Introduction

The relationship between substance use and depression for men who have sex with men and particularly Black men who have sex with men (Black MSM) is clearly a multifaceted issue. Several studies (Reisner et al. 2009; Cochran and Mays 2000; Meyer et al. 2008) found higher rates of depression among MSM compared to the general adult male population, with rates of 15 to 26 % for MSM compared to 5–12 % for the general adult male population. With respect to Black MSM, rates of depression among Black MSM were 33 % higher (Reisner et al. 2009) when compared to depression rates among heterosexual Black men and other MSM populations (Cochran and Mays 1994; Peterson et al. 1996).

Moreover, higher rates of depression have been positively associated with higher levels of sexual risk behavior among Black MSM (Alvy et al. 2011; Crawford et al. 2002; Perdue et al. 2003; Stall et al. 2003). Research found that depression predicted high-risk behavior among a subsample of Black MSM and Black man who have sex with women (MSM/W). For example, Alvy et al. (2011), Klobin et al. (2006), and Stall et al. (2003) reported positive associations with depression and high-risk behavior among MSM. These studies found positive relationships in both HIV-infected and HIV-uninfected participants (Klobin et al. 2006; Reisner et al. 2009; Stall et al. 2003). Similarly, Reisner et al. (2009) reported that Black MSM who reported unprotected anal sex were nine times as likely compared with other MSM to be depressed, and those diagnosed with an STI were six times compared with other MSM as likely to be depressed.

Research has also shown a positive association between substance use and high-risk behavior among MSM regardless of HIV serostatus (Boone et al. 2012; Bruce et al. 2012; Klobin et al. 2003; VanDevanter et al. 2010). Studies found that methamphetamine, cocaine, and alcohol use are the primary substances most associated with high-risk behavior among MSM (Bruce et al. 2012; Coalfax et al. 2005; Garofalo et al. 1998; Mustanski 2008). In a recent literature review analyzing event-level substance use immediately before or during a sexual encounter among MSM, Vosburgh et al. (2012) found methamphetamine use and binge alcohol use to be most likely associated with unprotected sexual behavior.

The degree to which religious beliefs or spirituality buffer depressive symptoms or substance use has been examined in prior research, although none with separate analyses for Black MSM. Rasic et al. (2011) found that religiosity was associated with lower odds of depression and higher rates of religious attendance were associated with lower rates of depression (protective) among a sample of 1615 adolescents. Similarly, Cotton et al. (2006) found that among 134 adolescents, higher levels of spirituality were associated with fewer depressive symptoms and so an inverse relationship between depression and spirituality was found. With regard to substance use, another study among college students found that those with higher spirituality and religiosity scores reported the lowest level of substance use (Dennis et al. 2009). Similarly, Piko and Fitzpatrick (2004) found religion to be protective in regard to alcohol use among adolescent participants.

Because Blacks in the USA typically have a strong association with religion and religious institutions compared to other racial and ethnic groups, understanding how religiosity and spirituality may interact with depression and substance use in increased HIV risk behaviors among Black MSM is a critically important issue. A recent national survey of religious behaviors and beliefs found that, relative to other racial and ethnic groups, Blacks are more likely to report a formal religious affiliation (Glick and Golden 2010, Pew 2008; Pitt 2010; Wilson et al. 2011) and to report that “homosexuality is always wrong.” Black MSM in the sample were more likely than White MSM to report that “homosexuality is always wrong,” and men in the sample who reported that homosexuality is always wrong were more likely to refrain from HIV testing.

Other studies similarly suggests that religiosity is associated with cognitive dissonance among Black MSM (Kegeles et al. 2009) which is associated with higher rates of substance use, and depression (Mahaffy 1996; Martin and Knox 1997; Miller 2007; Millett and Peterson 2007; Millett et al. 2006).

This paper examines relationships between substance abuse, depression, and religious and spiritual factors among Black MSM.

Methods

Description of the Data Sample

The present study used a subset of data from the CDC 2005 Brothers y Hermanos Survey (ByH). ByH is a sample of 1141 Black MSM (601 from New York City and 540 from Philadelphia). As described in the methods published by Watkins et al. (2013), the ByH identified participants with an average age of the participants was 41.5 years ranging from ages 18–71. The number and corresponding percentages of the participants’ characteristics are shown in Table 1. All variables were normally distributed. As Table 1 shows, the vast majority of the sample was identified as non-Hispanic Black, single/never married, and homosexual or gay. Education and employment were more variable, with the typical educational attainment being high school graduate. The average annual income of the participants was below the Federal poverty level. Most were insured, and approximately half reported currently being in a committed relationship.

Table 1 Participant characteristics of Black men who have sex with men, Brothers y Hermanos Study, 2005–2006
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Measures

Predictor Variables

This study examined polysubstance use as alcohol use along with eight other illicit substances as well as depression reported as “ever been depressed” and expressed as dichotomous depression, and days respondents have been depressed, which is expressed as a continuous depression measure. Polysubstance use and depression are reported in Table 2.

Table 2 Substance abuse variables of Black men who have sex with men, Brothers y Hermanos Study, 2005–2006
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Outcome Variables

The outcome variables were the following: religiosity, which consisted of four questions; and spirituality which consisted of three questions. These measures were presented with number and percentage as noted in Table 3.

Table 3 Outcome variable characteristics presented with variable name, number, and corresponding percent of Black men who have sex with men, Brothers y Hermanos Study, 2005–2006
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In an effort to better analyze the religiosity outcome variable, a new index “Religiosity” was created as a sum of the scale responses: sum of the worship + openness + religious beliefs + choosing religious beliefs. A religiosity index was created (Wu 2012) by summing the scale responses of theses four questions worship (0–4) + openness (0–4) + religious beliefs (0–4) + choosing religious beliefs (0–4) to develop a composite sum of the responses to the four original ByH religiosity questions.

An index was created (Wu 2012) by summing guidance (0–4) + spiritual connection (0–4) + spirituality and health (0–4) as noted in Table 3 with corresponding number and percentages.

Univariate and bivariate associations were examined along with spirituality and religiosity. For both religiosity and spirituality, Spearman’s associations were conducted between the individual substance use and nonprescription substance use, depression (continuous) and depression (dichotomous) variables, in an effort to ascertain the individual relationships between the existence of depression and the level of depression and religiosity and spirituality. To examine which risk variables were significantly correlated with both religiosity and spirituality, this study utilized a correlation matrix of previously identified risk variables derived from the literature. Univariate comparisons were made between religiosity, spirituality, age, race, socioeconomic status, etc. Nonprescription substance use, unprotected anal intercourse (UAI), both receptive and insertive, condom use, HIV infection status, and STD infection status were used as high-risk variables to examine the relationship between the religiosity and spirituality variables. Previously identified risk variables were identified through a series of Chi-square tests, between risk as outcomes and religiosity (Table 5) and spirituality (Table 6) as independent variables. A Spearman’s correlation was used to examine whether religiosity and spirituality were significantly correlated with the risk variables (as noted in Table 4).

Results

Description of the Data Sample

The Brothers y Hermanos Study (ByH) conducted by the Centers for Disease Control and Prevention (CDC) ByH collected a sample of both Black and Latino MSM, including 1154 Black MSM (601 from New York City, NY, and 540 from Philadelphia, PA). Eligibility criteria for ByH participants were as follows: being a biological male at birth and during the study, 18 years of age or older, a resident of their respective cites for at least the past 18 months, and being sexually active with another male (i.e., oral or anal sex, mutual masturbation) within the past 12 months. Recruitment was open to participants who were HIV-positive, HIV-negative, and unknown HIV status.

As noted in Table 4, religiosity was negatively associated with ecstasy and poppers use and positively associated with cocaine and crack use. Spirituality was significantly negatively associated with alcohol, cocaine, and crack use among Black MSM.

Table 4 Spearman’s associations and p values associated with religiosity and spirituality variables
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Conducting Chi-Square tests to examine religiosity (Table 5) and spirituality (Table 6) as indices as well as their individual subcomponent questions were examined with both of the depression variables, crack, cocaine, and alcohol use variables. The religiosity index was significantly associated with depression (last week), cocaine use, crack use; poppers use, and marginally associated with ecstasy use.

The spirituality index was significantly associated with both alcohol and crack use, but not significantly associated with either depression variable (Table 6).

Table 5 Chi-square and p values of religiosity associated with risk variables
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A series of logistic regression analysis were conducted to ascertain the significant associations between the depression (past week and past month), substance use, and religiosity and spirituality variables. Among Black MSM, religiosity was significantly positively associated with use of cocaine (OR 0.95, p = .0013) and crack (OR 0.94, p = 0.0001), and negatively associated with the use of poppers (OR −1.05, p = 0.0334). Spirituality was negatively associated with alcohol use (OR −1.06, p = 0.0093) and with crack use (OR −1.05, p = 0.0296). The spirituality index was not significantly associated with either depression variable (Table 6).

Table 6 Chi-square and p values of spirituality associated with depression and substance use variables
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We also examined the associations between depression, substance use, using religiosity, and spirituality as outcome variables.

Spirituality was not significantly associated with the nonprescription substance use or depression, neither continuous nor categorical variables. However, when the spirituality variable was examined with the individual substances, there were significant negative associations between crack and cocaine use, and alcohol use. A simple logistic regression analysis model was conducted to further demonstrate the significant associations with the spirituality variable along with depression, both continuous and categorical, in an effort to ascertain whether diagnoses of depression or level of depression were related to religion and spirituality as well as nonprescription substance use, and the interaction variable of nonprescription substance use and depression.

Discussion

Religiosity and spirituality were associated with substance use among Black MSM. Black MSM with higher religiosity scores also tended to report more use of crack, cocaine, and poppers as well as report being depressed in the past week. Those Black MSM with higher spirituality scores reported less use of alcohol and crack and cocaine. Spirituality was not significantly associated with ever being depressed or being depressed in the last week.

When depression was examined along with polysubstance use as they relate to religiosity and spirituality, there were significant associations present. Specifically, Black MSM who reported being depressed and using cocaine (both crack and powder) had higher religiosity scores. Black MSM who were depressed and using substances had higher overall religiosity scores. Black MSM with higher spirituality scores tended to report no depression and less substance use. Age was not significantly associated with depression or substance use among Black MSM.

Consistent with the hypothesis, an explanation could be that Black MSM who reported higher religiosity scores also abused more substances and had higher rates of depression typifying higher levels of cognitive dissonance such that religiosity seemed was associated with higher rates of substance abuse and depression report and higher risky behavior (Alvy et al. 2011; Reisner et al. 2009, Parsons et al. 2012). As found in Rasic et al. (2011), religiosity proved protective among certain Black MSM who reported no depressive symptoms, as they had lower rates of substance use and higher religiosity scores.

Black MSM with higher spirituality scores reported less crack and alcohol use. Spirituality scores were not significantly changed among those who reported using substances or being depressed. There were no significant differences in spirituality scores among Black MSM who reported being depressed or those who were both using substances and were depressed. One possible explanation is that many of the Black MSM surveyed identified as spiritual, and those Black MSM that reported using substances or being depressed had lower spirituality scores.

In this study, Black MSM who reported higher levels of spirituality experienced lower levels of substance use such that spirituality seemed to be a protective factor for these individuals, therefore mitigating risky behavior (Reisner et al. 2009). This finding is consistent with current research which found that Black MSM who report lower levels of depression and substance abuse tend to participate in less risky behavior (Alvy et al. 2011; Reisner et al. 2009).

Although religiosity and spirituality were highly correlated, they were correlated with distinct variables, and they were associated with different patterns of individual substance use, indicating that they are distinct but related constructs. Few studies have attempted to parse out differences among religiosity and spirituality variables, and such research is almost nonexistent among Black MSM. Understanding how these variables relate, and differ, is an important avenue for future research.

Considering the relationships found in this study of religiosity, spirituality, and substance use among Black MSM, namely that those individuals who had higher spirituality scores reported fewer instances of polysubstance abuse and depression, while those with higher religiosity scores reported more instance of polysubstance abuse and depression, a recommended course for future HIV prevention interventions is to examine the role religiosity and spirituality can have in augmenting or mitigating risky behavior among Black MSM.

Limitations

Limitations existed in the recruitment of participants in that a majority of respondents were associated with agencies or individuals associated with HIV-specific community-based organizations and so may have different or even less biases than Black MSM overall. The use of the cross-sectional study design introduces the possibility of measured and unmeasured confounding factors, and causality cannot be inferred from the associations presented in this study. The survey relied on the self-report of risk behaviors, which may not accurately reflect the true risk behaviors, although collected by confidential computer-assisted methods. The relationship between the constructs analyzed is multifaceted and interrelated, so conclusions from this paper are exploratory and may only be cursory, but important nonetheless.

Additional limitations in using an existing data set included that the ByH data set includes seven specific religiosity/spirituality variables (i.e., 4 religiosity and 3 spirituality). This limits, to some extent, the depth with which these domains can be examined. However, at this time, there are few studies of religiosity/spirituality in relation to HIV risk in Black MSM in the literature. An additional limitation is that the religiosity/spirituality items available in the ByH data set are not part of standardized scales. This limits comparisons of findings from this study to other studies that have relied on standardized measures. However, past research has not found clear-cut, gold standard religiosity/spirituality scales for use among risk behavior research, and none have been used with the Black MSM population making these data a valid resource with which to approach this study’s questions.

Summary

Those individuals who had higher spirituality scores reported fewer instances of polysubstance abuse and depression, while those with higher religiosity scores reported more instance of polysubstance abuse and depression, and so overall among Black MSM, religiosity seemed to be a risk factor and spirituality seemed to be a protective factor as correlations of risky behavior, particularly polysubstance use.

Given that both religiosity and spirituality were correlated with substance use and depression among Black MSM, specifically higher levels of religiosity were associated with polysubstance abuse, and depression and higher levels of spirituality were associated with lower reports of depression and substance use, future studies should consider incorporation of both religion and spirituality as constructs in an effort to better understand the relationships between cognition (dissonance and consonance) and risk behavior among Black MSM. With the new knowledge obtained by this study, culturally specific and appropriate prevention interventions that incorporate a religious and/or spirituality component can better inform existing prevention programs or serve as standalone models to decrease HIV infection among Black MSM.