Investigating Conceptual Models for the Relationship Between Depression and Condomless Sex Among Gay, Bisexual, and Other Men Who have Sex with Men: Using Structural Equation Modelling to Assess Mediation

Abstract

The aim of this study is to investigate five hypothesized mechanisms of causation between depression and condomless sex with ≥ 2 partners (CLS2+) among gay, bisexual, and other men who have sex with men (GBMSM), involving alternative roles of self-efficacy for sexual safety and recreational drug use. Data were from the AURAH cross-sectional study of 1340 GBMSM attending genitourinary medicine clinics in England (2013-2014). Structural equation modelling (SEM) was used to investigate which conceptual model was more consistent with the data. Twelve percent of men reported depression (PHQ-9 ≥ 10) and 32% reported CLS2+ in the past 3 months. AURAH data were more consistent with the model in which depression was considered to lead to CLS2+ indirectly via low self-efficacy for sexual safety (indirect Beta = 0.158; p < 0.001) as well as indirectly via higher levels of recreational drug use (indirect Beta = 0.158; p < 0.001). SEM assists in understanding the relationship between depression and CLS among GBMSM.

Opposing associations of depression with sexual behaviour: implications for epidemiological investigation among gay, bisexual and other men who have sex with men

“…In a previous analysis of sexually active GBMSM in AURAH, using structural equation modelling, there was evidence that depression was associated with CLS either by lowering one's self-efficacy for sexual safety or by leading to higher levels of recreational drug use, on a distinct causal pathway. 30 Similar findings have been observed in previous studies of sexually active US GBMSM 11 and South African GBMSM. w12 Data are needed to better understand the role of other factors such as intimate partner violence on the causal pathway between depression and STI/HIV transmission risk.…”

Psychosocial Mechanisms of Methamphetamine Use Among Gay, Bisexual, and Other Men Who Have Sex with Men: An Integrated Theoretical Approach

“…Given the strong association between sexualized methamphetamine use and sexual risk behaviours (e.g., condomless anal sex, multiple casual sexual partners), it seems likely that sexualized substance use, and sexualized methamphetamine use in particular, may further mediate the association between depression and sexual risk (i.e., depression cognitive escape sexualized substance use sexual risk behaviours). This is further supported by research demonstrating that, among GBM, depression was indirectly associated with condomless anal sex with multiple partners through higher levels of recreational drug use (Miltz et al, 2019). Future research would benefit from extending Model 1 to include sexual health outcomes to better understand how the variables in this model are associated with increased risk for HIV and STIs, indirectly through sexualized methamphetamine use.…”

“…However, recent findings suggest that the Escape Motives Scale may also measure an individual's motivation to use drugs as a means to cognitively escape from more general experiences of stress (Card et al, 2019). Additionally, there is research indicating that GBM may engage in recreational substance use a means to alleviate symptoms of depression or lessen feelings of inadequacy Miltz et al, 2019). The potential importance of cognitive escape as a mediating mechanism is also supported by the psychological mediation framework, which suggests that the association between distal stressors and adverse mental health outcomes is mediated by cognitive processes (e.g., cognitive avoidance, rumination; Hatzenbuehler, 2009).…”

Psychosocial Mechanisms of Methamphetamine Use Among Gay, Bisexual, and Other Men Who Have Sex with Men: An Integrated Theoretical Approach

“…Given the strong association between sexualized methamphetamine use and sexual risk behaviours (e.g., condomless anal sex, multiple casual sexual partners), it seems likely that sexualized substance use, and sexualized methamphetamine use in particular, may further mediate the association between depression and sexual risk (i.e., depression cognitive escape sexualized substance use sexual risk behaviours). This is further supported by research demonstrating that, among GBM, depression was indirectly associated with condomless anal sex with multiple partners through higher levels of recreational drug use (Miltz et al, 2019). Future research would benefit from extending Model 1 to include sexual health outcomes to better understand how the variables in this model are associated with increased risk for HIV and STIs, indirectly through sexualized methamphetamine use.…”

“…However, recent findings suggest that the Escape Motives Scale may also measure an individual's motivation to use drugs as a means to cognitively escape from more general experiences of stress (Card et al, 2019). Additionally, there is research indicating that GBM may engage in recreational substance use a means to alleviate symptoms of depression or lessen feelings of inadequacy Miltz et al, 2019). The potential importance of cognitive escape as a mediating mechanism is also supported by the psychological mediation framework, which suggests that the association between distal stressors and adverse mental health outcomes is mediated by cognitive processes (e.g., cognitive avoidance, rumination; Hatzenbuehler, 2009).…”