Internalized Homophobia, Psychological Distress, and Resilience as Correlates of Substance Use During Sexual Encounters in Young Adult Black Men who have Sex with Men

Background Young Black men who have sex with men (MSM) continue to be disproportionately at risk for HIV and other sexually transmitted infections. Substance use - the use of alcohol and other mood-altering drugs - before and during sexual encounters has long been connected with the HIV epidemic, especially in young Black MSM. Substance use can decrease inhibitions and lead to poor decision-making skills, especially in younger men with less sexual experience. Internalized homophobia - a facet of minority stress - may be a particularly important factor that influences substance use before or during sexual behavior, as young MSM may use drugs before sex to escape the psychological distress induced by engaging in the social taboo of sex with other men. In addition, resilience factors may play a key role in blocking the relationship between internalized homophobia and substance use before or during sex. This dissertation aimed to examine relationships between internalized homophobia, psychological distress, and substance use before or during sexual behavior. This dissertation also aimed to construct a model of resilience, as well as determine whether resilience may act as a moderator in the relationship between internalized homophobia and substance use before or during sex. Methods Young Black men who have sex with men between the ages of 18 and 34 participated in two phases of this study: 1) a cross-sectional survey (n = 228) and 2) a longitudinal sex diary (n = 153). In the cross-sectional survey, participants answered demographic questions as well as questions about their substance use behavior in the 2 months prior to baseline; they completed the Connor-Davidson Resilience Scale (CD-RISC), the Mastery Scale, and the Social Support from Friends and Social Support from Parents scales. A subset of participants was then followed for 8 weeks. Every week, they reported on their sexual behaviors, substance use behaviors before or during a sexual encounter, and their psychological distress using the Kessler Psychological Distress Scale (K10). Logistic regression was used to analyze the cross-sectional data. Multilevel logistic regressions and multilevel generalized structural equation models were used to analyze the structured diary data. Results Men with higher levels of internalized homophobia were also more likely to have used alcohol before or during sex during the eight weeks of the study, but not other substances. Men who had higher levels of internalized homophobia also had higher levels of weekly psychological distress, but psychological distress was not related to drug use. Four factors - hardiness, mastery, peer support and maternal support - were related to resilience. This construct of resilience did not moderate the relationship between internalized homophobia and substance use before or during sexual intercourse. However, peer support alone did moderate the relationship between these two variables - men who had higher levels of peer support had a weaker relationship between internalized homophobia and alcohol use. Conclusions The findings of this dissertation suggest that stigma, in the form of internalized homophobia, may be an important structurally-related factor that influences alcohol use before or during sex in young Black MSM. The results also highlight the importance of considering protective resilience factors that may weaken this relationship; however, the way in which resilience works in this relationship may be complex. Although the idea of a composite construct of resilience was supported, this composite construct did not moderate the relationship between internalized homophobia and drug use. However, peer support alone did, lending credence to the idea of resilience as a complex construct whose separate indicators may moderate relationships differently. This research has valuable implications for designing HIV and substance use prevention interventions in young Black MSM.