Confronting Crystal Methamphetamine Use
in New York City
Public Policy Recommendations
Task Force on Crystal, Syphilis and HIV
Submitted to the Board of Directors Gay Men's Health Crisis
July 2004
Having lost tens of thousands of lives to HIV/AIDS over the last
23 years, New York City's LGBT community now confronts a serious
and rapidly growing epidemic among gay men of crystal methamphetamine
abuse and addiction. Crystal use is contributing to an alarming
increase in sexual risk behavior, exposing many men to the danger
of life-threatening overdose, and causing potentially irreparable
economic, physical and psychological damage to habitual users.
Crystal is one of the most addictive of illicit drugs, with especially
dangerous attributes that have prompted many researchers to place
crystal in a class by itself.
Already, crystal is having a serious impact on New York's public
health. A substantial body of data now confirms that sexual risk
behaviors among gay and bisexual men have significantly increased
over the last several years, in part due to the sexual disinhibitions
associated with crystal use1.
In New York City, syphilis rates have doubled each of the last
three years, with men who have sex with men accounting for virtually
all of the increase in cases. Investigation by City health authorities
indicate that a syphilis diagnosis is strongly associated with
crystal use, HIV seropositivity, and having sex in a bathhouse,
at a sex party, or via an Internet connection. Although it is impossible
at this stage to draw firm conclusions, emerging evidence also
suggests that crystal use may be contributing to an increase in
new HIV infections among men who have sex with men in New York
and other cities.
Crystal is not a new drug. It is the second most commonly used
drug worldwide and has long been the drug of choice in many rural
parts of the US. Its rapidly rising popularity among gay men primarily
stems from its unique impact on sexual desire and sexual stamina.
Crystal intensifies sexual pleasure and reduces sexual inhibitions.
Crystal use often encourages men to have unprotected sex with multiple
partners over many hours or even days. As crystal use makes it
difficult to sustain an erection, users often gravitate to unprotected
receptive anal intercourse, the sexual behavior most likely to
lead to HIV transmission2.
When crystal is widely used in commercial sex venues and in other
situations that facilitate multiple sex partners, it risks creating
unique public health risks for gay and bisexual men due to the
already-high prevalence in this population of HIV, syphilis and
other sexually transmitted infections.
Echoing the early overlooking of the demographic facts in the
HIV/AIDS response in New York City, some have suggested that crystal
use is primarily confined to gay white men. Nothing could be further
from the truth. In Los Angeles and San Francisco, where crystal
use in the gay community has been widespread much longer than in
New York, studies indicate that crystal users are broadly diverse
from a racial/ethnic, age and socioeconomic standpoint. Studies
in New York have similarly confirmed that crystal users include
young gay men and those who are not so young, HIV-negative as well
as HIV-positive men, and all racial and ethnic groups.
Although the groups that have joined together in this Task Force
firmly believe it is possible to reverse the crystal epidemic,
it will not be easy. While certain psychosocial and peer-based
interventions have shown promise in helping people stop using crystal,
no recognized pharmacological modality exists for the treatment
of crystal addiction. Moreover, extensive ethnographic research
indicates that crystal use among gay men is intimately associated
with issues of gay identity, racial/ethnic identity, and HIV serostatus.
The reasons many HIV-positive men use crystal are often strikingly
different from those of HIV-negative men. Focus groups involving
ethnically and racially diverse gay and bisexual men in New York
City also indicate that men of color frequently have different
motivations for using crystal than white men. And while young men
are entering a world in which crystal use is often encouraged and
facilitated by peer networks in the gay community, many older men
are turning to crystal to help escape the memories, isolation and
emotional devastation that for many are the legacy of HIV/AIDS.
Because of crystal's unique role in the LGBT community, and due to
the close and complex connection between crystal use and issues of
personal identity, community-centered approaches represent
the only feasible strategy for reducing crystal use and
preventing non-users from trying it in the first place. These community-based
initiatives should include those that focus on the whole individual
as well as those that focus exclusively on crystal use, as the most
effective strategies are likely to be those that address the complex
and widely varying motivations for crystal use, as well as the social
and economic context in which crystal users live. These community-centered
strategies must acknowledge and honor healthy decision-making by
gay men, while forging new community norms that discourage unhealthy
behavior and encourage a commitment to good health and well being.
Community initiatives will need to address issues of belonging, identity,
self-esteem, stigma and discrimination. Given the widely varying
motivations and personal situations of crystal users in New York
City, the response must also be inclusive, encompassing mainstream
LGBT organizations, smaller service providers that may have the ability
to reach key populations, and grassroots groups that were the first
to embrace the fight against crystal addiction in New York City.
Community dialogue and leadership are also needed to challenge
bluntly the acceptance and glamorization of crystal meth. We must
state clearly that crystal meth destroys lives, and that to save
lives, we must change some community norms. We must articulate
and promote the view that defining and limiting unhealthy behavior
is not tantamount to placing limits on gay sexuality or placing
limits on gay identity and freedom.
In this effort, the community needs strong, educated and adaptable
partners, especially in the public health community. Unfortunately,
the history of HIV/AIDS provides cause for concern. The early prevention
programs that made public health history by dramatically lowering
sexual risk behaviors and HIV infection rates among gay men were
largely underwritten by LGBT organizations themselves, with only
limited support from public health agencies. Even though gay men
of color were present in large numbers among the very first AIDS
cases, the public health community provided little leadership in
addressing the rapid growth of HIV infection among men of color
in the 1990s3.
Once public health agencies began providing financial support for
HIV prevention efforts by mainstream LGBT organizations, follow-through
was poor. Since the 1990s, surveys by the Centers for Disease Control
and Prevention (CDC) and others have consistently shown that men
who have sex with men (MSM) and injecting drug users (IDUs) consistently
receive less prevention funding (per reported HIV/AIDS case) than
other populations at risk, even though MSM and IDUs account for
the vast majority of HIV infections in New York City and the US
as a whole. The crystal epidemic will not be overcome with half-hearted
or one-shot efforts. To reverse the crystal epidemic in New York
City, a strong, visible, sustained, and coordinated public-private
partnership is urgently needed.
Recent developments suggest that New York City has the opportunity
to create the kind of genuine public-private partnership required
to address the crystal epidemic. Within the LGBT community, grassroots
activists have mobilized to sponsor community forums and raise
community awareness, while LGBT organizations have begun reallocating
their resources to address the growing problem of crystal use.
The New York City Department of Health and Mental Hygiene has also
recently demonstrated leadership on this issue, issuing a public
health alert and providing $300,000 in funding for community-based
services to prevent and treat crystal use.
We know from our own experience that community-centered programs
can effectively address difficult health challenges. In response
to HIV/AIDS, the LGBT community created service organizations that
continue to serve as national and global models, implemented initiatives
to care for people with HIV and to prevent new infections, and
revolutionized (through advocacy and by example) the country's
approach to serious diseases. A comparable undertaking is needed
now to attack the latest threat to the health and well being of
gay men.
It is in this spirit that the Task Force submits the following
recommendations for public policies and community mobilization.
The recommendations included in this report have been developed
jointly by the entire Task Force. Although the charge from the
GMHC Board specifically focused only on public policy, the Task
Force determined that it would be difficult to craft a coherent
agenda without addressing the LGBT community's own obligations
to mobilize against this health threat. As a result, the recommendations
include a section on community mobilization. Although this document
is technically a report to the GMHC Board of Directors, it is the
hope of the Task Force that it will also prove a useful educational
and advocacy tool for the LGBT community and for our public health
partners and that it will provoke a reinvigorated, coordinated
effort to reset community norms for men who have sex with men.
Background on the Task Force
In January 2004, the board of directors of Gay Men's Health Crisis
directed the board's public policy committee to establish a task
force of diverse experts to make recommendations to the board on
a public policy agenda to address the crystal epidemic and its
impact on HIV and syphilis. Leading LGBT organizations, grassroots
activists, prominent researchers on sexual behavior and crystal
use among gay men, and individuals with backgrounds in public policy
advocacy agreed to serve on the Task Force.
Over a three-month period in the spring of 2004, the Task Force
reviewed and analyzed available data on the crystal epidemic and
its correlation to syphilis and HIV, including the drug's mechanisms
of action, the documented health risks associated with crystal,
successful strategies to treat crystal addiction, and approaches
adopted by LGBT communities on the west coast in response to their
much earlier crystal/syphilis/HIV epidemics. The Task Force met
face-to-face on several occasions, including one meeting with senior
leaders from the New York City Department of Health and Mental
Hygiene. The Task Force divided into work groups that developed
recommendations in the areas of prevention, treatment, law enforcement,
funding, and community mobilization.
Public Policy Recommendations
Treatment
Step One in a comprehensive response to the crystal epidemic is
to help addicts and problem users stop using crystal. Unfortunately,
treatment prospects for crystal confront major scientific, political,
financial, and social impediments.
New York City has only a fraction of the drug treatment slots
it needs to serve the hundreds of thousands of New Yorkers who
have serious drug and alcohol problems. Moreover, the range of
government-approved therapeutic interventions is quite narrow.
Arbitrary and counterproductive cost containment protocols of third-party
payers also limit treatment options.
The LGBT community has historically been poorly served by standard
substance abuse treatment services. Even though a large body of
scientific literature demonstrates that members of the LGBT community
often have unique medical and psychosocial needs, as well as severe
and non-mainstream substance use patterns, relatively few treatment
providers in New York City have developed the professional and
cultural competence to serve our community. Outside of the limited
number of community-based substance abuse treatment slots provided
by LGBT organizations, treatment programs specifically developed
to meet the needs of the LGBT community are exceedingly scarce.
Treatment of crystal addiction also presents particular challenges.
No proven pharmacological treatment exists to treat crystal addiction,
and relapse is common. Research is urgently needed to develop and
evaluate new treatment models for crystal. Crystal users have different
motivations for taking the drug. Moreover, the way a person takes
crystal (e.g., snorting, smoking, injection) will also affect the
choice of treatment modality. Therefore, a broad spectrum of treatment
approaches, ranging from abstinence-based to harm reduction-based
modalities, is needed.
The Task Force calls for a major and sustained expansion of drug
treatment capacity in the LGBT community.
- The Federal Government should aggressively finance research
to expand the clinical approaches for dealing with crystal use,
including funds to develop and test new treatment modalities.
- The City and State should ensure the availability of drug
treatment slots for crystal addiction that utilize a continuum
of modalities and care.
- Treatment for crystal should be available on demand, and such
services should be integrated with HIV and syphilis interventions
and mental health services. Attention should also be given to
the impact of crystal meth use on current substance users who
are HIV+.
- Medically supervised and State-licensed treatment offerings
should be increased to meet the needs of this burgeoning problem,
along with psychosocial interventions and "12 Step" model programs.
- The City and State should significantly increase the number
of treatment programs specifically for gay and bisexual men,
including gay and bisexual injection drug users. Such programs
should include relapse prevention services and needle exchange
among the continuum of care for crystal users. Effective treatments
should include LGBT competencies and be community-based.
- The City and State should ensure that funded facilities have
training programs that ensure the competence of staff to address
the needs of the LGBT community.
- The City and State should ensure that current substance abuse
providers are aware of the issues surrounding crystal meth.
- The City and State should ensure that both private insurance
and publicly supported health care programs fully cover crystal
treatment services, including harm reduction programs.
Prevention
The most effective long-term strategy to address crystal use is
to prevent individuals from trying crystal in the first place.
Crystal prevention programs have only recently emerged in New
York City. Unfortunately, these community efforts lack sufficient
financial means to address the magnitude of the crystal epidemic.
In general, society undervalues prevention. In the case of HIV/AIDS,
for example, while more than $2 billion is spent annually in New
York City on HIV-related medical services, the City's HIV prevention
budget for the current fiscal year (including support from CDC)
is a mere $36 million4.
The crystal epidemic demands that we not give careless attention
to prevention.
Prevention of crystal use is complicated by the broad diversity
of the LGBT community and the widely varying motivations for taking
the drug. As in the case of HIV prevention, strategies to prevent
crystal use must not only educate gay men about the dangers of
crystal but also help potential users develop the motivation and
skills to say no. Prevention efforts must operate at both an individual
and a community level, helping individuals navigate peer pressures
and simultaneously working to reduce such pressures by forging
new and healthier community norms.
Although crystal use occurs in a variety of places, including
in the privacy of the home, studies indicate the combination of
crystal use and risky sexual behavior is especially frequent in
bathhouses, other commercial sex venues, and private sex parties.
In addition, crystal use often occurs in the course of sexual connections
arranged over the Internet. The prominence of these venues strongly
argues for supplementing traditional prevention approaches (such
as individual counseling, group sessions, and public education)
with enhanced outreach to commercial sex venues and development
of innovative approaches to reach men who use the Internet for
sex.
- The City should increase its support for community-based public
information campaigns and ads to increase public awareness of
the growing epidemic of crystal use. In funding community-based
public awareness and education programs, the City should support
explicit approaches and accurate, culturally appropriate materials.
- The City should provide financial support for community-based
public awareness and prevention education campaigns that are
targeted to specific population groups and communities. Emphasis
must be placed on campaigns that target LGBT communities, communities
of color, women, low-income communities, adolescents, and young
adults. Targeted programs are also needed specifically for men
who have sex with men (MSM) who inject drugs (MSM-IDU). These
men often do not connect with either gay or IDU identities5.
Campaigns are also specifically needed for men who are currently
using crystal.
- Consideration should be given to supporting and funding community
education campaigns developed and led by community-based organizations
indigenous to communities of color. Their credibility among their
constituencies is important to raising awareness and developing
effective direct prevention and group support efforts focusing
on crystal meth.
- The City should provide substantial funding to community-based
organizations for outreach efforts and community interventions.
This should include support for venue-specific outreach and interventions,
e.g. the Internet, bathhouses, bars and clubs, and commercial
sex venues.
- The City should take steps to integrate crystal, syphilis,
and HIV interventions.
- The City and State should ensure that programs are in place
to prevent the transmission of HIV by and among those individuals
who are not ready to limit or discontinue their use of crystal.
Since one of the methods used to ingest crystal is by injection,
it is important to establish or expand needle exchange programs.
At least initially, these programs should be run by the LGBT
community to address the immediate epidemic within the gay population.
Law Enforcement
Even though substance addiction is an illness, the public policy
approach to substance abuse in New York State and throughout
the US remains heavily oriented toward criminalization, with
comparatively little attention devoted to public health strategies
for prevention and treatment. In recent years, leaders from across
the political spectrum in New York have come to recognize the
need to change the State's approach to steer non-violent drug
possession offenders to drug treatment rather than prison.
In response to the increase in crystal use in New York City, some
political leaders have recently called for even harsher penalties
for crystal possession. This would merely apply to the crystal
epidemic the same failed policies that have cost the taxpayers
sorely while failing to diminish use of other drugs. Law enforcement
efforts should focus on manufacturers and distribution networks
rather than facilitate the long-term incarceration of non-violent
offenders. Treatment, not incarceration, should be the touchstone
for New York City's response to the crystal epidemic.
- The State should repeal the Rockefeller drug laws.
- The City and State should increase the number and access to
alternative to incarceration programs, including programs that
target gay and bisexual men and crystal users.
- The State must avoid any move to increase penalties related
to the sale and possession of limited amounts of crystal.
Funding
It will not be feasible to effectively address the crystal epidemic
by reallocating existing funding streams. As noted above, substance
abuse treatment services and HIV prevention programs are already
badly under-funded. The same is true for non-clinic-based programs
to prevent sexually transmitted infections. Nor will it be workable
to expect any single governmental entity (i.e., City, State,
Federal) to finance the City's response to the crystal epidemic
on its own. To mount an effective response, substantial and sustained
funding will be needed for crystal prevention and treatment programs
from the City, State and Federal governments.
- The City should increase its annual support for community-based
crystal prevention and treatment programs from the $300,000 it
committed in FY 2004 to $1.5 million in FY2005. In recognition
of the ongoing challenge that crystal use poses for the City's
public health, these funds should become part of the City's budget
baseline.
- The State should provide $2 million in funding for community-based
crystal prevention and treatment programs in the 2004-05 State
Fiscal Year. Given the epidemiology of the crystal epidemic,
these funds should target gay and bisexual men in New York City.
- The Federal government should finance behavioral and social
science research to gain a better understanding of the psychological
and social dynamics that drive the use of crystal and other substances
and the dynamics that lead to high risk sexual behavior. All
levels of government, as well as private funders, should provide
financial support for developing and implementing prevention
strategies that are grounded in research findings.
Community Response
The crystal epidemic is fundamentally a community problem, and
LGBT organizations have a responsibility to lead the community
toward solutions. In proposing the creation of a strong public-private
partnership to combat the crystal epidemic, the Task Force is
not seeking to absolve the LGBT community itself of responsibility
for leadership. On the contrary, for New York City to break the
back of the epidemic, community leaders must help the LGBT community
look honestly at community norms and values that may inadvertently
facilitate crystal use. In essence, leadership will be required
to help gay men validate and celebrate their sexuality without
placing the health of themselves and others at risk.
In the LGBT community's quickening effort to mobilize against
the crystal epidemic, grassroots activists have played an essential
role. In the past six months, three community forums have initiated
a bold and honest discussion in the community on crystal use, including
its impact on transmission of HIV and other STIs. Community campaigns
have been created to warn gay men of the dangers of crystal; the
first one was financed privately by a gay activist. LGBT service
providers are now focusing on crystal prevention and treatment,
and the crystal epidemic has figured prominently in the gay press.
These are important beginnings but a much stronger, broad-based,
and sustained community dialogue around community norms, sex, wellness,
health, and responsibility is needed.
- LGBT organizations and grassroots activists should lead a
community dialogue on rethinking community norms on drug use
and sexuality. In particular, discussion is needed to clarify
and strengthen community and individual values regarding the
differences of healthy and destructive behavior.
- Community dialogue and leadership are needed to articulate
and promote the view that defining and limiting unhealthy behavior
is not tantamount to placing limits on gay sexuality or placing
limits on gay identity and freedom. Fundamental issues of gay
identity that influence drug use, high-risk behavior, and other
forms of self abuse must be addressed honestly and forthrightly.
- LGBT community leaders need to enter into dialogue with the
owners and managers of commercial and other business establishments
that rely heavily on gay patronage, such as gay bars and gay-oriented
commercial sex establishments, to clarify the role and responsibility
of such establishments to avoid facilitating or condoning substance
abuse and other high risk behaviors on their premises.
- Community forums and campaigns should be implemented that
move LGBT communities toward an increased awareness of LGBT health
and wellness. These efforts should promote individual self-esteem
and communal self-respect. These efforts should also encourage
individuals to reflect on how certain venues or situations may
affect individual decision-making on drug use and sexual behavior.
Footnotes:
1 Halkitis PN, Parsons JT, Stirratt
MJ. A double epidemic: crystal methamphetamine drug use in relation
to HIV transmission among gay men. Journal of Homosexuality. 2001;
41(2):17-35.
Urbina A and Jones K. Crystal methamphetamine, its analogues,
and HIV infection: medical and psychiatric aspects of a new epidemic.
Clinical Infectious Diseases. 2004; 38:890-894.
Colfax GN, Mansergh G, Guzman R, Vittinghoff E, Marks G, Rader
M, Buchbinder S. Drug use and sexual risk behavior among gay
and bisexual men who attend circuit parties: a venue-based comparison.
Journal of Acquired Immune Deficiency Syndrome. 2001; 28(4):373-379.
2 Many crystal users seek to address
this problem by combining crystal with Cialis or Viagra.
3 Alone among racial/ethnic groups
affected by HIV/AIDS, men of color who have sex with other men
experience HIV infection rates that are comparable to the hardest-hit
countries in sub-Saharan Africa.
4 The City's $36 million budget
for prevention services excludes amounts that CDC provides directly
to community-based organizations. As new contracts for directly-funded
agencies are currently being negotiated, it is not possible to
provide an authoritative statement of the level of such support,
although it is significantly smaller than the City's prevention
budget. In addition, it is worth noting that financing for prevention
services is almost exclusively provided by public health agencies,
as Medicaid and private third-party payers generally do not offer
reimbursement for prevention services.
5 Bull SS, Piper P, et al. Men
who have sex with men and also inject drugs—profiles of risk
related to the synergy of sex and drug injection behaviors. Journal
of Homosexuality. 2002; 42(3):31-51.
© 2004 Gay Men's Health Crisis |
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