Identity matters in understanding gay and bisexual men's injecting drug use: a grounded theory study

Background: Gay and bisexual men (GBM) report higher rates of sexualised and injecting drug use compared to heterosexual men. Stigmatisation of people who inject drugs is linked to negative health outcomes, but sexual minority perspectives remain underrepresented. We explored injecting drug use among GBM in Melbourne, Australia, to elucidate identity and stigma processes at the intersection of drug use and sexualities.

Methods: In-depth qualitative interviews were conducted with GBM who inject drugs between June-October 2020. Interviews explored participants’ experiences and concerns related to drug use, pleasure, risk, and relationality in drug using contexts and beyond. Data were analysed using grounded theory methods.

Results: Interviewees (n=19) were between 24 and 60 years of age. Injecting histories ranged from two to 32 years; most injected methamphetamine (n=18) in sexual settings. Four themes were identified: (1) Fear of stigmatisation was mirrored in 'othering discourses', suggesting a hierarchical organisation of local gay communities by drug practices, HIV status, and masculine ideals. (2) 'Group membership' was facilitated through sexualised/injecting drug use, enabling sexual identities to be self-actualised. (3) 'Dynamic self-hood' distinguished narratives of men who self-identified as ‘drug addicts’ from those rejecting such labels and who experienced holistic wellbeing regardless of drug use and/or HIV status. (4) Emotional pain resulting from internalised stigma was seen to feed negative outcomes, but 'understanding who I was, was curative'.

Conclusion: Findings revealed that social exclusion processes resurface within gay communities through intrasex competition and hegemonic masculinities; influencing GBM’s sense of self and drug use careers. Inhabiting a positive self-concept appears critical to holistic wellbeing beyond the benefits experienced from sexualised drug use. Further de-stigmatisation of drug use and HIV-acquisition could support fostering the 'dynamic self-hood' underlying such positive self-concepts. Findings highlight the broader societal dynamics of status and power as feeding into any health disparities experienced by GBM.