I have written previously about drug use and the HIV epidemic among LGBTQ+ people and sexual minority men specifically. Our recent study (Starks et al., 2026) published in The Journal of Acquired Immune Deficiency Syndromes indicates that a brief (4-session) counseling intervention tailored for sexual minority men in relationships resulted in significantly better drug use and HIV prevention outcomes compared to a highly competitive control condition.
It is unusual for a counseling intervention to focus on substance use and sexual health in an integrated way. There are existing treatments for drug use, and treatments for disorders of sexual arousal and orgasm, and there are public health interventions that address sexual health. Unfortunately, there are very few interventions that bring these outcomes together.
At least one intervention that addressed drug use and sexual risk taking showed promising effects on both outcomes in a sample of sexual minority men (Parsons et al., 2014). Unfortunately, the intervention did not work as well for those in relationships (Starks & Parsons, 2018). Designed primarily with single people in mind, it did not explicitly address the influence of relationship partners on drug use and sexual decision making.
It is even more rare to focus on drug use and sexual behavior in counseling for those in relationships. Motivational interviewing with couples (Starks, 2022) has demonstrated the potential to reduce drug use and address sexual risk taking (Starks et al., 2022); however, it requires the participation of both partners in a relationship. For those who are unable or unwilling to convince their partner to join them for the intervention session, this makes receipt of the intervention impossible (Starks et al., 2019).
Our recent study
We used a randomized controlled trial to test an individually delivered intervention that was tailored specifically for sexual minority men in relationships.
The intervention was delivered one-on-one. None of the participants recruited their relationship partner into the study. It emphasized exploration of how a relationship partner influences drug use and sexual health decision making. It incorporated multi-modal communication skills training to enhance abilities necessary to communicate with a relationship partner at home (Cain et al., 2023; Starks et al., 2024).
The control condition was highly competitive, encompassing 4 sessions of psycho education about drug use and HIV prevention strategies delivered one-on-one by a health educator.
The sample included 196 cisgender sexual minority men aged 18 to 34. From January 2018 to March 2020, they were recruited in New York City and participated in person. From March 2020 to February 2024 recruitment was national in the United States and participation was facilitate remotely with sessions conducted telehealth.
The findings
That emphasis on communication skill building may in part explain why the intervention resulted in significant immediate reductions (3 months after baseline) in drug use among those who had relatively poor communication prior to intervention.
Relationship quality mattered too. The intervention significantly reduced drug use 3 months after baseline among those who were highly satisfied with their relationship.
Finally, pre-exposure prophylaxis (PrEP) uptake among those in the treatment condition was more positive over the one-year follow-up period.
What we learn from this
Drug use can be associated with sex and sexual HIV transmission in various ways. Intoxication may alter decision making, inhibiting the use of prevention strategies (e.g., missing a dose of PrEP medication). For some, intoxication may enhance sexual pleasure and decrease sexual anxiety. Drug use may even be normative in some sexual contexts (e.g., party-and-play or chemsex). See here for more.
If drug use is connected to sex and sexual health for you – look for a counselor who can talk to you about it. Counselors who want to provide affirmative care to LGBTQ+ individuals should be prepared to address sexual decision making and sexual health in a robust manner. This includes assessing the variety of ways in which substance use might be connected to sexual health for members of this community. It also includes exploring sexual motivations that enhance or inhibit drug use.
Counseling can be helpful even if your partner is not part of the picture. Our intervention was intentionally created to be relevant for couples when only one partner is willing or able to participate in the intervention sessions. The needs of people in relationships can best be addressed through access to a combination of services for individuals as well as couples.