Exploring the Perspectives of Substance Abusing Black Men Who Have Sex With Men and Women in Addiction Treatment Programs

Abstract

This study examined the perspectives of African American male injection drug users who have sex with both men and women (IDU-MSM/W) and who are involved in sex trade regarding the need for a human sexuality educational model (HSEM) for addiction professionals. Focus groups were conducted involving an exploratory sample (N = 105) of men who met the following parameters: aged 18 to 40 years, African American, engage in injection drug using behavior, have sex with male and female partners, and who frequent parks and other sex working areas in Baltimore City and surrounding areas. Data suggest that an HSEM may be useful for addiction professionals who work with substance abusing Black MSM/W. Moreover, the model should include opportunities for addiction professionals to (a) identify their personal biases about homosexuality in general (acknowledging personal biases so not to allow those personal biases to influence service); (b) understand the diversity within the Black MSM/W community (e.g., challenge assumptions that all Black MSM/W self-identify as gay); (c) understand how to, and the need for, assessing sexual trauma in Black MSM/W; and (d) understand the need to incorporate risk factors and safer sex practices that may be of concern to a subpopulation of Black MSM/W, such as “barebacking.” These findings suggest the need for, and topics to include in, an HSEM that assists professionals with exploring their biases about sexuality and MSM/W and better prepares counselors to address HIV prevention and risky behavior using language that is appropriate for the Black IDU-MSM/W population.

Keywords

sexuality MSM/W HIV prevention injection drug use IDU addiction counselors

As of August 2009, a paucity of research exists that directly explores factors that may be useful for developing HIV prevention programs targeted toward sex-trading, injection drug using men who have sex with both men and women (MSM/W).

For the purpose of this study, MSM/W refers to injection drug using men who have sex with both men and women and who trade sex for drugs and/or money to purchase drugs. Since 1991, many studies of HIV infection that included injection drug users (IDUs) have focused on whether injection or sexual risk factors, or both, were associated with HIV seroconversion and have not included STDs (Bluthenthal, Kral, Erringer, & Edlin, 1999; Kral, Bluthenthal, Lorvick, & Gee, 2001; Longshore, Bluthenthal, & Stein, 2001). Others have examined risk factors among IDUs (Dushay, Singer, Weeks, Rohena, & Gruber, 2001; Kral, Bluthenthal, Erringer, Lorvick, & Edlin, 1999; McFarland, Kellog, Dilley, & Katz, 1997) and explored the relationship between self-reported sexual orientation and behavior among IDUs (Pathela, Hajat, et al., 2006; Washington et al., 2006).

At the end of 2005 (the most recent year for which statistics are available), an estimated 217,323 men who have sex with men (MSM) in the United States were living with AIDS, representing 67% of all men and 52% of all people living with AIDS (Centers for Disease Control and Prevention [CDC], 2007a). In the Unites States, MSM are the group at greatest risk: 72% of people diagnosed with AIDS in the United States in 2002 were MSM. In addition, MSM make up the largest group of new HIV cases in men (45%), compared with IV drug users who are not MSM (11%), men who have sex with women (9%), and MSM who inject drugs (3%; CDC, 2007b). Little is known about MSM/W involved in sex trade, which is a subpopulation of the MSM community. Additionally, evidence exists across numerous surveillance studies that despite HIV/STD prevention efforts, African American IDUs and MSM are still disproportionately affected and infected by HIV and other STDs (CDC, 2000; Celentano et al., 1991; de Luise, Blank, Brown, & Rubin, 2002; Strathdee et al., 1998).

The impact of HIV/AIDS on African American MSM/W varies among U.S. metropolitan cities (CDC, 2004). For example, Black residents represented 6.7% of the population in the state of California, and 9.6% in Los Angeles County (U.S. Census Bureau, 2001), yet represented approximately 33% of the AIDS cases reported in 2006 in Los Angeles County alone (County of LA Public Health, 2008). Furthermore, among Black men living with HIV/AIDS in Los Angeles County, MSM, MSM/injection drug use (IDU), and IDU were the three major exposure categories, and MSM exposure was the highest, at 62% in 2006 and 2007 (County of LA Public Health, 2008).

In a similar example, African Americans represented 27.9% of the population in the state of Maryland (U.S. Census Bureau, 2001), yet they represented 79.5% of the reported AIDS cases in the state of Maryland (CDC, 2003a). A similar disparity exists for the largest city in the state of Maryland: African Americans represented 64.3% of the population in the city of Baltimore, but represented 88% of all the reported AIDS cases in the city of Baltimore (CDC, 2003a). Furthermore, intravenous drug use has directly and indirectly accounted for more than one third (36%) of the AIDS cases in the United States since the epidemic began (CDC, 2003a). However, in the state of Maryland, IDUs accounted for more than half (53%) of the AIDS cases. IDU-associated AIDS cases continue to be an important public health issue. Reports on IDU-associated AIDS cases in the United States and Maryland among men who have sex with men in the United States accounted for 13% in the United States and 3% in Maryland (CDC, 2003a).

There have been significant medical diagnostic and management advances and improved treatment for people living with HIV since the epidemic began, particularly new antiretroviral agents. However, untreated STDs and undiagnosed HIV infection among MSM/W and IDUs remain high, particularly for the African American community where low rates of access to the prevention and treatment programs and high drop-out rates following access to service remain an important issue (CDC, 2007a).

According to Pathela, Blank, Sell, and Schillinger (2006), results from a study conducted in New York City suggested that MSM who exclusively had sex with men yet self-identified as heterosexual were more likely than their gay-identified counterparts to be from an ethnic minority, to be foreign-born, and to have had only one sexual partner within the past year. Just as important, they were less likely to have been tested for HIV and less likely to have used a condom during their last sexual encounter. Among those few who have participated in research, Courtenay-Quirk, Wolitski, Hoff, and Parsons (2003) reported that HIV-seropositive African American MSM had higher interest in programs focusing on safer sex and serostatus disclosure as compared with their White counterparts.

Since the beginning of the HIV epidemic, numerous quantitative and qualitative studies have examined MSM/W and the different sexual and drug use patterns of these men compared with homosexual men (CDC, 2003b; Chu, Peterman, Doll, Buehler, & Curan, 1992; Crawford, Allison, Zamboni, & Soto, 2002; Gorbach, Murphy, Weiss, Hucks-Ortiz, & Shoptaw, 2009; Peterson et al., 1992; Stokes, McKiman, Doll, & Burzette, 1996; Washington, Wang, & Browne, 2009). Yet these studies are limited in that they have not provided insight concerning the HIV-prevention needs that are specific to the MSM/W sex trade community, nor have these studies translated their findings into implications for effective practice. Even fewer studies have specifically explored HIV-prevention needs for the African American MSM/W sex trade community (Johnson et al., 2005; Washington & Meyer-Adams, 2009). Despite previous research that suggests that MSM/W are more likely to practice safer sex than self-identified homosexual men (Gorbach et al., 2009; Peterson et al., 1992), these studies have provided minimal information about the subpopulation of MSM/W who are involved in sex trade and are IDUs. This gap is critical as African American MSM/W who are IDUs and involved in sex trade pose a double concern when engaging in unprotected sex for both their male and female sex partners (Aral, Adimora, & Fenton, 2008; Newman, Rhodes, & Weiss, 2004).

Self-identified heterosexual males who are on the “down low” (men who do not self-identify as homosexual but secretly have sex with other men) may be at risk for HIV infection and require expanded and targeted HIV-prevention programs as they are less likely to access the few programs that specifically offer services for sexual minority populations, especially noting that women are more likely to be exposed to HIV through heterosexual contact (CDC, 2002; Millett, Malebranche, Mason, & Spikes, 2005). Data from one study indicated that the MSM/W sex trade community needs an HIV-prevention program that provides a “safe space,” a place where MSM/W can get information specifically relevant to this population (Washington & Meyer-Adams, 2009). Logically, considering the risk factors, this need for targeted programming is compounded for those MSM/W who are IDUs, involved in sex trade, and are African Americans.

In the past it has been reasonable to consider that community drug treatment programs could serve as ideal sites for prevention and intervention. Yet Brown et al. (2006) reported that not even half of the community drug treatment programs surveyed made HIV testing available on site or through referrals, and the National Survey of Substance Abuse Treatment Services (2007) indicates that only 55.5% of substance abuse treatment programs nationwide offer HIV education. Furthermore, a recent study by Cochran, Peavey, and Robohom (2007) determined that of the 854 substance abuse treatment programs that were identified in the National Survey of Substance Abuse Treatment Services as offering specialty services for sexual minority clients, less than 8% actually provided these services.

Concerning the capacity of traditional substance abuse treatment programs to provide targeted prevention services, studies have not explored how provider attitudes about human sexuality, specifically, the complexities of the continuum of sexual identity, have affected the ability of addiction professionals to deliver culturally competent HIV prevention in treatment programs when working with Black MSM/W. Consequently, without these insights addiction treatment providers may be inadequately prepared to provide effective services to sexual minorities (Alderson, 2004; Bahr, Brish, & Croteau, 2000; Morrison & L’Heureux, 2001). The study of human sexuality and attitudes toward sexual behaviors and sexual thoughts has an extensive tradition in biology, anthropology, psychology, and sociology. Most research on the subject acknowledges that sexuality-related variables, such as sexual orientation (Bem, 2000; Kinsey, 1998), gender (Bem, 1974, 1995; Fausto-Sterling, 1992), and sex (Fausto-Sterling, 1993), are continuous variables rather than dichotomous ones. In spite of this prevailing belief regarding continuity (especially in the case of sexual orientation and gender), research and anecdotal data demonstrate that many people are either unknowledgeable about the existence of several dimensions related to sex and sexual behavior or they have incomplete knowledge of the dimensions of which they are aware (Bem, 1996, 2000; Deihl & Ochs, 2000; Fausto-Sterling, 1993; Stokes, Miller, & Mundhenk, 1998). This lack of knowledge affects attitudes and behaviors from the macro/cultural level down to the micro/individual level (Kite & Deaux, 1986; Whitley & Ægisdóttir, 2000).

Research that explored the training in human sexuality that is offered across disciplines identified that 52% to 65% of psychiatric residency programs offered didactic training in sexuality only in the context of another course and that training in HIV was one of the few topics for which there was a clinical rotation in only 17% of the programs, and currently human sexuality is not a core competency for members of the American Board of Addiction Medicine (Sansone & Wiederman, 2000; Weirs, 2009). It is surprising to note that 35% of all the APA-accredited clinical psychology (PhD), doctor of psychology (PsyD), and counseling psychology programs offered nothing in terms of training in human sexuality (Wiederman & Sansone, 1999), and counseling programs were identified to have no consistent requirement for training in human sexuality (Kitzrow, 2002). Currently, human sexuality education is not required for certification as an addiction professional or prevention specialist; however, 6 hours of HIV education is required. Similarly, cultural competency hours are required for all levels of addiction and prevention certifications although the degree to which sexual diversity is included in the cultural competency training is unknown (California Association of Alcoholism and Drug Abuse Counselors, 2008; Florida Certification Board, 2009; National Association of ADA Coordinators, 2009).

To this end, this research explores the need for a human sexuality educational model (HSEM) for addiction counselors from the perspective of injection drug using men who have sex with both men and women (IDU-MSM/W) involved in sex trade. The purpose of this study was to explore the following questions: (a) What issues should be explored by addiction counselors to help prepare them for providing HIV prevention to Black MSM/W? (b) What issues do Black MSM/W perceive to be important for addiction counselors to include in HIV prevention during treatment? (c) What are some perceived barriers to Black MSM/W for receiving HIV prevention from addiction counselors?

Method

Research Design

This study involved a convenience sample (N = 105) composed of Black IDU-MSM/W who were recruited through extensive community outreach, as described elsewhere (Washington & Meyer-Adams, 2009). Participants (90% African American, 10% African American of Latino descent, mean age = 31.6 years, SD = 8) were invited to attend a focus group session at a location convenient to the area in which they were recruited (further characteristics of the participants are displayed in Table 1). Qualitative methods were used to explore perspectives of IDU-MSM/W on topics needed for addiction counselors to better serve this population. In addition, data were gathered regarding issues that should be explored by addiction counselors to help prepare them for providing HIV prevention to Black MSM/W. Similarly, Black MSM/W’s perceptions were explored concerning topics important for addiction counselors to include in HIV prevention during treatment. The perspective of IDU-MSM/W would likely produce useful information for the purpose of developing a human sexuality model for addiction counselors to better prepare them to influence treatment services for their clients. Thus, qualitative methods were used because of their usefulness for generating hypotheses that may be tested later using qualitative data (Bradley, 2001; de Luise et al., 2002). This study was reviewed and approved by the institutional review board of the university with which the principal investigator was affiliated at the time of the study.

Table 1.

Characteristics of Study Participants (N = 105)

Variable	Percentage (n)	M (SD)
Age (years)		31.6 (8)
Education
<High school	58 (61)
High school diploma	36 (38)
College attendance/degree	06 (06)
HIV status
HIV-seropositive known status	27 (28)
HIV-seronegative known status	14 (15)
HIV status unknown	59 (62)
Injection drug use^a
Yes	100 (105)
No	—
Marital status
Single	84 (88)
Domestic partner	03 (03)
Married	13 (14)
Race
African American (not of Hispanic origin)	90 (94)
African American (Hispanic origin)	10 (11)
Traded sex for drugs or money^a
Yes	100 (105)
No	—

All participants reported injection drug using behavior and involvement in sex trade.

Data Collection Methods

Self-report surveys were administered to IDU-MSM/W, and 11 focus groups (8-10 participants per group) were conducted involving IDU-MSM/W; sessions were between 60 and 95 minutes. Focus groups were conducted in community centers near areas most frequented by MSM/W. Two research assistants were trained by the principal investigator to moderate the focus group sessions.

The moderators used a script that included questions related to the study’s specific aims: (a) “What are some unique issues addiction counselors should explore to better understand Black MSM/W?” (b) “What are some topics important to MSM/W that should be included in treatment to enhance your experience?” (c) “What are some unique issues (in your opinion) that Black MSM should hear from their practitioner regarding HIV prevention?” (d) “How would you describe your comfort level [how you feel] talking to a practitioner concerning HIV prevention/knowledge?” (e) “If you have received, or if you were to be offered, HIV prevention from a practitioner, what topics would be helpful to you and other MSM/W (e.g., safer-sex practices, HIV knowledge, safer sex communication knowledge)?” (f) “What are some perceived [barriers] reasons why you and/or your peers may not talk about HIV prevention to a practitioner during inpatient/outpatient treatment?” The sessions were recorded using an audio recorder, and participants were provided a gift card for their time and participation in the study.

Coding and Analysis

Descriptive statistics (i.e., frequency distributions, measures of central tendency, and dispersion) were performed to analyze the demographic data from the self-report survey, as shown in Table 1. Emerging analysis, referred to as the naturalistic inquiry or constructivist paradigm, was used to analyze the focus group data for this study (Strauss & Corbin, 1998). Incorporating relevant literature in the research approach of evolved grounded theory provides the researcher with aspects of similar phenomena (Mills, Bonner, & Francis, 2006) that can “stimulate our thinking about properties or dimensions that we can then use to examine the data in front of us” (Strauss & Corbin, 1998, p. 45).

Transcripts were developed from the recorded focus group interviews by a Washington, D.C., based firm. The research team independently coded the data by repeatedly reviewing the transcripts of the participants’ recorded responses. Next, the research team compared the codes, identified categories, developed process notes, compared participants’ responses using Cohen’s kappa, and identified central themes relayed through the participants’ responses (Strauss & Corbin, 1998; Washington, 2002). Cohen’s kappa yielded a significant measure of agreement (κ = .792, p ≤ .01) for the degree to which the two reviewers’ codes were applied to the data.

Because qualitative research is subject to a researcher’s own bias in interpretation (Corbin & Strauss, 1998), a trained qualitative researcher included a second process to provide transparency in the data analysis. This process included entering the data into a software package (NVivo7, QRS International, Pty Ltd, Cambridge, MA) designed for qualitative data analysis. The common themes identified from this analysis were compared and cross-referenced with the themes identified by the research team.

Results

After review of the transcripts, respondents’ comments were organized using five major categories that Black MSM/W perceive as the content needed for an HSEM designed both to train addiction professionals on issues important to injection drug using Black MSM/W and ultimately to improve treatment for Black MSM/W. These broad categories were the following: (a) topics for an HSEM for addiction professionals, (b) discrimination and stigmatization, (c) sexual trauma, (d) multifaceted treatment approach, and (e) HIV program needs. Table 2 summarizes the five major elements that Black MSM/W perceive as the content needed for the HSEM.

Table 2.

Five Major Categories That Black MSM/W Perceive as the Content Needed for a Human Sexuality Educational Model Designed to Train Addiction Professionals

(1) Topics for a human sexuality model for addiction counselors

“To help [counselors] understand how substance abuse plays into the sexual acts that go on between MSMs and substance abuse . . . coming into a facility and you feel like you have an issue like sexuality and that facility is not equipped to handle that.”

“We found our safe haven in getting high. Because there were people like myself that wanted to do the same thing that I wanted to do. They was escaping. The fact of being molested, the fact of being raped, the fact of being rejected.”

“I am getting high with dudes and when I was getting high I would get horny.”

“Need to talk about different forms of sex, oral sex, anal sex, water sports, those types of things and how transmission can be passed in every sexual activity, even in use of sex toys and S&M practices.”

(2) Discrimination and stigmatization

“I was the only open gay male, it was assumed that I’m screwing everybody in the place in the program.”

“I’m sorry, disclosure. Your status. Sometimes I didn’t feel comfortable with certain counselors due to the fact that I knew counselors knew certain people . . . our community is small so we interact with each other.”

“If I’m not behaving a certain way, if I tell him [the counselor] that I slept with a man, then automatically I see his [the counselor] body change . . . if I have those kinds of barriers then how forthcoming am I going to be with him when it relates to my drug treatment . . . that’s why there’s still the need to have more of this work [sexual identity education] done because the more you sensitize and educate those perspective counselors along with the curricula that they’ve been given . . . they’re going to be more efficient.”

(3) Sexual trauma

“The first time I had a sexual orgasm was with a man. . . . I didn’t know you’re not suppose to like it. You’re not supposed to like no sex at 11, 12 years.”

“You’re not supposed to know about it.”

“When you’re a child and you get exposed, you get predisposed to sexual activity at a young age. . . . You don’t have a sense of balance, of morality, because it was stolen from you. . . . My choices were taken away from me because a man decided to rape me.”

(4) Multifaceted treatment approach

“I think addiction counselors would be well versed in having conversations as it relates to contradictions with meds and the drugs and the sexual activity and the likelihood of becoming infected.”

“Talk about what happens to the penis, what happens to the anus and get into that and how susceptible they [MSM] both are to HIV transmission.”

(5) HIV program needs

“One of the things that I would hope to get out of it [treatment] would be to be in an environment where I was with brothers who were not afraid to talk about the things that really affected them . . . knowing that we would be in a safe environment and we could just let our hair down.”

“That’s how I got infected, working the street, hustling, getting caught by the police, getting locked up . . . it’s a lot of pain out there.”

“It got a little hectic for a moment, simply because with nothing happening with my HIV, I honestly lived like didn’t have it. That means there was unprotected sex.”

“I think there should be a greater emphasis placed on sensitivity, whether it be gender sensitivity or sexual orientation sensitivity training.”

Topics for a Human Sexuality Model for Addiction Counselors

Participants suggested that an HSEM is needed to help addiction counselors confront their biases about sexual minorities in general. Participants identified five distinct topics to be included in the HSEM to train addiction professionals to better work with the Black MSM/W community. The topics included were (a) language used among the MSM/W community, (b) knowledge about the within-group differences that exist among the Black MSM and MSM/W communities, (c) the drug choices most prevalent among the Black MSM/W community, (d) HIV-prevention messages that are specific for addressing the Black MSM/W community, and (e) skills to use a nonjudgmental (person-in-environment) approach for working with sexual minorities in treatment.

Discrimination and Stigmatization

Responses revealed that homophobia was an issue among addiction counselors and that participants did not perceive the treatment environment to be a space where they could disclose their same-sex sexual behavior in therapy. Furthermore, participants discussed their experience with discrimination by counselors during the treatment process. In addition, participants indicated that the homophobia, stigmatization, and discrimination may result in a possible barrier to a successful completion of treatment. Participants also noted their desire to discuss their HIV-seropositive status yet how difficult it can be to disclose their status in treatment.

Sexual Trauma

Many of the participants disclosed their history of sexual/violent trauma, which mostly occurred during early childhood (aged ≤5 years) and middle childhood (aged 6-12 years). The data strongly suggested a need for identifying trauma and exploring effective treatment approaches to address childhood trauma, particularly sexual trauma. Participants stated that they did not address sexual trauma during drug treatment. At least two participants per focus group discussed a history of sexual trauma as a child by another male, reporting that they feared that disclosing their history of sexual trauma would make others associate them with being gay (or an MSM). Some of the participants discussed that sexual trauma might be the reason they have sex encounters with other men (even though all the participants self-identify as heterosexuals and state that they have had sex with other men only for drugs or money for drugs).

Multifaceted Treatment Approach

Participants reported needing a multifaceted approach that services the various needs of the Black MSM/W clients with a comprehensive approach to care, support, HIV information/education, and advocacy for MSM clients. Participants’ responses revealed that drug treatment should not be an isolated event; rather, a successful [effective] treatment should involve a comprehensive approach. This approach should include providing addiction professionals training that emphasizes the importance of a safe space conducive for Black MSM/W who may have been involved in same-sex behavior only as a means of getting money for drugs.

HIV Program Needs

Participants expressed the need for providers to better understand how the substance abuse and sexual behaviors of MSM/W are interconnected. Moreover, participants discussed the need to have an environment that is conducive for them to openly discuss issues about their sexuality. Participants suggested that in some cases their sex trading behavior could lead to unsafe sexual practices. Thus, a substance abuse program that will encourage MSM/W to talk about their sexuality, sex trading, and HIV risk behaviors is needed.

Participants suggested that a comprehensive approach to care is needed. The comprehensive care would include HIV information/education and advocacy for MSM and MSM/W clients. Participants emphasized the need to have an HIV-prevention/education program that focuses on exclusively MSM sexual behaviors, such as multiple sex partners, and material that discusses different high-risk sexual practices that MSM/W may engage with other male sex partners. In addition, participants reported that spirituality may be a base for creating an alliance with African American MSM clients.

Discussion

The emphasis of this study was not only on clinical issues but also on the institutional/societal oppression experienced by Black MSM/W in traditional substance abuse treatment environments. The major findings of this study were twofold. First, it was identified that Black MSM/W experienced a range of homophobic attitudes, acts of stigmatization, and discrimination in traditional drug treatment programs from addiction professionals, and further the culture and climate of the drug treatment environments are not perceived as a safe space where the Black MSM/W could disclose their same-sex sexual behavior in therapy. Second a high prevalence of childhood sexual abuse was reported among this population that is underassessed and unaddressed. Moreover, as indicated in previous research, this lack of cultural competency to serve sexual minorities affects attitudes and behaviors across the macro/cultural and micro/individual levels (Kite & Deaux, 1986; Whitley & Ægisdóttir, 2000). Hence, these experiences may result in a possible barrier to both retention in and successful completion of treatment.

To adequately address this issue it is important to take a broad approach. To systemically change an institutional culture on a macro level, it is recommended that states develop policies requiring that programs licensed to provide substance abuse services employ counseling staff who can document that they have been trained in cultural competency and human sexuality specifically relevant to sexual minorities including Black MSM/W. When states have adopted policies regarding the quality of services provided, there has been a positive impact on programs (Chriqui, Terry-McElrath, McBride, & Eidson, 2008). Moreover, certifying boards that credential addiction counselors can require both candidates for certification and addiction professionals applying for recertification to provide evidence of training and education in cultural competency and human sexuality. Nationally, less than 30% of state credentialing organizations require training in cultural diversity and human sexuality is not a requirement (Kerwin, Walker-Smith, & Kirby, 2006). Furthermore, because addiction counseling is learned to a large degree through apprenticeship (Horvatich & Wergin, 1998), accrediting bodies such as the Joint Commission and Commission on Accreditation of Rehabilitation Facilities and the Commission on Accreditation may be prompted to consider sexual orientation as well as race and ethnicity when they assess cultural diversity in the human resource practices of programs they evaluate; it is important that the staff reflect the populations they serve in behavioral health programs (Office of Minority Health, U.S. Department of Health and Human Services, 2000; Wells et al., 2007). When an organizational environment is nonheterosexist, the counseling staff is positively influenced and conceptualizes sexual minorities as cultural minorities (Barrett & McWhirter, 2002; Bieschke & Matthews, 1996). Furthermore, drawing from the experience of related disciplines it has been established that training in and of itself is not sufficient to implement new practices; there must be purveyors to model the desired attitude and behavior (Blasé, 2007). On a micro level, the components of human sexuality training models should allow addiction treatment and prevention professionals the ability to identify any personal biases and through this awareness not to allow those personal biases to influence treatment with Black MSM/W. Research sampling over 350 addiction professionals in both rural and urban environments has demonstrated that almost half of the addiction professionals reported having ambivalent or negative attitudes regarding sexual minorities and limited knowledge of the needs specific to this population, particularly the effects of both external and internal homophobias on recovery (Eliason, 2000; Eliason & Hughes, 2004).

In addition, the HSEM should include content to help the counselors better understand the diversity within the Black MSM/W community. The model should aim to challenge the assumption that all Black MSM/W self-identify as gay or bisexual. Increased knowledge about the continuum of human sexuality may further assist addiction professionals to explore their own biases about sexuality and MSM/W and better prepare them to address HIV prevention. Achieving a degree of fluency in the language and idioms of this culture as well as gaining an understanding of the types of risky behavior that drug use, sex work, and the contextual sexual experiences while incarcerated have within the Black IDU-MSM/W population may serve to build the therapeutic alliance and to engage and retain these clients in the treatment process. Because MSM/W may not report same-sex behavior, HIV-prevention programs targeting heterosexual males should consider the need to provide support for bisexual men and gay men who are potentially experiencing internalized and externalized homophobias (Washington et al., 2006).

Our second major finding revealed that many of the participants had a history of child sexual abuse (CSA). Even though the relationship between substance abuse and CSA among MSM has been well documented (Brennan, Hellerstedt, Ross, & Welles, 2007; Welles et al., 2009), the prevalence of CSA reported among the Black MSM/W in our clinical sample was a surprising finding. In addition, it was revealed that many of the men did not discuss CSA during drug treatment. This is a major issue to address in substance abuse treatment with Black MSM/W with a history of sex trade, as each of these issues can coexist (Orellana, El-Bassel, Gilbert, Wu, & Epperson, 2008) and may be a barrier to completing treatment. Thus, counselors should understand how to, and the need for, assessing sexual trauma in Black MSM/W. Janikowski and Glover-Graf (2003), in examining the qualifications, training, and perceptions of addiction professionals who work with victims of incest, found that the majority of addiction programs routinely screen for CSA on intake. Although in this same study 24% of the clients reported being victims, the addiction professionals estimated that almost half of their clients had experienced CSA; counselors further reported that the primary client-related barrier to disclosure were related to shame and trust and that the counselor-related barriers to intervening were related to competency in dealing with the issue, for reasons that included a lack of training, insufficient time, insufficient resources, and a lack of support from administration.

Summary

Again, the current findings suggest that substance abuse programming is needed to encourage MSM/W to talk about their sexuality, sex trading, and HIV risk behaviors. Treatment should address issues related to the whole person and the behaviors that might be triggered by drug abuse. For example, an injection drug using MSM/W who has been involved with trading sex for drugs may need a program that will not only address the substance abuse but will simultaneously address co-occurring HIV risk behaviors, such as multiple sex partners and the sex trade. A comprehensive program may thus help reduce the chance of relapse should MSM/W complete treatment without addressing all relevant issues, particularly internalized homophobia. The well-established best practice model of providing services for substance abuse and co-occurring mental health disorders is that they should be expected, not considered an exception (Minkoff, 2001); that same practice can be applied to expecting sexual trauma has occurred among all clients applying for substance use services. Considering that addiction professionals are frontline workers with their clients and have an impact on their treatment services, an HSEM for addiction professionals may be useful to increase their knowledge of the existence of several dimensions related to sex and sexual behavior.

This study’s findings may be used to develop hypotheses that might be tested regarding an association between CSA history, HIV-seropositive status, and substance abuse history. Future research should include a larger sample with reliable measures to examine the impact of a human sexuality model to effect change on addiction professionals’ treatment practices with Black MSM/W. Furthermore, future research is needed that examines the effects of an HSEM that aims to increase knowledge among addiction professionals about Black MSM/W and HIV messages specifically for Black MSM/W, on the climate and culture. It is again important to realize that training is only part of the equation in institutional change.

There are a number of limitations to this study. First, the use of focus groups does not allow for an exploration of extraneous variables (e.g., frequency of CSA, drug use). Moreover, the participants were from different treatment programs, thus the differences in the participants’ perceptions could be influenced by different environments or length of time in treatment. Furthermore, qualitative data may have been overreported or underreported. However, this study is a first step to understand more about the treatment needs of Black MSM/W involved in sex trade and how addiction counselors may better work with this population.

Footnotes

The author(s) declared no potential conflicts of interests with respect to the authorship and/or publication of this article.

The author(s) received no financial support for the research and/or authorship of this article.

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