Risky behaviours Substance use Marginalised communities 21 st November 2013

1. Risky behavioursSubstance useMarginalised communities21st November2013 Dr. Christopher Whiteley Consultant Clinical Psychologist Alcohol and Drugs, Health & Wellbeing Directorate Public Health England

2. Risky behaviors and substance use • How might we understand the nature of the relationships? • Importance in relation to people from marginalised communities • How might this be used to improve the health and wellbeing of people from specific marginalised communities? • Reference to a current area of PHE work

3. Risky behaviours & substance use Use Who knows what will happen Intoxication Chronic physical & mental health Social Accidents, Crime Suicide / self harm Physical health Mental health Dependence

4. Relationship of substance use and risky behaviour • Pharmacological and physiological effects • Perceptions, expectations, understanding • e.g. Placebo effect • Social and cultural influences • Rhodes (1996) ‘Social pharmacology’ perceived and expected drug effects are socially culturally organised • Research and common sense understanding more often focus only on the pharmacological and physiological

5. Total drug effect

6. ‘Disinhibition’ theory • That substance use / intoxication leads to behavoiurs that wouldn’t otherwise happen; less under control • Commonly held view for which the evidence is unclear • Selective disinhibition • Situational disinhibition • Individual differences • Cross cultural MacAndrew & Edgerton (1969) in some non-Western cultures no evidence of disinhibitive effects of alcohol • Disinhibition may provide a socially accepted explanation for engaging in a socially sanctioned behaviour (Rhodes 1996)

7. Does substance use lead to risky sexual behaviour? • Global association level research typically shows an association between substance use and increased rates of risky sexual behaviour (e.g. Shillington et all 1995; Valdiserri et al 1988) • But this is not universal (Rhodes & Stimson 1994) • Weinhardt & Carey (2000) meta analysis event level research into alcohol use and risky sexual behaviour • Condoms sober condoms when drinking • No condoms drinking probably no condoms sober

8. “It is not known whether drug use is a marker for high risk sexual behaviour, drug use leads to high risk sexual behaviour, high risk sexual behaviour leads to drug use or some combination” Marx et al 1991

9. Drugs Sex and Apps • “High risk drug practices tighten grip on London gay scene” Kirby & Thomber-Dunwell; Lancert 2013 • Combination of behaviours among some MSM +/- • Drug use (crystal meth. & mephedrone) • Injecting • Sex, unprotected sex, sex parties, specific sexual behaviours • HIV / STI transmission • Smart phone Apps

10. Public health challenge • New pattern of behaviours • New substances • New technology • Sexual health problem? Drug problem? Social problem? • Which services? • Extent of behaviour unknown • Potential risks are significant (HIV, Hep C, STI) • Actual incidence of transmission unknown

11. PHE and stakeholders • Cross PHE collaboration with community stakeholders • Sexual health & HIV • Health Protection • Alcohol & Drugs • Strategic leadership • Cultural competence • Guidance informed by research & evidence • Cross sector expertise & collaboration • Learn from innovations