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This article describes changing definitions and models of harm reduction along with their practice applications. This article then provides an overview of harm reduction strategies for methamphetamine-using gay men and will conclude with suggestions for psychotherapists and clinicians who are, or who will be, working with this population. KEYWORDS. AIDS, bisexual men, crystal meth, gay men, harm reduction, HIV, homosexuality, men having sex with men (MSM), methamphetamine substance abuse

Methamphetamine addiction in men having sex with men (MSM) represents a particular challenge to the clinician. It requires attention both to the fundamental skills the client needs to acquire in order to attain abstinence, and to the client's level of motivation to change his behavior. What follows is a brief review of the state of the art of Motivational Interviewing (MI) and Cognitive-Behavioral Therapy (CBT) for addictions in general, and for crystal meth specifically. Much of the material presented here is not specific to treatment of crystal meth addiction in gay men; however, there are some aspects of treatment that are specific to treating crystal problems in MSM that are highlighted throughout this paper. This paper goes on to present the rationale and basic strategies encompassed by both motivation enhancement and skills-based treatment approaches. KEYWORDS. Addiction, cognitive-behavioral therapy, crystal methamphetamine, gay men, homosexuality, men having sex with men, motivation enhancement, motivation interviewing, skills-based treatment

There is a growing need for treatment services that specifically target methamphetamine for gay and bisexual men. There may be significant barriers for the client in engaging in a treatment program, including thought disturbances and paranoia. A high level of ambivalence in spite of extreme adverse consequences from use is also relatively common among those presenting for treatment. Many people do recover if they are willing to commit to a structured treatment plan. Models of treatment that have been shown to be successful include motivational interviewing (MI), cognitive behavioral therapy (CBT), and community reinforcement with contingency management. The Matrix Model was developed specifically for stimulant use disorders and includes many of these components as well as 12-step facilitation. Although it has been suggested that methamphetamine dependence may be more difficult to treat than other drug use dependence, empirical evidence suggests that success for methamphetamine treatment has not been shown to be different than for other stimulants, such as cocaine. KEYWORDS. Bisexual men, cognitive-behavioral therapy (CBT), gay men, homosexuality, matrix model, men who have sex with men (MSM), methamphetamine, motivational interviewing (MI), substance abuse treatment

This paper describes crystal methamphetamine (crystal) use and sexual risk behaviors for two web-based surveys of men who have sex with men (MSM). The subjects were recruited online. Crystal use was associated with young age, having a greater number of sex partners, having unprotected anal intercourse (UAI), having a sexually transmitted infection (STI), and being HIV-positive. Significant regional differences were seen in the prevalence of crystal use. Findings are discussed in relation to the need to integrate messages about the relationship between drug use and sexual behavior into HIV prevention programs. KEYWORDS. AIDS, crystal, gay, HIV, HIV prevention, homosexuality, Internet research, men who have sex with men (MSM), methamphetamine, STI, substance use, unprotected anal intercourse (UAI)

The purpose of this ethnographic study was to conduct an exploratory research investigation examining the phenomenon of barebacking among men-who-have-sex-with-men (MSM) on the Internet. The researchers selected a case sample of 100 MSM advertisers on an Internet bareback sex site to assess HIV transmission risk as related to HIV serostatus, partner selection, and sexual risk-taking. The data suggest that while intentionally seeking to transmit or contract HIV was extremely rare, a small proportion of advertisers appeared to be relatively indifferent to HIV transmission. However, the great majority of advertisers for bareback sex appeared to practice 'sero-sorting' or seroconcordant behavior by HIV status with potential sexual partners as a strategy to minimize HIV transmission risk. KEYWORDS. AIDS, anal sex, barebacking, bisexual men, gay men, HIV, homosexuality, Internet, men-who-have-sex-with-men (MSM), safer sex, seroconcordant, serodiscordant, sero-sorting, STI

HIV prevention programs and clinicians have a need to identify clients' attitudes toward unprotected anal intercourse (UAI). This study reports on the development of the Unprotected Anal Intercourse Attitudes Inventory (UAI-AI), a multi-factorial measure designed to assess gay and bisexual men who are HIV-negative or untested. This self-report measure may be useful in helping both counselors and clients discuss the complex psychosocial issues that can be associated with UAI and safer sex. Factors identified include Anger/Self-Destructiveness/Fatalism, Pleasure Seeking/Risk-Taking/Escapism, Intimacy Needs/Rational Choice Making, Erroneous Perception of Risk, and Condom Related Erectile Dysfunction. Based on their work with hundreds of clients at TalkSafe, a NYC prevention program for HIV-negative gay and bisexual men, the authors suggest clinical guidelines for counseling these populations. KEYWORDS. AIDS, anal intercourse, barebacking, gay and bisexual men, high-risk sexual behavior, HIV-negative MSM, homosexuality, safer sex, STI, Unprotected Anal Intercourse Attitudes Inventory

Some have raised concern that male sex workers (MSWs) serve as 'vectors of transmission' of HIV into the heterosexual community. Research on MSWs, however, has found that these men report unsafe sex more often with casual partners than with clients. In the mid-1990s, two new phenomena emerged: the Internet, providing a new way for MSWs to meet clients, and barebacking or intentional anal sex without condoms. Using qualitative and quantitative methods in an effort to understand the impact of these phenomena, this study sought to explore intentions for unsafe sex among MSWs who reach clients through the Internet. Findings suggest that most MSWs do not intentionally seek out sex without condoms or engage in barebacking. This does not denote the complete absence of sexual risk behaviors, particularly with casual partners as found in previous research. Interview data suggest that these men may be employing harm reduction strategies such as partner characteristics and sex role positioning in their decision making processes. These findings can be helpful to service providers who currently or plan to provide intervention services to members of this population. KEYWORDS. AIDS, anal sex, barebacking, condoms, gay men, harm reduction, HIV, homosexuality, male sex workers, MSW, prostitution, safer sex, sex workers, STI

The author's image of his body as small and weak was formed as a child but has remained with him although he is no longer physically weak. At times of emotional stress, he is susceptible to poor body image. A radical prostatectomy done after being diagnosed with prostate cancer eliminated the reliability of the author's erections and gravely affected his identity. In his recovery from surgery, the author realized that having reliable erections, not as a condition to sexual pleasure but simply having them, was a part of his identity. In the aftermath of cancer and major surgery, he doubts that his body will appear appealing to other gay men. In light of the after-effects of radical prostatectomy, and in consideration of intimations of mortality, he worries that he will not be loved. KEYWORDS. Body image, coming out, depression, erections, external identity, gay men, identity, internal identity, prostate cancer, prostatectomy

Although, the diagnosis of prostate cancer is devastating, the disease is highly treatable. Treatment, however, does have side effects that can drastically affect sexual function-both from a physiologic and psychological standpoint. This problem can be particularly difficult for gay men to deal with as many are too afraid or embarrassed to discuss altered sexual function with their physicians and sexual partners. Physicians may incorrectly assume that an unmarried male patient is not sexually active when he may, in fact, be very sexually active. Sexual dysfunction after prostate cancer treatment can include impotence or a weak erection, failure to ejaculate and anal discomfort. Radiation therapy may produce impotence that is of gradual onset often beginning after treatment has terminated. Surgery can produce impotence immediately after the operation that can gradually improve over time. External beam radiation can also affect a gay man's ability to have anal sex because of bleeding, diarrhea and discomfort. Younger men, men with less extensive prostate cancer and those who have had an active sex life before developing prostate cancer are less likely to experience difficulties with sexual function after cancer treatment. This article discusses treatment options for sexual dysfunction including medication, sexual aids, and surgery to restore erections. Communication between sexual partners and physicians is also crucial for dealing with alterations of sexual function. Sex with another man did not cause the prostate cancer and it will not cause it to return. KEYWORDS. Anal sex, cancer, ejaculation, erection, gay, homosexuality, impotence, leuprolide, masturbation, potency, proctitis, prostate gland, prostatectomy, radiation therapy, semen, sex, sexual function, sildenafil, tadalafil, vardenafil

A middle-aged gay man describes his experience and that of his partner in facing the diagnosis and treatment of prostate cancer. The author describes his reactions to various urologists and support groups. The author offers a candid look at the sexual and psychological issues he and his partner faced when dealing with prostate cancer and the side effects of its treatment. The paper highlights the importance of patient involvement in treatment. KEYWORDS. Biopsy, gay couple, homosexuality, impotence, libido, lycopene, prostate cancer, PSA, seed implants (brachytherapy), sexuality, side effects, sildenafil, support group, urologist

The author, a gay man diagnosed with prostate cancer at age 48, describes his experience deciding on a course of treatment and coping with sexual dysfunction following a prostatectomy. His experience was made more difficult by ignorance in the medical community, the straight community and the gay community. Frustrated by the absence of a source of fully accepting and understanding support, he started his own support group for gay men with prostate cancer. KEYWORDS. Dry orgasm, erectile dysfunction, gay community, gay support group, prostate cancer, prostatectomy, sexual dysfunction, support group

This is an overview of the causes, screening guidelines and treatments for prostate cancer. The paper also highlights issues of particular concern to gay men including the potential effect of testosterone supplements, HIV status, anal sex and its impact on PSA testing, and the potential change in sexual response during anal sex resulting from the removal of the prostate. Issues of doctor-patient communication as they specifically relate to the gay prostate cancer patient are explored. KEYWORDS. AIDS, anabolic steroids, anal sex, cancer, diet, erectile dysfunction, finasteride, gay, gay couples, gay relationships, HIV, homosexuality, impotence, incontinence, informed consent, prostate, prostatectomy, PSA testing, testosterone

This is a personal account of a 33-year-old gay man's discovery of his prostate cancer, its treatment, his recovery and the effect it had on his life. The paper underscores the importance of physician-patient communication, informed consent for patients, and involving the patient's partner when treating prostate cancer. In addition to dealing with incontinence and post-operative depression, the author recounts the many steps he undertook to treat erectile dysfunction as well as the difficulties that caused for him and in the relationship with his partner of twelve years. KEYWORDS. Alprostadil, cancer, depression, erectile dysfunction, gay, gay couples, homosexuality, imipramine, impotence, incontinence, informed consent, prostate, prostatectomy, sildenafil, gay relationships

A gay man is first diagnosed with prostate cancer at age 84. The cancer is aggressive and requires treatment. He struggles with the choice of treatment. Surgery is inadvisable because the cancer has already advanced beyond the capsule, and surgery raises the danger of possible metastasis. Preservation of erectile potency is ruled out as a cause of concern, since he is no longer sexually potent. Due to the lack of knowledge and experience (as opposed to present-day advances) radiation, in its form at that time, is ruled out. There was danger of radiation burns to adjacent healthy tissue. Chemotherapy was not recommended to him at that time. Patient settled on hormone therapy, deciding that he could manage the consequences of hormonal castration, even though his doctors never discussed his homosexual lifestyle with him. This oversight seemed less important at the time, because the patient was already impotent. Patient's overriding concern was with the formation of a living situation or home with another man, for the remainder of his life. KEYWORDS. Age and cancer, gay sex life, homosexuality, hormonal therapy, impotence, prostate cancer, treatment choices, treatment consequences

Describing himself as a physically fit and sexually-active African-American gay man of mature years, and having survived more than a decade of being HIV-positive, the author writes about being faced with another significant and completely new challenge to his health and quality of life: prostate cancer. He describes his choice of treatment and road to recovery in the context of his own personal philosophy of life. KEYWORDS. Assertive self care, African American men, gay, erection, HIV+, libido, men of color, prostate cancer, sex-positive, testosterone

Prostate cancer treatment should run along two parallel tracks: (1) reducing the biological threat of the disease and (2) reducing the psychological symptoms which ensue from internalizing the diagnosis and undergoing physical treatment. Many patients diagnosed with prostate cancer report symptoms of both depression and anxiety. Using examples from his psychotherapy practice, the author depicts and offers treatment strategies for the psychological reactions to diagnosis, treatment, and the consequences of treatment as they affect the gay man struggling with prostate cancer. Prostate cancer in gay men often intersects with the social issues of minority status, discrimination and stigmatization. As gay men navigate the heterosexually biased world of prostate cancer treatment, they must also confront potential problems of stigmatization, including scarring, ejaculation problems, erectile dysfunction, and HIV/AIDS envy. The author stresses the need for gay oriented programs and gender bias free materials as both appropriate and empowering to the community of all prostate cancer patients and their families. KEYWORDS. AIDS, antihomosexual bias, anxiety, depression, ejaculation, gay, heterosexism, HIV, homophobia, homosexuality, impotence, incontinence, prostate cancer, psychosocial support, psychotherapy, scarring, stigma, support groups

The author provides a personal account of crystal methamphetamine addiction. He describes the difficulties and treatment experienced by someone who is gay and an AIDS community activist. The author describes his first encounter with crystal meth, the consequences of using it, treatment strategies he found helpful, and, from the patient's perspective, what clinicians can do to prevent and treat crystal use. KEYWORDS. Abstinence, addiction, AIDS, anal intercourse, club drugs, cocaine, crystal meth, harm reduction, gay men, HIV, homosexuality, men having sex with men (MSM), sexual risk taking, treatment, unsafe sex