explain from the sociocultural model, substance use is interpreted as a field of intersubjective relations between objects, subjects, and cultural contexts where consumption acquires particular meaning for constructing identity and organizing daily life. In other words, this paradigm challenges the purely biological notion of addiction, seeking to understand the phenomenon from the perspective of users about the surrounding stigmatized, pathological, and illegal contexts, helping to establish better strategies for healthcare education and prevention methods (Alvarez Licona, 2010; Romaní, 2007), which is all closely linked to harm reduction.

A harm reduction approach is among the key prevention strategies to reduce harm (rather than stop substance use per se) as it considers what an individual finds harmful or beneficial rather than emphasizing risk behavior in moral terms of right or wrong (Marlatt, 1996; Ritter & Cameron, 2006). Research conducted at an LGBT harm reduction treatment center in Sydney, Australia, showed positive outcomes and improved psychosocial well-being for gay and bisexual crystal meth users. Participants reported lower use and dependence after free, short-term, individual outpatient counseling using a culturally sensitive LGBTQ peer-led model recognizing the historical-social context of substance use and inequalities faced in healthcare institutions (Lea et al., 2017).

Birch et al. (2022) examined a US sample of private sex party hosts as “gatekeepers” who promoted harm reduction strategies before the events for gay and bi men which included screening participants, disseminating rules about sexual behaviors and substance use, reinforcing rules, providing condoms and lube, specifying which substances were allowed, and turning away uninvited guests, suggesting that these men may be the focus of group-based sexuality education and intervention programs. Relatedly, Zucker et al. (2022) evaluated a four-hour course (“Party Keepers”) aimed at Israeli gay men who frequent LGBT parties to identify, prevent, and treat medical emergencies associated with excessive substance use. Researchers found a reduction in the use of alcohol, cocaine, and risky sexual practices by study participants and less likelihood of emergencies at such events, in addition to an increase in the use of pre-exposure prophylaxis (PrEP) by course attendees. Other intervention strategies for gay men who use substances, such as cognitive behavioral therapy (CBT), have been shown to reduce the likelihood of unprotected anal sex (Melendez-Torres & Bonell, 2014). However, this systematic literature review suggests that CBT is not more effective than other intervention approaches (Melendez-Torres & Bonell, 2014), like community-based harm reduction strategies that include in-person or online counseling led by peers or clinicians; distribution of safe sex packets, STI, and substance use information; and clinical screenings (Hugo et al., 2018; Stardust et al., 2018).

From this perspective, some studies analyze not only substance use risk among gay men but also the motivations and non-harmful effects, whether related to use among peers or living in hostile environments, and so on. Thus, substance use among gay men may also be seen as a survival mechanism for navigating stressful events (e.g., HIV diagnosis, discrimination, homophobia, death of a family member) and/or to improve social connections with other gay men to find acceptance, inclusion, emotional closeness, improved self-esteem, or increased sexual pleasure and satisfaction (Lafortune et al., 2021; Nimbi et al., 2021). As Romaní (2007) explains, the abstinence paradigm is not only insufficient but may also be detrimental to biopsychosocial well-being (e.g., increase in HIV transmission or other health and mental health problems arising from secretive substance use); therefore, as an impactful alternative, the harm reduction model can offer not only effective biomedical strategies yet social and cultural sensitivity toward diverse populations.

It may be helpful to examine perceptions of well-being among substance-using Mexican gay men, along with the benefits and adverse effects of substance use, as it will critically contribute to a greater understanding of behaviors beyond a framework of risk. Such an examination of gay men in Mexico may result in improving best practices in culturally affirming health and mental health care based on respect for human rights and autonomy. Therefore, the objective of this study is to examine substance use among gay men from three unique geographical areas in Mexico and the perceived benefits and adverse effects upon their well-being.

A mixed-method study utilizing an online survey and focus groups examined substance use among gay men living in Mexico to understand their lived experiences and perceptions of well-being (Denzin & Lincoln, 2012). From the perspective of social constructionism, this study sought to understand the meanings associated with substance use as a result of social interactions and communication between gay men living in Mexico, which may be impacted by several factors including peer and societal beliefs, personal values, and knowledge about substance use (Berger & Luckmann, 2003; Maines, 2000).

The results section is organized into three parts. In the first section, the types of substances and prevalence of use are described for lifetime use and use in the past month. In the second section, a list of perceived adverse effects and benefits of substance use is presented concerning the four substance use environments described above by Mendoza-Pérez et al. (2023). Finally, the third section examines the perceived adverse effects or benefits via qualitative participant responses. Please note that the analysis of perceived positive and negative impacts of substance use spans the physical, mental, and social domains of participant health and well-being.

In this study, the effects of substance use on the biopsychosocial well-being of gay men encompass two distinct perspectives that include perceived positive benefits and adverse effects. The first three substance use environments (initiation drug environment, recreational drug environment, sexual drug environment) were primarily associated with perceived benefits, particularly with substances such as marijuana, poppers, and recreational drugs. A few participants noted improvements in mental health and emotional well-being because of substance use. Additionally, substances were reported to increase sexual desire and more pleasurable receptive anal sex (e.g., bottoming). Furthermore, substance use was also perceived by participants as a way to enhance socialization in bars, clubs, and other social settings.

In contrast, excessive use of substances within sexual environments (e.g., ethyl chloride, poppers, and GHB/GBL) and for greater sexual pleasure (e.g., crystal meth) was associated with a range of adverse effects, including an impact upon physical (e.g., seizures, headaches, weight loss, insomnia, tachycardia, liver damage), mental health (e.g., hallucinations and psychotic episodes), and social domains (e.g., relationship difficulties, violence, and stigma).

Research examining the effect of substance use on gay men is often framed in terms of risks related to sexualized substance use. In this study, results showed that much of the harmful health effects were associated with the sexual drug environment and the greater sexual pleasure drug environment environments (especially the latter), with crystal meth use accounting for much of the adverse effects, which far outweigh the perceived benefits across physical, mental health, and social domains. Other studies on sexualized substance use have found some adverse effects on mental health and physical well-being, including injuries to the skin/veins due to intravenous use; cardiovascular complications; psychotic, depressive, and anxiety disorders; visual, kinesthetic, tactile, and auditory hallucinations; and suicide ideation and attempts (Batisse et al., 2022; Knoops et al., 2022; Moreno-Gámez et al., 2022). Likewise, while less discussed, the relationship between substance use and intimate partner violence among gay men has been reported (Duncan et al., 2018), as well as the adverse social effects of substance use, including stigma and rejection from peers and sexual partners (Davis-Ewart et al., 2023), which was also reflected upon as negative experiences associated with sexualized substance use in this study.

The results of this study align with existing research examining motivations and benefits of substance use among gay men related to pleasurable sexual experiences. For example, the perceived benefits of using marijuana and poppers aligns with the work of Parent et al. (2021) and Schwartz et al. (2020) as substances that improve pleasure, increase physical sensations, reduce inhibitions and anxiety, and allow for muscle relaxation during anal sex. The benefits reported in other research on crystal meth use relate to engaging in certain sexual practices without stigma and non-sexual benefits such as increased energy, the ability to focus, weight loss, and happiness (Davis-Ewart et al., 2023; Gish et al., 2020).

An unexpected result of this study was related to the impact of substance use on sexual health, which was not seen as harmful for gay male participants, even though the sexual context is often linked to use among this diverse population (Florêncio, 2021; Stanton et al., 2022). However, multiple studies describe the correlation between sexualized substance use and HIV (via condomless sex or sex with multiple partners) along with other STIs (Rodríguez-Bolaños et al., 2022; Takeuchi et al., 2023); it was not notable among study participants other than for situational reasons, including coping with a new HIV diagnosis, for specific sexual practices (e.g., anal sex), and related to self-care.

A possible explanation for this finding is that, socially, the sexual health care of gay men is often closely associated with HIV prevention (Koester et al., 2013). However, in our study, more than half of the participants were living with HIV, and half of those without HIV were taking PrEP, which minimized concerns about contracting HIV (Koester et al., 2017). Another potential explanation is that sexual expression may serve as a rebellious response to sexual repression linked to specific HIV prevention strategies (Íncera-Fernández et al., 2023). Ultimately, the prioritization of pleasure derived from the combination of substance use and sexual practices may have outweighed concerns about the risk of acquiring STIs (Gaspar et al., 2022).

Faced with a phenomenon as complex and multi-causal as the health-disease model when applied to a minority social group, and rather than delving into the moral binary of assessing “good” or “bad” health or risk behaviors, the focus should be on evaluating the usefulness of the findings for explanations or solutions to meeting the unique health, mental health, and sexual health needs of gay men in Mexico. Relatedly, Castiel and Álvarez-Dardet (2007) use the term “persecutory health” to refer to the secondary effect of health promotion that frames decisions related to one’s health solely dependent upon an individual without consideration for structural and systemic supports and connections or lack thereof.

In this regard, Gaspar et al. (2022) argue that it is essential to move beyond the risk-pleasure binary in studies related to substance use among gay men, drawing from the concept that perceived adverse effects or benefits may depend upon an individual’s specific relationship with substances. The risk-pleasure dichotomy may not manifest equally for each person. Therefore, it is necessary to elevate the voices of gay men and their uniquely lived experiences. This approach affords a more intimate analysis of perceived benefits or harms, including other emotional dimensions such as curiosity, expectations, fears, pain, and desires. In short, it highlights the role of gay men as agents in shaping their worldviews, their health-illness processes, connections to substance use, and the potential for resolution of their problems (Romaní, 2007).

This study lends supportive evidence for developing education and prevention strategies that address substance use among gay men that can positively impact their well-being, relationships, and sexual health. Study findings may also assist practitioners with developing affirming healthcare strategies that provide better support for their gay male clients navigating what they perceive to be the benefits and adverse effects of sexualized substance use in unique environments.

In conclusion, results from this study provide important insight into substance use experiences among Mexican gay men and the perceived benefits and harm to their health and well-being. A few perceived benefits related to the use of recreational substances were identified, such as an improvement in mental health and emotional well-being, heightened sexual experiences, and increased socialization. Oppositely, notable harmful effects were reported, particularly with crystal meth, related to a higher proportion of negative impacts upon physical, mental, and social health. This contrast highlights the complexity of decisions and experiences related to substance use among the gay male participants. In contrast, risks to health and interpersonal relationships were often conflicted with the pursuit of sexual pleasure and other perceived benefits.

Knowledge of the effects of substance use and sexual health among gay men may assist with health promotion efforts, harm-reduction strategies, public policies, and clinical support from the fields of medicine and psychology alike. Such interventions must also attend to the unique sociocultural aspects of practice with this diverse population and continually promote human rights, self-determination, non-discrimination, and health equity.