Associations Between Crystal Methamphetamine Use and Potentially Unsafe Sexual
Activity Among Gay Men in Australia
Patrick Rawstorne, Ph.D., Erol Digiusto, Ph.D., Heather Worth, Ph.D., and Iryna Zablotska,
National Centre in HIV Social Research, University of New South Wales, Sydney, Australia.
Dr Erol Digiusto
It has been suggested that crystal methamphetamine may have disinhibiting or aphrodisiac
effects, which may lead to unsafe sexual behavior and increase the risk of HIV transmission.
Using data from two ongoing Australian studies, the Sydney Gay Community Periodic Survey
(SGCPS) study and the Positive Health (PH) cohort study, we examined changes over time in
use of crystal, other recreational drugs, and Viagra, and in a range of sex-related behaviors.
Compared to non-users, crystal users reported having more sex partners, looking for sex in
more types of venues, and being more likely to engage in unprotected anal intercourse with
casual partners (UAIC) and in esoteric sex. Crystal users were also more likely to be using
other recreational drugs and Viagra than non-users. Crystal use remained significantly
associated with UAIC after adjustment for other relevant variables in a log-binomial regression
analysis (adjusted prevalence rate ratio = 1.26; 95% CI: 1.19-1.34). The other variables (HIV
status, number of sex partners, number of types of venue where men looked for sex, Viagra
use, other drug use) were independently associated with UAIC, and did not show confounding
or mediating effects on the crystal-UAIC association. Nevertheless, these data do not allow
reliable attribution of higher levels of these sex-related behaviors among crystal users
specifically to the effects of crystal. The prevalence of crystal use among Australian men who
have sex with men (MSM) increased between 2002 and 2005, e.g. from 26% to 39% among
HIV-positive MSM. However the prevalence of UAIC remained stable or decreased over time
in various study subgroups, as did the prevalence of other sex-related behaviors, suggesting
that crystal use does not necessarily drive unsafe sexual behavior. Crystal use and unsafe
sexual behavior can, and should, be considered and addressed separately in health promotion
and community education campaigns.
KEY WORDS: methamphetamine; crystal; HIV; unsafe sex.
“Crystal” methamphetamine is a synthetic central nervous stimulant drug, which can
enhance the pleasure involved in many activities, increase energy and endurance, increase
alertness, help a person to stay awake for long periods of time, and can produce a euphoric
effect that is sustained for many hours. Recent surveys of the general community have
recorded low prevalence of crystal use by adults of 0.6% in the U.S. (Substance Abuse and
Mental Health Services Administration, 2005), 0.9% in New Zealand (Wilkins, Pledger,
Bhatta, & Casswell, 2004), and 1.2% in Australia (Australian Institute of Health and Welfare,
2005). However, there is increasing concern in many countries about the increasing rates of
recreational crystal use among gay men.
Crystal is commonly believed to have “disinhibiting” effects, particularly with regard to
sexual activity, sexual risk-taking, and adventurous sexual practices that may carry risk of HIV
transmission, such as those that involve blood. Semple, Patterson, and Grant (2004) found that
86% of HIV-negative heterosexual crystal users who participated in a sexual risk reduction
intervention reported having engaged in marathon sex while using crystal. Several studies have
found statistically significant associations between crystal use and risky sexual behavior in
community samples. Farabee, Prendergast, and Cartier (2002) surveyed 807 prison inmates and
found that those who had been using crystal prior to being jailed were more likely to report
having had unprotected sex with a casual partner and unprotected sex with an injecting drug
user. Bogart et al. (2005) studied 698 injecting drug users and found that those who injected
amphetamines were less likely to consistently use condoms. Wohl et al. (2002) carried out a
case-control study of HIV-infected and uninfected heterosexual males and found that a history
of injecting crystal was associated with HIV infection.
In contrast to the relatively low rates of crystal use in the general population, surveys of
men who have sex with men (MSM) have recorded markedly higher prevalence: 6% in a
national online survey in the U.S. (Hirshfield, Remien, Humberstone, Walavalkar, & Chiasson,
2004) and 10-16% among samples recruited in gay community venues and clinics (Fernandez
et al., 2005; Hull et al., 2004, 2005; Purcell, Moss, Remien, Woods, & Parsons, 2005). Van de
Ven, Rawstorne, Crawford, and Kippax (2002) reported an increasing incidence among
Australian gay men of using crystal to enhance sexual pleasure, and a concurrent increase in
unprotected anal intercourse with casual partners (UAIC). These increases, which have also
been observed in other jurisdictions, have prompted research regarding the possible association
between crystal use and unsafe sexual behavior and thereby with transmission of HIV. Semple,
Patterson, and Grant (2002) interviewed 25 HIV-positive MSM and found that 84% reported
engaging in high risk sexual behavior, such as unprotected anal sex or sex with anonymous
partners, when using crystal. Several large surveys of MSM have found that crystal users were
more likely than non-users to engage in unsafe sexual activities that carried a risk of
transmitting HIV (e.g., Hirshfield et al., 2004; Morin et al., 2005; Urbina & Jones, 2004).
gay men in several countries over the past few years. Annual incidence rates of new HIV
diagnosis among gay men in the U.S. were stable from 2001 to 2003, but increased 8% in 2004
(Centres for Disease Control, 2005); in Britain, there has been a small but steady increase in
HIV diagnoses among gay men since 1999 (Macdonald et al., 2004); in New Zealand, there has
been an upward trend in new diagnoses among MSM since 2000 (Johnston, Fernando, &
MacBride-Stewart, 2005); sero-surveillance in Australia has indicated a recent increase in the
incidence of newly-acquired HIV infection amongst MSM (National Centre in HIV
Epidemiological and Clinical Research, 2004).
In this paper, we report recent Australian data regarding crystal use, unsafe sexual
behavior, and the association between them, using the data from two ongoing studies of gay
men: the repeated cross-sectional Sydney Gay Community Periodic Survey (SGCPS) and the
prospective longitudinal cohort Positive Health (PH) study of HIV positive gay men.
Specifically, we report data regarding whether crystal-using MSM engage in more sex, more
adventurous sex, have more sexual partners, more unsafe sex, and look for sex in more types of
locations, and whether changes in crystal use over time have been accompanied by similar
changes in potentially unsafe sexual behavior.
Data extracted from two studies are presented in this article, the Sydney Gay
Community Periodic Survey (SGCPS) and the Positive Health (PH) study. For this article,
SGCPS data from 7,354 men who were recruited in 2002-2005 were analyzed. In the 2005
sample, the median age of men in the study, 95% of whom identified as gay or homosexual,
was 36 years, with 65% aged under 40 years. The majority of participants were employed
(75% full-time, 10% part-time), and 55% held a university degree. Most participants lived in
metropolitan Sydney (82%) or elsewhere in the state of New South Wales (5%), but 13% were
visitors to Sydney. PH data from 448 participants who contributed 804 observations in 2002-
2005 were used in the analyses that are reported in this article. The median age of PH
participants was 43, 44 and 46 years in 2002/3, 2004, and 2005, respectively. In the 2005
sample, 27% of participants were aged less than 40 years, most were employed (54% full-time,
25% part-time), 41% held a university degree, and their median time since being diagnosed
with HIV was 14 years (1 – 24 years).
Measures and Procedure
Both the SGCPS and the PH study were approved by the University of New South Wales
Human Research Ethics Committee. The SGCPS started in 1996 and is a twice-yearly, cross-
Indeed, there has been an increase in the annual number of new HIV diagnoses among
sectional survey of gay and homosexually active men (MSM) who are recruited at a range of
sites in Sydney, including gay social venues, gay sex-on-premises venues, gay men’s health
clinics, and the Annual Gay and Lesbian Mardi Gras Fair Day (Van de Ven, Prestage, French,
Knox, & Kippax, 1998). The SGCPS uses a self-administered questionnaire to collect data
regarding sexual behaviors, unprotected anal intercourse (UAI), HIV status, recreational drug
use, and demographic characteristics. Recruiters visit the venues at scheduled times and invite
each person who arrives to participate; participation rates in 2002-2005 were 67%, 67%, 72%,
and 76%, respectively. It is possible that some individuals participated on more than one of the
cross-sectional survey occasions. Positive Health (PH) is an open longitudinal cohort of gay-
identified, HIV-positive MSM which started in 1999. PH enrols people who volunteer through
HIV-positive organisations and events, general gay community organisations and events, HIV
treatment clinics, advertisements, websites, and word-of-mouth in urban and rural locations in
New South Wales and Victoria (two Australian states). Participants completed annual
interviewer-administered questionnaires which collected information about their knowledge of
HIV/AIDS treatments, treatment uptake and cessation, difficulties with adherence to treatment
drug regimens, treatment side effects, and sexual practices (Rawstorne, Prestage, Grierson,
Song, Grulich, & Kippax, 2005). It is not possible to specify a participation rate for PH,
however the participant retention rates ranged from 75% - 79% for the interview phases
between 2002 and 2005.
Data from the SGCPS and PH studies were used to examine the associations between
use of drugs (viagra, crystal, other illicit drugs) and sex-related behavior (unprotected anal
intercourse, number of sex partners, engaging in adventurous/esoteric sex, number of types of
venues where men looked for sex). We also compared behaviors of HIV positive versus HIV
Unprotected anal intercourse with casual partners (UAIC, No vs. Yes) as a marker of
potentially unsafe sex was based on reported occurrence of any UAIC in the past six months in
SGCPS, and was based on the reported number of episodes of UAIC in the PH study (the
relevant questions that were asked in the two surveys were different). Participants’ level of
sexual activity was measured in terms of their number of sex partners (less than 10 vs. 10 or
more in a six-month period; the dichotomy was based on the distribution of the variable).
SGCPS collected information about the total number of casual and regular partners, whereas
the PH cohort reported specifically on their numbers of casual partners.
The SGCPS also collected data regarding use of drugs other than crystal, including
marijuana, ecstasy, amyl nitrite (“poppers”), ketamine (“special K”), cocaine, GHB, and
Viagra. The variable “other drug use” (No vs. Yes) indicated use of any of those drugs apart
from crystal or Viagra. Recent studies have indicated an increasing trend in concurrent use of
crystal and Viagra, and have suggested a possibility that both drugs may be involved in the
increasing HIV incidence (Elford, 2006; Purcell et al., 2005), so we constructed a separate
binary variable for Viagra use (No vs. Yes). Finally, SGCPS participants’ self-reported
serostatus (HIV-positive vs. HIV-negative) was used to compare the behaviors of those two
The concept of gay adventurous sex was suggested by Kalichman, Heckman, and Kelly
(1996), and its association with UAIC and seroconversion was reported in Australian studies of
gay men (Kippax at al., 1998). Using PH data, a variable with three categories (0, 1-2, and 3 or
more relevant types of sexual activity) was created, based on that variable’s distribution, to
summarize the number of the following activities that men had engaged in with casual sex
partners during the previous six months: fisting (receiving, giving), use of toys/dildos
(receiving, giving), engaging in sado-masochistic activities (with blood, without blood),
engaging in “water sports”, and engaging in group sex (with men only, with both men and
women). The number of types of venues where men reported looking for sex may be also
indicative of their sexual adventurism. Thus, we summarised the number of types of different
venues where men reported looking for sex (including venues such as social functions for HIV
positive men, dance parties, gay community scenes, gay non-scenes, leather, bear, drug, gym,
trainee/drag and other scenes, sexual venues, and internet chat rooms) and generated a binary
variable (0-1 versus 2 or more venues).
We examined trends over time (i.e., study years) in crystal use, other drug use, UAIC,
and other sex-related behaviors in the six months prior to each interview, analyzed separately
by study and HIV status of participants. We also examined differences between crystal users
versus non-users in terms of sexual behavior and other drug use in each study year.
Associations between pairs of binary variables were assessed with χ2 tests, and trends over time
were assessed with χ2 tests for linear trend. We examined the association between crystal use
(No vs. Yes) and UAIC (None vs. Any) among SGCPS participants using multivariate log-
binomial regression and estimated prevalence rate ratios (PRRs). The effects of variables
measuring behaviors such as number of partners, number of venues where men looked for sex,
Viagra use, other drug use, and self-reported HIV status on the relationship between crystal use
and UAIC were examined in bivariate analyses and in multivariate regression models. All
significance testing was carried out on a two-tailed, decision-wise basis with alpha level of .05.
Table I shows that crystal use among MSM increased significantly from 2002 to 2005,
among both HIV positive men (χ2 = 4.19, p < .001), and HIV negative men (χ2 = 6.25, p <
.001) in the SGCPS, and among participants in the PH study (χ2 = 4.62, p <.001). In contrast,
as shown in Table II, there was a marginally significant downward trend in UAIC prevalence
over time among SGCPS HIV negative participants (χ2 = -1.94, p =.05), and no significant
change over time among the other two participant groups.
Insert Tables I and II about here
prevalence in the SGCPS; 47-54% of crystal users reported having engaged in UAIC in each of
the four study years compared with 28-33% of non-users (all p values < .001). Table IV shows
PH data regarding the relationship between crystal use and the number of casual sex partners,
the number of different types of venues where men looked for sex partners, and the extent to
which HIV-positive men engaged in esoteric sex. There was a non-significant decrease across
survey years in crystal users’ having had 10 or more casual sex partners, and a significant
increase over time in the prevalence of non-users having had 10 or more partners. Crystal users
were significantly more likely than non-users to have had 10 or more partners in 2002/03, but
the differences were no longer significant in 2004 or 2005. There were significant associations
in all three PH study years, between crystal use and both the number of different types of
venues where men looked for sex partners and the number of different types of esoteric sex that
men engaged in; the prevalence of high levels of both variables among crystal users was 1.6 –
2.6 times the prevalence among non-users (all p values < .01). The trends across time in both
variables among both participant groups were non-significant, except that the prevalence
among crystal users of having looked for sex in two or more types of venues decreased
significantly over time (p < .05).
Insert Tables III and IV about here
Table V shows the prevalence during each of 2002 to 2005 of five behavioural
variables among HIV-positive and HIV-negative men in the SGCPS who reported either using
or not using crystal. The five variables were: having had more than ten regular or casual
partners, use of Viagra, use of other drugs, having looked for sex in three or more different
types of venues, and having had any UAIC in the previous six months. In 36 of the 38
comparisons between groups, a larger proportion of crystal users than of non-users reported
having engaged in the investigated behaviours; two-thirds of the 38 comparisons were
significant at a p-level of < .001. Examination of behavioural trends over time showed that,
among HIV-positive participants, Viagra use increased significantly among crystal non-users,
and the prevalence of having had 10 or more sex partners decreased significantly among both
crystal users and non-users. Among HIV-negative participants, the prevalence of Viagra use
and other drug use increased significantly over time among crystal users, and the prevalence of
other drug use and of UAIC decreased significantly among crystal nonusers. All of the other
trends were not statistically significant.
Insert Table V about here
Table III shows that there was a significant association between crystal use and UAIC
that other behaviors may have influenced the relationship between crystal use and UAIC
(Table VI). The regression model was constructed using data from the SGCPS and included six
variables: crystal use, Viagra use, other drug use (excluding Viagra), number of sex partners,
number of different types of venues where men looked for sex, and participants’ HIV status.
There was a significant association between crystal use and UAIC (unadjusted PRR = 1.64;
95% CI: 1.59-1.68). After the inclusion of the other variables in the model, the magnitude of
this association decreased but remained significant (adjusted PRR = 1.26; 95% CI: 1.19-1.34).
Each of the other variables that were examined remained independently significant predictors
of UAIC in the final regression model. Specifically, the likelihood of having engaged in UAIC
was increased among participants who: used Viagra, used other drugs, had more than 10 sex
partners, looked for sex in three or more types of venue, and were HIV negative.
Insert Table VI about here
We found that crystal users were more likely to engage in a range of potentially risky
sex-related behaviors than non-users. The SGCPS study found that crystal users reported
having had significantly more sex partners than non-users in each of the four study years, but
the PH study found a significant relationship between number of sex partners and crystal use
only in 2002/03. PH found that crystal users looked for sex in more types of venues than non-
users in all three study years; SGCPS found such a difference in three of the four study years
among HIV-negative respondents, and in two study years among HIV-positive respondents.
SGCPS found that crystal users were more likely to engage in UAIC than non-users in all four
study years. Finally, PH found that crystal users engaged in more esoteric sex than non-users in
all three study years. Our regression analysis of SGCPS data found that a set of relevant
behavioral variables (number of sex partners, number of venues where men looked for sex, use
of Viagra, and use of other drugs), were independently associated with UAIC, and did not
indicate a confounding or mediating effect on the association between crystal use and UAIC.
These findings were consistent with those of other published studies which have found
associations between crystal use and risky sexual behavior (Halkitis, Parsons, & Stirratt, 2001;
Kalichman, Heckman, & Kelly, 1996; McKirnan, Valnable, Ostrow, & Hope, 2001; Molitor,
Truax, Ruiz, & Sun, 1998; Urbina & Jones, 2004). Taken at face value, such findings appear to
support the idea that crystal use may be a cause of unsafe sexual behavior, thereby contributing
to the increasing HIV incidence that has been observed among gay men in recent years in
several Western countries.
However, if crystal use were causing a significant proportion of UAIC, one would
expect to see any changes in the prevalence of crystal use over time reflected in proportional
A multivariate regression analysis was conducted in order to examine the possibility
changes in the same direction in the prevalence of UAIC. Our data demonstrated an increasing
prevalence of crystal use in the MSM community in Australia in recent years. For example, the
SGCPS found that, between 2002 and 2005, the reported prevalence of crystal use in the past
six months increased from 26% to 39% among HIV-positive MSM, and from 14% to 22%
among HIV-negative men. These levels of use of a very addictive and potentially quite
dangerous illicit drug are higher than have been reported in recent U.S. studies of MSM
(Fernandez et al., 2005; Hirshfield, et al. 2004; Purcell et al., 2005).
However, the increasing use of crystal in our studies was not accompanied by an
overall increasing prevalence of UAIC, which, in fact, decreased significantly over time among
SGCPS HIV-negative participants, and which showed no significant change among SGCPS
HIV-positive participants, or among PH participants. Generally similar trends were observed in
terms of other sex-related behaviors. PH found no change over time in the number of types of
esoteric sex that were engaged in by either crystal users or non-users; the prevalence of having
looked for sex in two or more types of venues decreased among crystal users, and did not
change among non-users; there was no change over time in the prevalence of having had 10 or
more casual sex partners among crystal users, but a significant increase over time in this
variable among non-users. SGCPS found that the number of different types of venues where
men looked for sex did not change over time among either crystal users or non-users; the
prevalence of having had 10 or more sex partners decreased significantly among HIV-positive
crystal users and non-users, and did not change among either group of HIV-negative
SGCPS found that crystal users were more likely than non-users to have used other
recreational drugs and Viagra in all four study years; 63-76% of the HIV-positive and 41-55%
of the HIV-negative crystal users had used Viagra, and more than 97% of crystal users in both
of the HIV-status subgroups had used other recreational drugs in each study year. Among
crystal users, the prevalence of Viagra and other drug use in each year was two to three times
higher than the corresponding prevalence among non-users. The prevalence of Viagra and
other drug use increased over time among HIV-negative crystal users, but did not change
among HIV-positive users. In these circumstances it would be impossible to reliably attribute
any type of behavior among crystal users specifically to crystal.
In summary, crystal users in our PH and SGCPS studies were clearly engaging in more
potentially risky and more “adventurous” sexual and drug using behaviors. However, our
analyses were not able to test or confirm causality in the relationship between crystal use and
UAIC or other sexual behaviors; the findings presented herein provide evidence only of
correlational associations. Halkitis et al. (2001) reported similar findings and interpreted them
as indicating that crystal may attract a hypersexual group of risk-takers who are already
predisposed to engaging in unsafe sex regardless of their crystal use.
We propose a more sociological explanation of the relationships between UAIC, other
sex-related behaviors and crystal (and other recreational drug) use. As Kippax and Stephenson
(2005) have suggested, “sexual practice (safe or unsafe) is a social and cultural practice
embedded within a particular historical time and place and embedded in specific locations and
formations” (p. 363). Drug use has been a part of gay sexual culture since at least the 1960s,
but the particular drug of choice has changed over time. The relationship between unsafe sex,
drug use, and esoteric sex is complex. For some gay men, UAIC may occur while using crystal
and in environments where adventurous or esoteric sex is taking place. However, we do not
have any conclusive evidence about the proportion of unsafe sex practice that is directly caused
by crystal use per se. The statistical associations that have been observed between crystal use
and unsafe sex may actually be due to other variables that they are both correlated with,
including relationship status, personality factors, mental health, community norms in gay sub-
cultures, exposure to situations and environments in which both drug use and adventurous sex
occur, and socially-mediated expectations about the effects of crystal and other drugs (Colfax
et al., 2004; Purcell et al., 2005; Rhodes, 1996). The increasing prevalence of crystal use
observed in our studies was associated with either a decrease or no change over time in the
prevalence of UAIC, illustrating the fact that these two problems are at least somewhat
independent, and can, and should be considered and addressed separately. We should take care
not to misdirect health promotion and community education resources that are aimed at
reducing potentially unsafe sexual behavior by focusing too narrowly on crystal itself or on
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The New South Wales Health Department, Australia, provided funding for the Positive
Health Cohort (RMT2798) and the Sydney Gay Community Periodic Survey (RMT2799). We
gratefully acknowledge the sustained involvement and contribution of Peter Hull, Garrett
Prestage, Andrea Fogarty, and Susan Kippax in the studies that generated the data that are
Table I. Prevalence (%) of any crystal use in the six months prior to interview, by survey year,
study, and HIV status
2002 2003 2004 2005
χ2 value for
*** p < .001
1 The data shown for PH HIV+ men in 2003 were collected in 2002-2003.
Table II. Prevalence (%) of any unprotected anal intercourse with casual partners (UAIC) in
the six months prior to interview, by survey year, study, and HIV status
χ2 value for linear
trend across years
320 (63.1%) 263 (61.6%) 283 (60.8%) 321 (59.2%) - 1.04
1,434 (31.4%) 1,232 (30.1%) 1,320 (30.4%) 1,503 (27.7%) - 1.94 *
345 (68.7%) 235 (49.8%) 224 (62.9%) - 1.88
* p = .05
1 The data shown for PH HIV+ men in 2003 were collected in 2002-03.
Table III. Relationship between crystal use and unprotected anal intercourse with casual
partners (UAIC): SGCPS study, 2002-2005
Was crystal used in
the past six months?
No UAIC Some UAIC
*** p < .001
Table IV. Prevalence (%) of behaviors by survey year and crystal use: PH study, 2002-2005
χ2 value for linear
trend across years
2002/03 2004 2005
Number of casual partners
10 or more
χ2 for users vs.
Number of different venue types
where men looked for sex
0 - 1
2 or more
χ2 for users vs.
Number of different types of esoteric sex
1 - 2
3 or more
χ2 for users vs.
22.6 ** 2.19 0.30 3.57 ** - 1.77
27.7 ** 27.1 ** 11.1 ** - 0.40 - 2.37 *
18.1 ** 38.2 ** 14.8 ** 0.54 - 0.60
* p < .05, ** p < .01
Table V. Prevalence (%) of risky behaviors by year, HIV status and crystal use: SGCPS study, 2002-2005
χ2 value for linear trend
Number of partners (regular + casual)
10 or more
Other drug use
Number of different venue types where men looked for sex
3 or more
7.7 ** 19.5 *** 4.6 * 6.6 * - 2.25 *
- 2.80 **
Table V continued.
6.9 ** 23.0 *** 21.8 *** 8.6 **
1 ND = No data available. Information on the types of venues where men looked for sex was not collected in 2002.
Number of partners (regular + casual)
10 or more
Other drug use
No. of different venue types where men looked for sex
3 or more
* p < .05, ** p < .01, *** p < .001
51.8 - 1.89
- 3.46 **
2.2 12.9 *** 27.5 *** 17.5 ***
72.1 *** 82.3 *** 141.8 *** 161.2 ***
83.4 *** 124.7 *** 163.3 *** 215.1 ***
6.9 ** 31.1 *** 4.8 *
17.0 *** 6.0 * 20.2 *** 25.7 ***
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Table VI. Relationship between crystal use and unprotected anal intercourse with casual
partners (UAIC) in the 6 months before interview: SGCPS study, 2002-2005 1
(N = 7,354)
Unadj. PRR 2
Adj. PRR 2
Other drug use
No. of partners (regular and casual)
10 or more
No. of different types of venues where
men looked for sex
0 - 2
3 or more
1 All regression models were adjusted for clustering by year
2 PRR = prevalence rate ratio