INTRODUCTION

There is a tendency to view Asian Pacific Islanders (APIs) in the United States as having low risk for substance use (Maddahian et al., 1985; Bachman et al., 1991). The perception of APIs as a “model minority” bolsters this perception (Zane & Kim, 1994). According to this belief, APIs represent a socioeconomically privileged minority group having only modest risk for adverse psychosocial and health outcomes such as substance use (Chen & Hawks, 1995). Epidemiological data from national samples have suggested that APIs experience the lowest substance use rates compared with African Americans, Latinos, and White Americans (Bachman et al., 1991;Maddahian et al., 1985; SAMHSA, 2002). However, some studies challenge this categorical view with findings that show high substance use among certain API demographic subgroups (Ellickson & Morton, 1999; Nemoto et al., 2002; Oetting et al., 2000; Price et al., 2002). Recent assessments have indicated that there exist few substance use prevention or treatment programs for API individuals and that approximately 10% of APIs in need of substance use treatment obtain services (Chow, 2002; NAPAFASA, 2001). Researchers have argued that studies must look within the general API category to identify particular subgroups at high risk for substance use, as well as examine the social context for substance use, in order to develop appropriate prevention and treatment interventions (Harachi et al., 2001; Nemoto et al., 1999). API men who have sex with men (MSM) is one particular API subcategory that warrants attention for further research into substance use prevalence and prevention strategies.

Studies of young MSM in general (predominantly White samples) have shown high levels of substance use (Crosby et al., 1998). An analysis of the San Francisco Young Men's Study, a probability household sample of single men between the ages of 18 and 29 in San Francisco by Greenwood et al. (2001), found the most common drugs used were marijuana (69%), methylenedioxymethamphetamine (MDMA) (37%), hallucinogens (37%), and methamphetamines (30%), and that 43% of the sample engaged in polydrug use—that is, three or more drugs—during the past year (Greenwood et al., 2001). Stall et al. (2001) also examined substance use behaviors in a probability sample of MSM in four urban areas, and found that MSM between 18 and 29 years of age were 2.6 times more likely to engage in polydrug use compared to older men (50 years and older).

Substance use is a potent risk factor for HIV infection (see Stall & Purcell, 2000, for a review). Strong associations between substance use and sexual risk behavior among young MSM have been documented (Chesney et al., 1998; Woody et al., 1999). A family of specific substances referred to as club drugs is widely used in MSM-themed dance clubs and circuit parties (i.e., weekend-long parties that cater to MSM clientele) and has been shown to be associated with sexual risk behaviors (Colfax et al., 2001; Mattison et al., 2001; Ross & Williams, 2001). These substances include MDMA, methamphetamines, gamma-hydroxybutyrate (GHB), ketamine, and lysergic acid diethylamide (LSD). Prevalence of club drugs is high among young MSM (Koesters et al., 2002; Tong & Boyer, 2002). However, to date most substance use and club drug prevalence studies have not included large samples of young MSM of color in general, or young API MSM in particular.

There is a need to identify and describe health risk behaviors such as substance use in the API MSM community. No known studies have examined prevalence and correlates of frequent drug use, club drug use, and polydrug use among API MSM. Preliminary findings suggest a link between substance use and unprotected sex among API MSM. A study of 241 API MSM revealed that substance use was associated with a fivefold increased likelihood for engaging in unprotected anal sex (Choi et al., 1995). Focus groups with API MSM indicated that alcohol and drug use were seen as normative behaviors among young gay men who frequent gay bars and clubs to meet other men, and that young API MSM may rely on substances to uninhibit themselves socially and sexually (Nemoto et al., 2003). In another study of 40 young API MSM, participants attributed their unsafe sexual behaviors to losing control of their judgments and behaviors while under the influence (Choi et al., 1999). However, specific drugs used by young API MSM have not been examined, and little is known about demographic and behavioral patterns associated with their drug use.

Table 1. Sample Characteristics
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In this paper, we present data from the Asian Counseling and Testing (ACT) study (see Choi et al., 2004, for more details) to provide an epidemiological profile of substance use among young API MSM in San Francisco. This is one of the first known studies to do so with a large API MSM sample. The paper investigates three research questions: (1) What is the prevalence of illicit substance use in young API MSM? (2) What are the correlates of three specific types of substance use—frequent drug use, club drug use, and polydrug use? and (3) In what ways are substance use associated with sexual behavior? Findings from this study can offer an important preliminary step toward developing substance use and HIV prevention intervention strategies for this understudied ethnic and sexual minority group.

METHODS

Sample and Procedure

Participants were recruited between January 2000 and September 2001 using the venue-based, time/space sampling procedure developed by the Centers for Disease Control and Prevention for their Young Men's Survey (Mackellar et al., 1996).

Before and throughout the survey, research staff identified all venues frequented by API MSM in San Francisco. Formative research was conducted to identify all possible venues by reviewing local publications, interviewing key community informants, and meeting with focus groups of young gay men. When the staff found venues, they would identify the days of the weeks and times of day when API MSM frequented the venues. Staff would then visit those venues and conduct enumerations and brief street interviews with API men at the venue. Ethnically heterogenous populations were present at most venues; the venues that consisted of predominantly Asian men were social organizations for API individuals. A sampling frame was then developed of venues deemed to yield at least seven eligible men in a 4-h period. The cutoff of 7 was chosen for logistical and efficiency purposes. Types of venues identified included bars, clubs, shopping blocks, street corners, public places (i.e., parks), bathhouses/sex clubs, social organizations, and fitness clubs. During the course of the study, venues were added or deleted and day/time periods were adjusted depending on whether they met the criterion of finding seven eligible men to participate.

During each 4-h sampling event (e.g., at a specified bar on Saturday night between 10 p.m. and 2 a.m.), individuals who appeared to meet eligibility criteria were approached and screened. Because a primary goal of this project was to examine risk behaviors among young MSM, API men who appeared to be 29 years and younger were targeted (Choi et al., in press). Eligibility criteria were (1) being male, (2) being of Asian or Pacific Islander descent, (3) being between 18 and 29 years of age, (4) sexual encounter with at least one other man in their lifetime, and (5) residing in one of the six counties of the San Francisco Bay Area (San Francisco, Alameda, Marin, Contra Costa, Santa Clara, San Mateo). We minimized the likelihood of recruiting men more than once by asking each individual if they had already participated in our study.

In all, the team went to 27 different venues. Because of the random selection of venues according to time sampling period, some venues may have been sampled more than once. An eligibility screener was used to determine men's age, ethnicity, residence, and if they had previously participated in the survey. A total of 2,393 men were approached. Some men (n = 259) would not stop to complete the eligibility screener. Eligibility was assessed for those men who did complete the screener (n = 2,134; 89% of those approached). Men who were screened as eligible (n = 909) were told what the study was about and asked to participate. There are a wide range of reasons eligible men refused to participate, including not having enough time, meeting friends, going to work, having recently been tested for HIV, discomfort with needles, not interested in the project, and not interested in being tested. Participation rates were not significantly different by age and ethnicity.

Table 2. Substance Use Prevalence (Lifetime and 6 Months)
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Eligible men who agreed to participate (n = 566) were escorted to a large recreational vehicle that contained a private interview and counseling space. Participants provided informed consent and were interviewed using a standardized questionnaire. Participants also had their blood drawn via venipuncture (see Choi et al., in press, for more detail on HIV posttest counseling procedure and seroprevalence data). Specimens of suspected duplicate enrollees who reported the same ethnicity and date-of-birth were tested using a human antibody fingerprinting method (Viral & Rickettsial Disease Laboratory, CA DHS, Richmond, CA). When antibody profiles matched, we considered that specimens were from the same person and only analyzed data from the first enrollment. Following the interview participants received $50. All study procedures were approved by the institutional review board of CDC and the University of California, San Francisco.

Measures

Participants were asked about general sociodemographic background characteristics including ethnicity, age, birthplace, and highest level of education completed. They described their sexual orientation (response options included gay [homosexual], bisexual, straight [heterosexual], none of the above, or other) and assessed their degree of being “out” to others using a scale from 1 (not out to anyone) to 7 (out to everyone). Participants described their frequency of attending gay clubs during the past 6 months using a scale from 1 (never) to 7 (every day or almost every day) and whether they had ever attended a circuit party. They also described their sexual behaviors during the past 6 months, including number of sex partners and ever having unprotected anal sex.

Table 3. Correlates of Three Substance Use Outcomes—Frequent Drug Use, Club Drug Use, Polydrug Use (Past 6 Months)
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Participants described whether they had ever used various substances during their lifetime and during the past 6 months (response categories yes/no), and for each substance used during the past 6 months, how frequently they used the substance (response categories included less than once a month, once a month, 2–3 times a month, weekly, more than weekly), and whether they were ever “high” or “buzzed” on each specified substance during sex in the past 6 months. Substance categories included alcohol, marijuana, MDMA/ecstasy, LSD/hallucinogens, poppers/nitrate inhalants, crystal/speed, cocaine or crack, Special K, GHB, uppers (other than crystal or cocaine), downers or other barbituates, heroin, or any other drugs.

Frequent drug use reflected use of any illicit substance (all substance categories except alcohol) weekly or more frequently during the past 6 months. Club drug use reflected any use of MDMA/ecstasy, crystal/speed, GHB, ketamine/Special K, or LSD during the past 6 months (defined according to NIDA, 2000). Polydrug use reflected the use of three or more illicit substances during the past 6 months.

Statistical Analyses

For each individual substance, we report the prevalence of lifetime use and the frequency of use during the past 6 months. Pearson chi-square tests were conducted to assess the association between three substance use outcome measures—frequent drug use, club drug use, polydrug use—with demographic characteristics, sexual orientation, degree of outness, venue attendance, and sexual behaviors.

Multivariate logistic regression was performed to identify significant (p < .05) predictors of each of three substance use outcomes. Variables with an alpha level of less than 0.25 in Pearson chi-square test were selected as entry candidates in multivariate logistic regression models. A backward stepwise procedure was then used to remove those variables with an adjusted statistical significance level greater than .20, following procedures described by Hosmer and Lemeshow (1989). Adjusted odds ratios and 95% confidence intervals were calculated and used to determine independent predictors of each of the three substance use outcomes. Finally, Wald chi-square statistics testing the global null hypothesis for each regression model are reported.

RESULTS

Participant Characteristics

Of 566 men who participated in the study, 496 reported male–male sex and only data from these men are analyzed here. The final sample (Table 1) was predominantly Filipino, Chinese, and Vietnamese. The mean age was 24. Most were foreign born, and half had graduated from college. A majority of the sample identified as gay, with over half stating they were out to more than half of the people they knew. The modal frequency of going to gay clubs was once a week. Sixty-four percent reported two or more sex partners during the past 6 months. Nearly half reported in the past 6 months having sex while under the influence of an illicit substance (any drug, excluding alcohol) and engaging in unprotected anal intercourse.

Club Drug Use

In bivariate analyses (Table 3), club drug use varied significantly by ethnicity and was more common among men who were born in the United States, out to more than half the people they knew, frequently went to gay clubs, ever attended a circuit party, had multiple sex partners, had sex while under the influence of any illicit substance, and had unprotected anal sex. Multivariate analyses (Table 4) revealed that club drug use was significantly higher among Vietnamese and Korean compared to Chinese men, as well as among men who were 18–24 years old, frequently went to gay clubs, ever attended a circuit party, and had sex while under the influence of an illicit substance. A marginal association was found between club drug use and being out to most people.

Prevalence of Substance Use Behaviors

Table 2 shows that the majority of participants reported using alcohol, marijuana, and ecstasy in their lifetime, with over one fourth reporting use of speed/crystal, poppers, LSD, and Special K. Alcohol was the most commonly used substance during the past 6 months, followed by ecstasy, marijuana, speed/crystal, Special K, GHB, poppers, and LSD. During the past 6 months, 24% frequently used one or more illicit substances, 51% used a club drug, and 44% reported polydrug use.

Correlates and Multivariate Models of Substance Use Behaviors

Frequent Drug Use

In bivariate analyses (Table 3), we found that frequent drug use was more common among men who were born in the United States, less educated, out to more than half the people they knew, and ever had sex while under the influence of an illicit substance. Multivariate analyses (Table 4) revealed that frequent substance use was significantly correlated with not attending or completing college, being out to most people, and having sex while under the influence of an illicit substance.

Table 4. Multivariate Models of Three Substance Use Outcomes—Frequent Drug Use, Club Drug Use, Polydrug Use (All Past 6 Months)
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Polydrug Use

In bivariate analyses (Table 3), polydrug use varied by ethnicity and was more common among men who were born in the United States, out to more than half the people they knew, frequently went to gay clubs, ever attended a circuit party, had multiple sex partners, had sex while under the influence of an illicit substance, and had unprotected anal sex. Multivariate analyses (Table 4) revealed that polydrug use was significantly higher among Vietnamese and Korean compared to Chinese men, as well as among men who were 18–24 years old, frequently went to gay clubs, ever attended a circuit party, and had sex while under the influence of an illicit substance.

DISCUSSION

These data offer a closer look at substance use among young API MSM in San Francisco. Findings indicate that API MSM who frequent venues such as gay neighborhoods, bars, and bookstores engage in high rates of substance use, particularly alcohol, marijuana, and ecstasy. Half of these men reported club drug use, nearly half reported polydrug use, and nearly one quarter reported weekly substance use during the past 6 months, and each of these behaviors was associated with sex while under the influence substances. This API subgroup challenges the model minority view of APIs as a low-risk category for adverse health outcomes.

Prevalence of use for certain substances exceeded findings from other studies with mostly White MSM respondents in San Francisco. However, direct comparisons between our venue-based API MSM sample and probability samples used by Stall et al. (2001) and Greenwood et al. (2001) should be made with caution. Compared to findings from Stall et al. (2001), who reported on substance use prevalence in a probability sample of MSM in San Francisco, API MSM in our sample were more likely to report the use in the past 6 months of ecstasy (47% compared to 11%), LSD or other hallucinogens (14% compared to 6%), crystal or speed (20% compared to 13%), and other uppers (5% compared to 2%). Likewise, compared to Greenwood et al. (2001) who reported on young MSM in San Francisco, API MSM in our sample were more likely to report monthly or more frequent use of ecstasy (26.4% compared to 8%). In addition, 24% of API MSM reported frequent drug use compared to 21%, and 44% of API MSM reported polydrug use compared to 20% in Stall et al. (2001). Polydrug use prevalence was comparable to the 43% in Greenwood et al.‘s (2001) sample of young MSM. It is also important to note that Stall et al. (2001) and Greenwood et al. (2001) were earlier studies, so prevalence of some drugs that have become more popular since then (e.g., crystal) would not be as high.

In comparison with other venue-based samples of young MSM, the API men described here appear to have comparable or slightly higher prevalence rates of substance use risk behaviors. Prevalence of club drugs in this sample was roughly equivalent to findings from the Young Men's Survey (52%), which was a multisite study of 15- to 22-year-old MSM recruited from sampled venues (Valleroy et al., 2000). Further analysis of the Young Men's Study by Thiede et al. (2003) found comparable or slightly lower rates of illicit drugs used during the prior 6 months, weekly drug use, and polydrug use. Stueve et al. (2002) found that less than one-third of participants were high during the last sexual episode with a non-main partner and nearly one-fifth were high during the last sexual episode with a main partner. Both estimates appear lower than the findings reported here. However, geographic differences in behavior may account for some of the differences between our San Francisco study compared to the multisite studies of Valleroy et al. (2000) and Thiede et al. (2003).

Most of the substances used at high prevalence rates in our API MSM sample belong to the club drug category. Indeed, 51% reported using club drugs during the past 6 months, corroborating prior qualitative findings by Nemoto et al. (2003) indicating that many young API MSM view club drug use as normative among young gay men. Reback (1997) has also described the cultural pervasiveness of club drug use among young gay men in Los Angeles. It is evident that young API MSM in San Francisco are similarly impacted by the surge in club drug use described in other reports (Koesters et al., 2002; NIDA, 2000; Ross et al., 2003).

Multivariate models revealed some common demographic correlates for each substance use outcome as well as unique correlates. Frequent drug use was correlated with not completing college and being out to more than half the people they knew. Club drug use was associated with specific ethnic groups (Vietnamese and Korean compared to Chinese men), being 18–24 years old, going to clubs more than once a month, ever attending a circuit party, and, marginally, with degree of being out to others. Polydrug use was similar to club drug use in being associated with Vietnamese and Korean ethnicity, age, frequency of going to clubs, and ever attending a circuit party (associations with Korean ethnicity must be interpreted caution because of wide confidence intervals and small sample size). As attendance at gay clubs and circuit parties appeared uniquely associated with club- and polydrug use, these venues can be important areas for conducting substance use outreach intervention to high-risk API MSM (Colfax et al., 2001; Mattison et al., 2001).

Frequent substance use, club drug use, and polydrug use were each associated with over a threefold increased likelihood of sex while under the influence of substances. This is a compelling pattern of findings given the growing body of research showing substance use operates as a co-factor in risk for HIV transmission (Ostrow, 2000; Ross and Williams, 2001; Stall and Purcell, 2000). Prior research has hypothesized four potential explanations of the association between substance use and high-risk sexual activity among MSM (Chesney et al., 1998; Ross & Williams, 2001). First, physiological responses to illicit substances use may act as an aphrodisiac that leads to increased sexual desires. Second, illicit substances may uninhibit controlled sexual urges. Third, environmental and contextual factors associated with drug use might increase the chance of high-risk sexual behavior (e.g., the sexually charged atmosphere of gay clubs or circuit parties where club drug use co-occurs). Fourth, a third variable, such as having a risk-taking personality, might explain both substance use and sexual behaviors. All four explanations might contribute to the association between substance use and sexual risk-taking observed in the present study. Our cross-sectional data do not allow for interpretation of any causal or temporal associations between substance use and sexual behavior. Further research is needed to explore the influence of substance use on sexual behavior of young API MSM outside of San Francisco, as data from this San Francisco-based sample might not reflect phenomena in other cities. Intervention programs that address the association between substance use and sexual behavior among API MSM in San Francisco are warranted, as these data clearly show that the two risk factors co-occur at high rates.

It is important to consider further the limitations of the present study. First, the use of venue-based sampling limits generalizability of findings. Because of the use of venue-based sampling methods for accessing this hard-to-reach population, the respondents in this study might not represent API MSM who do not frequent gay venues such as bars, bookstores, clubs, and gay community spaces. Substance use prevalence rates might differ in a population-based sample of API MSM. Second, because nearly 4 of 10 identified eligibles chose not to participate, our findings may be subject to nonparticipation biases. Although no demographic differences emerged among those who were screened and chose to participate versus those who were screened yet chose not to participate, there may have been nonobserved differences in patterns of substance use and sexual risk behavior; for example, men who engage in the highest risk substance use and sexual risk behaviors might have systematically opted out of participating. Furthermore, there may have been nonrecorded differences between those who agreed to be screened and those who did not agree to be screened. Third, because patterns of drug use change with time, the data presented here (collected during years 2000 and 2001) might not reflect current patterns. Fourth, our research was limited in our ability to interview only English-speaking API men, thereby precluding monolingual men and, potentially, less acculturated API men from participation. Fifth, it is difficult to interpret ethnic group differences obtained, particularly in light of the wide confidence intervals (perhaps due to small Korean sample size). Furthermore, ethnicity often reflects macro-level factors that were not measured here such as community norms, socioeconomic status, migration history, housing and accommodation, and acculturation level. Indeed, these factors may introduce important sources of heterogeneity between and within API ethnic groups in San Francisco, and future research should consider their implications for health risk behaviors (e.g., Srinivasan & Guillermo, 2000). However such considerations reach beyond the scope of analysis here.

Our study clearly demonstrates that young API MSM do not conform to a stereotype of model minorities who are protected from substance use and health risks such as HIV. Because of the view that health vulnerabilities for APIs are generally less severe than other minority groups, it is likely that this group remains overlooked by general (non-API-specific) substance use programs and HIV prevention outreach specialists. Substance use prevention and outreach intervention efforts should target MSM-themed venues where young API men congregate, and educational programs should address linkages between substance use and unprotected sex. Prevalence of substance use, particularly club drugs, points to the need for more in-depth research on the motivations, social context, and personal meanings associated with using substances among young API MSM, as well as for culturally sensitive substance use prevention programs to respond to this epidemic. However, there remain few high-quality interventions for this group. The only known evidence-based HIV prevention intervention for API MSM (Choi et al., 1996) does not include substance use as a primary focus, and substance use prevention programs for this community tend not to be driven by sufficient research and generally lack appropriate resources for addressing issues associated with sexuality, ethnicity, and sexual risk (Chow, 2002). Further practical steps based on this data can include training substance use providers on cultural issues and diversity among API populations, educating HIV outreach specialists who target API communities on co-occurring substance use risk factors, and targeting outreach at public spaces where high-risk activity is known to occur such as gay clubs, API social venues, and circuit parities. Next steps in developing culturally sensitive prevention interventions for this group should include ethnographic studies to understand the life contexts among API MSM who use substances, epidemiological studies with API MSM in other geographic settings to clarify whether the observed patterns generalize to other cities or reflect site-specific processes, and community-collaborative endeavors to involve stakeholders and community members in the effort to reduce substance use and HIV risk among API MSM. It will be important for this growing body of research to build theoretical frameworks that can address how social and cultural processes contribute to public health outcomes such as substance use and sexual risk, and which should be tested in controlled health intervention trials.