Citation
Body image dissatisfaction among men who have sex with men

Material Information

Title:
Body image dissatisfaction among men who have sex with men predicting risky sexual behavior
Creator:
Luckman, Diana
Publication Date:
Language:
English
Physical Description:
vii, 71 leaves : ; 28 cm

Thesis/Dissertation Information

Degree:
Master's ( Master of Arts)
Degree Grantor:
University of Colorado Denver
Degree Divisions:
Department of Psychology, CU Denver
Degree Disciplines:
Clinical psychology

Subjects

Subjects / Keywords:
Body image in men ( lcsh )
Gay men -- Sexual behavior ( lcsh )
Gay men -- Health risk assessment ( lcsh )
Genre:
bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )

Notes

Bibliography:
Includes bibliographical references (leaves 62-71).
General Note:
Department of Psychology
Statement of Responsibility:
by Diana Luckman.

Record Information

Source Institution:
University of Colorado Denver
Holding Location:
Auraria Library
Rights Management:
All applicable rights reserved by the source institution and holding location.
Resource Identifier:
656249375 ( OCLC )
ocn656249375
Classification:
LD1193.L645 2010m L82 ( lcc )

Full Text
BODY IMAGE DISSATISFACTION AMONG MEN WHO HAVE SEX WITH MEN
PREDICTING RISKY SEXUAL BEHAVIOR
by
Diana Luckman
B.A., American University, 2004
A thesis submitted to the
University of Colorado Denver
in partial fulfillment
of the requirements for the degree of
Master of Arts
Clinical Psychology
2010


This thesis for the Master of Arts
degree by
Diana Luckman
has been approved
Elizabeth Allen


Luckman, Diana, J. (Master of Arts, Clinical Psychology)
Body Image Dissatisfaction among Men Who Have Sex with Men:
Predicting Risky Sexual Behavior
Thesis directed by Assistant Professor Elizabeth Allen
ABSTRACT
Due to the increasing spread of HIV and AIDS among the gay community within
the US, it is important to identify key factors that predict risky sexual behavior among this
subset of the population. The current study sought to examine how body image
dissatisfaction (BID) among men who have sex with men (MSM) could predict engagement
in the highest sexual risk behavior, unprotected receptive anal sex, mediated by the use of
various substances.
Adult MSM attending the 2009 Denver Pride Fest completed self-report measures
of (1) BID, including dissatisfaction with weight and overall masculinity; (2) substance use,
including use of disinhibiting substances such as alcohol, marijuana, poppers, ecstasy,
cocaine, methamphetamine, ketamine, rohypnol, and ghb; and (3) HIV risk behavior,
specifically engagement in unprotected receptive anal sex. Participants were subdivided
into two groups, those who endorsed having had unprotected receptive anal sex after
drinking (n = 124) and those who endorsed having had unprotected receptive anal sex
after using drugs (n = 74), over the past 3 months.
Though the initial plan was to conduct a mediation analysis (with BID as a
predictor variable, substance use as a mediator, and risky sex as an outcome variable),
assumptions for mediation were not met. However, exploratory analyses illustrated some
interesting findings when examining interrelationships among different variables. There
were significant positive correlations between risky sex and use of both poppers and
methamphetamine, indicating that these two drugs could be related to engagement in more
risky sex. Higher muscle dissatisfaction was correlated with a decrease in illicit drug use.
Though some of these findings were contrary to initial hypotheses, this study
indicates the need for further investigation of such variables in MSM, perhaps with more
refined data collection techniques and possible assessment of various other
interconnected variables.
This abstract accurately represents the content of the candidate!
publication.
Signed
sis. I recommend its
Elizabeth Allen


ACKNOWLEDGMENT
Thanks to my advisor, Elizabeth Allen, for all her contributions and support during this
research process. I would also like to thank Eric Benotsch for including my questions in his
survey and inviting me to participate in the data collection process. Finally, I would like to
give additional thanks to all other members of my thesis committee.


TABLE OF CONTENTS
Tables.................................................................vii
CHAPTER
1. INTRODUCTION.........................................................1
Risky Sexual Behavior............................................1
Body Image Dissatisfaction.......................................2
Body Image Dissatisfaction among MSM.............................3
Emotional and Physical Health Risks of BID.......................5
Health Risks In MSM..............................................7
Specific Aims...................................................11
2. METHODS.............................................................12
Participants....................................................12
Procedure.......................................................13
Measures........................................................13
Substances....................................................13
Body Image Dissatisfaction....................................15
Risky Sexual Behavior.........................................18
3. RESULTS.............................................................21
Assumptions for Mediation.......................................21
Correlations....................................................22
Exploratory Analyses............................................22
4. DISCUSSION..........................................................25
Significance of the Study.......................................25
v


Limitations
26
Directions for Future Research........................29
APPENDIX
A. GAY PRIDE SURVEY.........................................31
B. IRB REQUEST FOR EXEMPTION................................41
BIBLIOGRAPHY ....................................................62
vi


TABLES
Table
1.1 Descriptives: Risky Sex and BID in both groups.....................................19
1.2 Descriptives: Substances in both groups............................................20
1.3 Kendalls tau correlation coefficients: individual drugs, BID, and risky sex.......24
VII


CHAPTER 1
INTRODUCTION
Risky Sexual Behavior
The HIV and AIDS epidemic is one of extreme national and global concern. As of
2006, there were an estimated 850,000-950,000 people infected with HIV living in the US.
Moreover, there are approximately 40,000 to 60,000 new cases of HIV infection per year, a
large proportion found within the gay male community (Bryant, 2006). The primary mode of
transmission, risky sexual behavior (i.e. unprotected intercourse), is extremely common
among men whom have sex with men (MSM). Due to the devastating consequences
associated with such an illness, it is essential to uncover all possible predictors of risky
sexual behavior, specifically among the homosexual community.
The current study is focused on evaluating body image dissatisfaction (BID) as a
predictor for sexual risk behavior. Some preliminary research has found a link between BID
and sexual risk in both HIV-positive and negative MSM (Browning et al., 2006). I plan to
expand such research through using a more comprehensive measure of BID, as well as
exploring a possible mediator (substance use) of the relationship between BID and sexual
risk among a sample of MSM. Therefore, I will begin by describing the construct of body
image dissatisfaction and its relevance to MSM, including the impact of BID on a range of
emotional problems and health risk behaviors.
1


Body Image Dissatisfaction
Body image is a multidimensional construct, reflecting not only how people think, feel
and behave regarding their own physical appearance, but also how they perceive others to
view their appearance. Body image dissatisfaction (BID) can occur when people become
overly invested in their appearance and/or develop a distorted discrepancy between what
they actually look like, and what they believe themselves to look like. This can subsequently
manifest in a variety of ways. People can become unhappy their weight, shape/ muscularity,
specific body parts, or their physical appearance as a whole (McCreary & Sass, 2000;
Morrison et al, 2004; Vartanian et al., 2001).
Due to the frequency of excessively thin women portrayed in the media, as well as
the huge increase in eating disorders among women in Western society, most of the research
on BID has been done with females. Body image dissatisfaction scales have been developed
over the past few decades to assess such characteristics in women, such as the Body
Esteem Scale (Franzoi & Shields, 1984), The Body Shape Questionnaire (Cooper et al.,
1987), and The Objectified Body Consciousness Scale (McKinley & Hyde, 1996), to name a
few. Overwhelmingly, research has shown that socially implemented norms of the ideal body
has perpetuated women to feel fat, idealizing smaller figures and wanting to lose weight, as
well as disliking certain parts of their bodies (i.e. hips, breasts, and legs). Women look
towards ways in which they can change their bodies via exercise, food restriction, or cosmetic
alterations (Conner et al., 2004; Cooper et al., 1987; Franzoi & Shields, 1984; McCreary &
Sass, 2000). However, this social phenomenon has transcended beyond just women.
Research now shows that, for the most part, MSM experience increased body image
dissatisfaction comparable to heterosexual women, above and beyond that experienced by
2


heterosexual men (Conner et al., 2004; Martins et al., 2007; Russell & Keel, 2002;
Tiggemann et al., 2007; Vartanian et al., 2001; Yelland & Tiggemann, 2003).
Body Dissatisfaction among MSM
MSM are part of a subculture in which physical appearance is highly valued and acts
as a means of defining identity. MSM often evaluate their bodies solely by how they look as
opposed to how they feel, the goal no longer being primarily to stay fit and feel healthy, but to
attain the perfect appearance (Halkitis et al., 2004; McKinley & Hyde, 1996; Steer &
Tiggemann, 2008). Gay pornography acts as a means of reinforcing this ideal body and its
consumption appears to be highly normative among the gay community, one study revealing
that over 98% of its gay male participants had viewed some type of pornography in the past
month (i.e. pornographic magazines or videos) (Duggan & McCreary, 2004). Like any form of
media, the more frequently people view images of an ideal body, the more accustomed to it
they become, and the more likely they are to become dissatisfied with their own body.
A desire to be thinner has become a central focus in the attainment of an ideal body
among MSM. One study indicated that at least 36.5% of MSM had been on a diet at some
point, quite possibly precipitating the over 15% of MSM in the US who suffer from some type
of eating disorder, specifically bulimia nervosa. MSM scored higher with regards to their
desire to be thinner when compared to straight men, yet the same when compared to women
(Yelland & Tiggemann, 2003). Among MSM, views towards ideal bodies have continued to
become significantly thinner when compared to those of straight men (Herzog et al., 1991;
Martins et al., 2007; Tiggemann et al., 2007).
Aside from merely idolizing slimness, there has been a subsequent push among the
gay community to reach the ideal body shape that has been socially created. The masculine
3


ideal is one that requires muscularity, which indicates obvious fitness (Vartanian et al.,
2001). In the eyes of MSM, this ideal is one that is not only lean, but also muscular, and v-
shaped, defined by a well-toned upper body, broad shoulders, a flat stomach and narrow
hips. Despite how muscular they actually are, most men, especially MSM, consistently report
that they view themselves as less muscular than they are and desire to be more muscular
(Cafri et al., 2006; Martins et al., 2008; Pope et al., 2000; Tiggemann et al., 2007; Vartanian
et al., 2001; Yelland & Tiggemann, 2003).
Research has also illustrated that, though weight and muscularity are the most
important to gay men, much dissatisfaction is often experienced with regards to specific body
parts (i.e. arms, chest, and penis) and body hair (i.e. lack of head hair and excess body hair)
(Franzoi & Shields, 1984; Martins et al, 2008). Though both heterosexual men and MSM
generally report dissatisfaction with their upper and lower body appearance, MSM tend to
report increased levels (Martins et al., 2007; Tiggemann et al., 2008). This concept also holds
true for other parts of the male body, including shoulders, waist size, arms, and overall body
build (Franzoi & Shields, 1984).
Studies show that gay men engage in higher levels of self-objectification when
compared with heterosexual men (similar to women), spending far more time not only
criticizing their looks but attempting to find ways to fix them (Kozak et al., 2009; McKinley &
Hyde, 1989; Russell & Keel, 2002). How MSM perceive their observers (men) to view them
also holds extreme bearing on how satisfied they become with themselves, leading to an
increased body awareness (Martins et al., 2007; Morrison et al., 2004). In a study comparing
levels of body dissatisfaction between heterosexual women and gay men, both groups body
4


dissatisfaction was largely attributed to the increasing importance placed on attracting and
pleasing a male partner (Pope et al., 2000).
Gender Role Strain Theory examines differences between mens personal body
characteristics and their ideal. Though many straight men show large discrepancies between
their current and desired thinness and muscularity (Vartanian et al., 2001), increased
dissonance often develops among MSM upon the acceptance of a gay identity, whereas a
masculine self-concept is threatened by the social stereotype of gay men as effeminate
(Reilly & Rudd, 2006). Speculations also exist that MSMs negative body image and identity
could be partially attributed to problems during childhood, such as increased teasing over
lack of perceived masculinity (Duggan & McCreary, 2004).
Emotional and Physical Health Risks of BID
Research has demonstrated that body image dissatisfaction can lead to an array of
emotional and health risk consequences among the population as whole. Defining identity
solely by appearance can subsequently lead to various negative pathologies such as: body
shame, in which people feel shame when their bodies do not meet cultural expectations;
appearance anxiety; depression; low self-esteem; compulsive exercise; and eating disorders
(Cooper et al., 1987; Kozak et al., 2009; McKinley & Hyde, 1989; Russell & Keel, 2002). Such
issues, specifically body shame and appearance anxiety, can also lead to self-
consciousness, lack of assertion, and a need for reassurance, especially during sexual
activity (Steer & Tiggemann, 2008).
Those whom are anxious about their appearances are also more likely to engage in
potentially detrimental health risk behaviors. One way for people to cope with the negative
affect created by BID is through the use of substances (Littleton et al., 2005), which
5


subsequently impairs judgment, decision-making skills, and assertiveness. Many people use
alcohol and other downers to numb, uppers to lose weight, and hallucinogens, ecstasy, and
other sexual enhancement drugs to increase sexual appeal, all of which further weaken the
ability to make rational decisions. All such substances use is also connected with risky sex
(Gritz & Crane, 1991; Leigh, 1990; Parkes et al., 2008). In addition, drinking alcohol
suppresses immune function, thereby increasing the likelihood of contracting STDs (such as
HIV) in the context of risky sex and also increases the mortality rate of those who have
progressed to full blown AIDS (Bryant, 2006).
Research has also examined the direct relationship between BID and sexual risk
behaviors. Some argue that negative body image may lead one to avoid sexual activity for
reasons of discomfort or embarrassment, yet some research illustrates a correlation between
poor body image and various self-harm behaviors, including increased sexual risk behavior
(Browning et al., 2006; Ostrow et al., 1993). Comfort and confidence in sexual interactions
comes into play. When assessed in heterosexual women, body dissatisfaction evoked shame
that was correlated with fear of negotiating condom use, as well as the use of sex as a
means to secure a relationship (Littleton et al., 2005). Some studies have also shown that
those with increased body image dissatisfaction are more likely to have both a higher number
of lifetime sex partners as well as engage in inconsistent condom use (Gillen et al., 2006;
Littleton et al., 2005; Steer & Tiggemann, 2008). There is also a cyclic effect between
negative body image beliefs and sexual dysfunction. The feelings of guilt and shame about
ones body are often strongly correlated with orgasmic disorders, thus further bolstering ones
intrinsic negative automatic thoughts about his/her body (Nobre and Pinto-Gouveai, 2008).
6


Health Risks in MSM
Among MSM, the pursuit to reach an ideal level of muscularity and thinness can have
extremely harmful consequences. The discrepancy between actual and ideal body
satisfaction is related to negative outcomes, such as lower self-esteem and increased
depression (Barbara, 2002; Martins et al., 2008; Reilly & Rudd, 2006; Russell & Keel, 2002).
The literature comparing heterosexual and homosexual men has repeatedly illustrated that
gay men report lower levels of self-acceptance tied to their body image dissatisfaction (Gil,
2007; Morrison et al, 2004). Obsessive self-scrutiny over muscles can often lead to a clinical
subtype of body dysmorphic disorder, known as muscle dysmorphia, in which men have
increased negative perception and distorted view of their muscle mass (Cafri et al., 2006;
Chaney, 2008; Mayville et al., 2002). Studies have shown that MSM with symptoms of
muscle dysmorphia reported increased feelings of loneliness and decreased self-esteem
when compared with MSM with fewer symptoms (Chaney, 2008).
Homosexuality and its connection with staying slim and dieting has not only become
a specific risk factor for body image dissatisfaction, but also for life-threatening illnesses,
such as bulimia or anorexia nervosa. Research has shown that gay men score significantly
higher on disordered eating assessments, such as the Eating Attitudes Test-26 and the
Eating Disorder Inventory Bulimia subscale, when compared with heterosexual men (Conner
et al, 2004; Duggan & McCreary, 2004; Russell & Keel, 2002).
Similar to the rest of the population, MSM also cope with feelings of inadequacy and
compensate for their believed shortcomings attributed to BID through the use of substances.
Substance use among MSM becomes increasingly dangerous due to an already increased
risk for abuse/ dependency among this population. One of the larger studies to date
7


examining substance use patterns in the gay community is that of McKirnan and Peterson.
Comparing levels of alcohol consumption across two samples of adult (primarily Caucasian)
homosexuals and heterosexuals, remarkable results were found. Though both samples
reported approximately the same levels of heavy drinking (15% vs. 14%), the homosexual
sample reporting far higher levels of moderate drinking (71% vs. 57%). With regards to
abstaining from alcohol, homosexuals were found to abstain from drinking at about half the
rate of heterosexuals, with the homosexual men also reporting higher levels of overall alcohol
consumption than homosexual women (McKirnan & Peterson, 1989). Another study
illustrated the increased rate of homosexual heavy drinking (defined by at least 60 drinks
per month), 28%, compared to that of the general male population at the time, only 19%.
However, rates in both samples tended to attenuate over time (Ostrow et al., 1993).
The literature also reflects increased drug use among the homosexual population.
Elevated lifetime use of various substances among homosexuals is typical, as well as
increased (though attenuated) levels of recent use. One such study showed in particular that
homosexual men were not only significantly more likely to have used cocaine within the last
month, but also more likely to have reported cocaine or marijuana use in the past week.
There were also increased levels of most other substance use, though not significant
(Cochran et al., 2004). In McKirnan & Petersons study (1989), the homosexual sample
reported higher rates of lifetime marijuana and cocaine use, while it typically dropped
significantly as they aged. Amyl nitrate (popper) use was reported at a rate of 14%
(occasionally or weekly) and 7% (daily) by the homosexual sample. These rates are typically
not studied as frequently within the heterosexual population, though are estimated to be
significantly lower. Overall, 23% of the gay male sample reported at least two problems
8


related to the loss-of-control/ dependence upon a substance (including alcohol) within the
past year (McKirnan & Peterson, 1989).
There are many speculations within the research community as to why such
increased rates of substance abuse among MSM exist. It could be attributed to the lack of
pressure and responsibility to enter into traditional marriage, occupation, child-rearing and
sex roles at specific developmental time points, as well as the lack of such circumstantial
restraints which may hinder heavy drinking and drug use (Cabaj, 2000; Israelstam & Lambert,
1989; McKirnan & Peterson, 1989). Internalized homophobia, as well as strong adherence to
conformed masculinity, has also been connected with greater substance use among MSM
(Cabaj, 2000; Hamilton & Mahalik, 2009; Israelstam & Lambert, 1989). Increased substance
use among MSM can, perhaps, also be attributed to social affiliations within the large number
of gay satellite cultures. For example, membership to the Circuit Boys (those who follow the
circuit party and club scene) is highly correlated with increased drug and alcohol use (as well
as unprotected sex) (Willoughby et al., 2008).
The likelihood of engagement in risky sex, specifically lack of condom use and
increase in random partners, increases when one is intoxicated (Kalichman & Tannenbaum,
1998; Kelaher et al., 1994). Alcohol and other drugs have been noted as determinants of
risky sexual behavior as a means of decreasing ones inhibitions, often with partners who are
HIV positive (Bryant, 2006). Many report that when using substances, they lose feelings of
shyness and uncertainty, replaced with increased self-esteem, increased self-confidence,
and the ability to allow partners to do things that they normally wouldnt do (Myers et al.,
2004). In one study looking at substance abuse patterns among seronegative gay men, the
last six month heavy alcohol use, and last six month use of stimulants, nitrate inhalants, or
9


hallucinogens was each associated with a higher sexual risk, though marijuana did not have
any significant effect. Results also showed that past use (over a year ago) was not correlated
with increased sexual risk, indicating that termination of substance use is correlated with a
reduction in risk (Woody et al., 1999).
As discussed earlier, some preliminary research has found a (sole) link between
body image dissatisfaction and sexual risk in MSM (Browning et al., 2006), regardless of the
use of substances. There are various speculations as to why. Many MSM often seek to
eradicate feelings of physical undesirability and affirm self-efficacy through sex, with
engagement in frequent and adventurous sex among HIV positive men often reported as a
way of affirming their attractiveness (Halkitis et al., 2004). Thus, any sort of sexual
opportunity, regardless of the risk involved, can act as a means for MSM with poor body
image to gain positive reassurance from a male sexual partner (Orbach, 1996; Steer &
Tiggemann, 2008).
As the research illustrates, levels of BID, substance use, and risky sex are all quite
common in the MSM population and are often interrelated. MSM often cope with BID via the
use of substances as well as risky sex for means of reassurance-seeking. However, no study
has formally evaluated the mediating role that substance abuse may play in the relationship
between BID and risky sex. For this study, it is hypothesized that BID will lead to increased
substance abuse and that increased substance use will predict more risky sex. At the same
time, risky sex can also be a direct way that MSM cope with BID. Thus, a partial mediation
may be expected, where the relationship between BID and risky sex is partially, but not fully
mediated by substance abuse. Knowing the level of the indirect effect of substance abuse
can help isolate how much of the relationship between BID and risky sex can be accounted
10


for by substance abuse, and how much BID predicts risky sex independent of substance
abuse.
Specific Aims
R1: Does body dissatisfaction in MSM, specifically with regards to dissatisfaction with weight
and elements of perceived masculinity (i.e. muscularity and satisfaction with specific body
parts), predict their subsequent engagement in risky sexual behavior (i.e. engaging in
unprotected receptive anal sex)?
H1: The more dissatisfied MSM are with their bodies, the more likely they will be to engage in
risky sexual behavior (i.e. unprotected receptive anal sex).
R2: Does substance abuse act as a mediating factor between body dissatisfaction and risky
sexual behavior?
H2: Substance abuse will at least partially mediate the relationship between body
dissatisfaction and risky sexual behavior.
11


CHAPTER 2
METHODS
Participants
A total of 450 surveys were collected. Once inappropriate surveys were removed, the
estimated total sample size was smaller (A/ = 371). This sample is comprised of all men
whom have sex with men (MSM), including men whom identify as gay (n = 299), men whom
identify as bisexual (n = 62), as well as men whom identify as heterosexual, though endorsed
having had sex with another man in the past three months (n = 10).
However, the final sample size was reduced again when I subdivided it into two
groups, for I was only interested in those participants who actually engaged in risky acts after
using substances. Those MSM who endorsed having had sex after drinking over the past
three months were placed in the Alcohol Group (n = 124). This group was comprised of MSM
ranging in age from 18 to 58 years (M= 31.44, SD = 10.74). Participants in this group were
primarily Caucasian (66.9%). The remaining participants were Hispanic (16.1%), African
American (5.6%), Native American (3.2%), and Asian American (.8%), those who identified
as Other (4.8%), as well as several participants who neglected to report their ethnicities.
Among the MSM within this group, most identified as gay (81.5%), some identified as
bisexual (16.1%), and some identified as heterosexual (2.4%), though reported having had
sex with a man within the past 3 months.
Those MSM who endorsed having had sex after using drugs over the past three
months were placed in the Drug Group (n = 74). This group was comprised of MSM ranging
12


in age from 18 to 67 years (M = 31.30, SD =11.89). Participants in this group were primarily
Caucasian (60.3%). The remaining participants were Hispanic (17.8%), African American
(11%), Native American (2.7%), and Asian American (1.4%), and those who identified as
Other (6.8%). Among the MSM within this group, most identified as gay (70.3%), some
identified as bisexual (24.3%), and some identified as heterosexual (5.4%), though reported
having had sex with a man within the past 3 months.
Procedure
MSM, over the age of 18 and regardless of HIV status, were recruited at Denvers
Gay Pride Fest (June 27-28, 2009). This event was chosen as a site for recruitment due to
the sheer amount of gay men who typically attend such events, as well due to the large
amount of research indicating that many gay men who attend such events often engage in
various types of risky sexual behavior (The Center, 2008). Such volunteers approached a
booth and were given 8 page questionnaires, typically taking approximately ten minutes to
complete. Upon completion, they were paid with a 2 dollar bill, as well as having 2 dollars
donated to a charitable HIV/AIDS organization on their behalf.
Measures
Substances
Alcohol was assessed on its own within the Alcohol Group, based on the average
ratings of items from the substance use scale: 1 indicating no use within the past three
months; 2 indicating use once or twice within the past three months; 3" indicating use
several times within the past three months; and 4 indicating use at least every week over
the past three months. (See Appendix A). The measures of central tendency indicated high
levels of overall alcohol use within this group (M = 3.49, SD = .74) (See Table 1.2).
13


It was initially challenging to decide how to group the various drugs within the Drug
Group since measures of substance use often do not use internal consistency estimates
(Cronbach's alpha, etc.). For example, one would expect each item on a depression inventory
to be correlated with the others in that it is assessing the same, overall, construct. However,
since each item on the drug scale assesses a separate substance use, an internal
consistency estimate might not make sense. There could be a degree of correlation between
separate behaviors but not necessarily a high correlation. For example, one who uses
methamphetamine does not necessarily use cocaine. However, the goal of data reduction
motivated me to evaluate the internal consistency of the drug items.
Reliability analyses were initially conducted within the Drug Group to identify how to
properly group the drugs: all together; in various categories; or individually. All the drugs
combined (i.e. marijuana, poppers, ecstasy, meth, cocaine, ketamine, rohypnol, ghb) had
adequate psychometric properties, indicating that they could be analyzed as a cohesive unit
(a = .77). However, item total correlations showed that marijuana was not correlated with the
larger scale, and excluding marijuana from the drug scale empirically proved to increase the
reliability of the drug scale (a = .82). Thus, this scale of drugs was comprised of the average
frequency of use of the following disinhibiting drugs: poppers, ecstasy, meth, cocaine,
ketamine, rohypnol, ghb. That is, a mean scale score was created for this composite drug
group based on the average ratings of items from the substance use scale: 1 indicating no
use within the past three months; 2 indicating use once or twice within the past three
months; 3" indicating use several times within the past three months; and 4 indicating use
at least every week over the past three months. I also attempted to explore other possible
14


clusters of drugs base on an initial correlation matrix to see if there were any other drug
groupings with increased reliability, though none were found.
The measures of central tendency among the Drug Group showed lower levels of
overall drug use (including marijuana) when compared with alcohol use for the Alcohol Group
(M = 1.64, SD = .61). When marijuana was excluded from the drug category, there was a
slight decrease in the frequency of drug use among the Drug Group (M = 1.48, SD = .64)
(See Table 1.2). Marijuana was the most frequently used (M = 2.74, SD = 1.17), followed by
poppers (M = 1.68, SD = .96), cocaine (M = 1.64, SD = .94), meth (M = 1.59, SD = .98),
ecstasy (M = 1.53, SD = .90), ghb (M = 1.35, SD = .79), ketamine (M = 1.24, SD = .64), and
rohypnol (M = 1.21, SD = .63).
Body Image Dissatisfaction
Body image dissatisfaction was assessed through asking questions derived from
several scales with established reliability and validity. The scales included in the survey from
which items were taken for the analysis each assess unique types of body dissatisfaction.
(See Appendix A). To assess perception and satisfaction with muscularity, I used items from
two different scales. The Muscle Appearance Satisfaction Scale (Mayville et al., 2002), with
established psychometric properties (a > .90), is a brief self report measure used to assess
the value that men put on their own muscularity and help identify symptoms of muscle
dsymorphia. Questions are asked, Over the past 4 weeks, please rate how often have you
felt this way." Participants are then asked to rate their answers on a 5-point scale from (1)
never to (5) always. Some example questions used are: My self worth is often focused on
how my muscles look and I must get bigger muscles by any means necessary
15


Items were also taken from The Drive for Muscularity Scale (McCreary and Sasse,
2000), with established psychometric properties (a = .83). This scale looks to assess the
value that men put on attaining ideal muscularity. Questions are also asked on a 5-point
scale from never (1) to always (5). Some example questions used are I wish that I were
more muscular and I think I would feel more confident if I had more muscle mass.
Another self-report measure from which items were taken, The Emphasis on Body
Scale (Halkitis et al., 2004), with established psychometric properties (a = .82), was used to
assess the value that men place on physical appearance, specifically muscularity and body-
building, Participants are asked to rate answers on a 5-point scale from (1) not at all like me
to (5) completely like me. Examples of questions used from this scale are: I work hard to
look muscular and I use testosterone or deca durabolin to help pump up.
To assess MSMs overall satisfaction with specific body parts, items were used from
The Body Esteem Scale (Franzoi & Shields, 1984), with established psychometric properties
(a = .84). Participants rate each item on a 5-point scale from (1) Have strong positive feelings
to (5) Have strong negative feelings. They are asked about their feelings regarding their
Body Build Weight Body Hair Sex Organs and Arms.
Items from several scales were also used to assess MSMs overall opinion of their
appearance. First, items from The Conceptions of Masculinity Scale (Halkitis et al., 2004)
were used to assess mens conceptions of masculinity, once again with established
psychometric properties (a = .82). Participants are asked to rate their answers on a 5-point
scale from (1) completely disagree to (5) completely agree. Examples of questions used from
this scale are Well built men give the impression of masculinity as first sight and Physical
Appearance is an important element of masculinity in the gay community.
16


Items from The Body Shape Questionnaire (Cooper et al., 1987), with established
psychometric properties (a = .88), were used to assess how men feel about their size and
shape. Participants are asked, Over the past 4 weeks, please rate how often you have felt
this way" and rate their answers on a 5-point scale from (1) never to (5) always. Examples of
questions used from this scale are: Have you ever been so worried about your shape that
you feel you ought to diet? and Have you avoided situations where people could see your
body?
Items were used from The Objectified Body Consciousness Scale, specifically its
Surveillance subscale, a = .89, and Body Shame subscale, a = .75 (McKinley & Hyde,
1996), to assess how MSM view their bodies (from the perspective of an outside observer) as
well as feelings of shame that surround thinking about their bodies. Participants are asked to
rate their answers from (1) strongly disagree to (5) strongly agree. Examples of questions
used from this scale are: I would be ashamed for people to know what I really weigh and
When Im not the size I think I should be, I feel ashamed.
Though the initial reliability analysis of the all the BID items used proved sufficient (a
= .86), a rationally and empirically driven iterative process resulted in the removal of four BID
items due to their low item-total correlations. These items all referred to behaviors regarding
efforts to build muscle mass, rather than thoughts that reflected possible body image
dissatisfaction. Examples of such items are: I work hard to look muscular; and I use other
steroids to help pump my body up. Upon removal of such items, reliability analyses
demonstrated a slightly stronger cohesion among the BID items (a = .87).
A mean scale score (from 1 to 5) was then created for the remaining BID items,
based on an average of the answers to various items scored on the following scale: 1,
17


strongly disagree; 2, disagree; 3" neither agree or disagree; 4, agree; and 5, strongly
agree. The higher overall score indicated a higher level of BID. Measures of central tendency
for this BID predictor variable were as follows: Alcohol Group (M = 2.99, SD = .68); and Drug
Group (M = 2.85, SD = .69) (See Table 1.1).
Risky Sexual Behavior
A Risky Sex score was created for each participant through examining relationship
status and frequency of any unprotected receptive anal sex over the past three months. (See
Appendix A). Though there were many possible ways in which to categorize sexual risk, six
categories were ultimately created to account for the increased risk in having unprotected
receptive anal sex with a monogamous partner more than once over the past three months,
though they are not evenly distributed on an interval scale. Participants were scored as
follows: 0 indicated no unprotected receptive anal sex; 1 indicated unprotected anal
receptive sex once with a monogamous partner; 2 indicated unprotected receptive anal sex
more than once with a monogamous partner; 3 indicated unprotected receptive anal sex
once with a random partner; 4" indicated unprotected receptive anal sex twice with random
partners; and 5 indicated unprotected anal receptive sex more than three times with random
partners.
Measures of central tendency for the Risky Sex outcome variable were as follows:
Alcohol Group (Mdn = 1.00,'SD = 2.08); and Drug Group (Mdn = 2.00, SD = 2.11) (See Table
1.1).
18


Table 1.1 Descriptives: Risky Sex and BID in both groups
Alcohol Group Drug Group
Risky Sex
Mean 1.95 2.18
Median 1.00 2.00
Mode .00 .00
SD 2.08 2.11
Range 5.00 5.00
Minimum .00 .00
Maximum 5.00 5.00
Sum 242.00 161.00
BID
Mean 2.99 2.85
Median 3.05 2.84
Mode 2.90 2.52*
SD .68 .69
Range 3.76 3.95
Minimum 1.19 1.00
Maximum 4.95 4.95
Sum 371.24 210.83
Note. Multiple modes exist. The smallest value is shown.
19


Table 1.2 Descriptives: Substances in both groups
Alcohol Group Drug Group
Alcohol
Mean 3.49
Median 4.00
Mode 4.00
SD .74
Range 3.00
Minimum 1.00
Maximum 4.00
Sum 433.00
Drugs (w/o marijuana)
Mean 1.48
Median 1.29
Mode 1.00
SD. .64
Range 2.86
Minimum 1.00
Maximum 3.86
Sum 109.86
20


CHAPTER 3
Results
Assumptions for Mediation
Initial examinations of the distributions of the variables indicated that the BID variable
was normally distributed, but that the Risky Sex variable, as well as the Alcohol and Drug
variables, violated assumptions for normal distribution (i.e. significant levels of skew and
kurtosis) for both the Alcohol and Drug Group. The K-S and S-W tests indicated that the
Risky Sex variable for both the Alcohol and Drug Groups were significantly different from
normal: Alcohol Group, D(124) = .28, p < .01 & D(124) = .78, p < .01; Drug Group, D(74) =
.25, p < .01 & D(74) = .79, p < .01. They also indicated that both alcohol and drug
categorizations were significantly different from normal: Alcohol, 0(124) = .36, p<.01 &
D(124) = .68, p < .01; all drugs, D(74) = .214, p <.01 & D(74) = .80, p < .01; all drugs
excluding marijuana, D(74) = .25, p < .01 & D(74) = .74, p < .01. When each individual drug
was assessed separately, such tests still indicated that the data was not normally distributed.
The Risky Sex variable as well as the Alcohol and Drug variables (all drugs, all drugs
excluding marijuana, and each individual drug) were then transformed in three ways (log,
square root, and reciprocal). However, none of the transformations improved the normality of
the data; thus, nonparametric analyses were conducted with these variables.
21


Correlations
Non-parametric correlations (i.e. Spearmans Rho and Kendalls Tau) were
conducted between all of the variables included in the analysis (BID, Risky Sex, Alcohol, and
Drugs).
I first examined non-parametric correlations within the Alcohol Group. All results were
non-significant. There was a weak (non-significant) positive correlation between BID and
alcohol use, x = .08 and rs= .09, as well as non-significant correlations between risky sex and
alcohol use, t = .01 and rs = .01. This indicates that participants may have had slightly higher
BID if they consumed more alcohol as well as having possibly engaged in some more risky
sex. Unexpectedly, there was a weak (non-significant) negative correlation between BID and
risky sex in the Alcohol group, x = -.08 and rs= -.10, indicating that the higher levels of BID
reported in this group, the less risky sex they engaged in. Because the basic conditions for
mediation or indirect effects were not met, these models were not explored further.
In the Drug group, there was a weak (non-significant) positive correlation, x = .05 and
rs = .06, between BID and risky sex. There was a weak (non-significant) positive correlation
between BID and drug use, x = .02 and rs= .04. There was a slightly higher, but still non-
significant, positive correlation between risky sex and drug use, x = .17 and rs= .21. Thus, as
in the case of alcohol, the basic conditions for mediation analyses were not met and thus
mediation analyses were not conducted.
Exploratory Analyses
Although the basic hypotheses were not confirmed, I examined interrelationships
among variables to provide more information within the study. When examining individual
drugs, there were significant positive correlations between risky sex and poppers, x = .22 and
22


rs= .25, and risky sex and meth, x = .25 and rs= .29, indicating that these two drugs might, in
fact, be related to engagement in more risky sex.
Looking at high dissatisfaction with muscularity alone, there was a significant
negative correlation between this and overall drug use, x = -.18 and rs = -.25, indicating that
higher muscle dissatisfaction was correlated with a decrease in illicit drug use. Perhaps these
participants concern about their bodies results in some healthier choices, such as refraining
from drug use.
Surprisingly, higher confidence in assertion abilities with regards to when and with
whom to have sex was significantly positively correlated with BID, x = .17 and rs= .22. This
finding is contrary the hypothesis that having high BID may lead one to have a decreased
ability to assert oneself in the bedroom.
23


Table 1.3 Kendalls tau correlation coefficients: individual drugs, BID, and risky sex
BID Risky Sex
Marijuana .04 -.02
Poppers -.05 .22*
Ecstasy .08 .03
Meth .08 .25*
Cocaine .10 .07
Ketamine .10 .02
Rohypnol .13 .12
GHB .01 .13
Note. indicates significant values.
24


CHAPTER 4
Discussion
Significance of the Study
The overarching aim of this study was to examine if overall body image
dissatisfaction in MSM predicted risky sexual behavior (i.e. unprotected receptive anal sex),
perhaps mediated through the use of various substances. Such variables were analyzed
within two separate groups, MSM who had endorsed having had sex after using alcohol and
those who had endorsed having had sex after using certain disinhibiting drugs. There was an
overall lack of significance in the results of the study, all of the proposed variables
exemplifying very weak correlations, some even indicating results that were contrary to what
was hypothesized. For example, in the Alcohol group, it appeared that those who endorsed
higher levels of BID were actually less likely to engage in unprotected receptive anal sex.
Though opposite from the hypothesized direction, it could be that higher levels of BID could,
in fact, inhibit individuals from engaging in as many sexual acts total, due to embarrassment
of their bodies.
However, despite lack of significance in the correlations that were hypothesized,
exploratory analyses did provide some meaningful information. Though most of the
substances assessed have been shown to have significant use among the homosexual
population and be correlated with sexual risk behavior (Cochran et al., 2004; Israelstam &
Lambert, 1989; Kalichman & Tannenbaum,1998; McKiman & Peterson, 1989), many
substances in the study (including alcohol) did not have a significant correlation with
25


unprotected receptive anal sex. However, both poppers and meth were significantly
correlated with increased engagement in risky sex behavior. Research has illustrated that
poppers are commonly associated with unprotected receptive anal sex, as well as other
sexually risky acts, among the homosexual population for its use in sexual stimulation as well
as other disinhibiting factors (i.e. disregard for personal safety) (Ostrow et al., 1997) and this
was certainly supported in this study. Surprisingly, meth was associated with risky sex acts in
this study, while cocaine was not, and cocaine is typically more commonly connected with
such risky acts (Woody et al.,1999).
The negative correlation between dissatisfaction with muscularity and overall drug
use exemplified in the study also has important implications. Such a drive towards attaining
the perfect muscular male body is highly associated with mens increased engagement in
physical fitness and/or use of steroids (Duggan & McCreary, 2004), which was not directly
examined in this study due to its lack of connection to other disinhibiting drugs. However,
such lifestyles, in fact, may directly conflict with tendencies to use other illicit substances,
including alcohol, because of its likelihood to detract from the ability to consistently workout
and stay on track with a physical fitness regimen.
Limitations
The extremely low correlations within the study were unexpected. Several
possibilities exist to explain the results. It is possible that the results demonstrated true
findings and there really were no significant results. Alternatively, the measures may have
been flawed, undermining the hypotheses. For example, it may be that the coding for risky
sexual behavior, which was developed for this study, could have been an insensitive
measure of risky sexual behavior. Though the scoring levels appeared to indicate
26


consecutive levels of risk, it was not an interval scale; for example, unprotected sex with
random partners indicate far higher levels of risk than with monogamous partners. Also, due
to the lack of BID measures used specifically for the adult male homosexual population,
some of the established scales from which the body image questions were derived have
been used primarily with only women, adolescents, or heterosexual men and do not have
established norms for the adult gay male population (Cooper et al., 1987; Franzoi & Shields,
1984; Mayville et al., 2002; McCreary & Sass, 2000). Thus, though the BID scale I created
proved reliable, it may have lacked validity for the purpose it was used.
The sampling method used and the environment of Gay Pride, alone, could have also
elicited some problems. Gay Pride Fest is known for large amounts of alcohol assumption.
Thus, ones perception of ones own body may change under the influence of alcohol. There
is also a strong possibility that people are less honest when under the influence of alcohol, in
addition to any already existing self-report biases. To control for such affects of alcohol
consumption, those individuals who completed surveys were screened and their surveys
flagged if they appeared extremely intoxicated. However, minor intoxication could have been
easily overlooked. Also, perhaps only those MSM who felt confident that they engaged in
healthy life choices were the ones who chose to fill out a mens health survey.
Restriction of range in the data could have also contributed to a lack of findings. The
initial sample (N = 371) was subdivided only into those who endorsed having had sex after
drinking (n = 124) and using drugs (n = 74). Since analyses were only conducted amongst
the two smaller groups, it is plausible that correlations do, in fact, exist among the larger
sample that was initially obtained. I could have either chose to run correlations on the entire
27


sample, or employed one of many correction formulas to correct for the range restriction
(Wiberg & Sundstrom, 2009).
There may have been non-linear (curvilinear) relationships among variables. For
example, perhaps very low levels of BID and very high levels of BID are both associated with
risky sex, while moderate levels are not. A relationship such as this would be obscured by the
analyses conducted.
Moreover, a relationship might not have been detected due to possible variability in
the effects of BID on risky sex. As evidenced through the research, BID can manifest in two
very different directions. Those with BID may engage in a lot of risky sex, due to a need for
reassurance, or alternatively may engage in less sex, due to their sheer embarrassment of
their bodies (Steer & Tiggemann, 2008). Therefore, MSM in this study who endorsed higher
levels of BID may have had either extremely high or low risky sex scores. Because of this,
there might have been no visible relationship in the results.
There were a few other limitations within the study as well. There are many other
confounding variables associated with body image dissatisfaction and sexual risk behavior.
Depression, as well as sexual adventurism and risk-seeking, could be underlying factors that
affected the likelihood of engagement in risky sex (Ostrow et al., 1997); such variables were
not measured in this particular survey. Also, the inability of the survey to measure body size
estimation, or how accurately one perceives the reality of his body, was another limitation
that, had it been included, could have greatly contributed to the information obtained from this
study. Due to the fact that there was insufficient time at Gay Pride to weigh and measure
participants, we were unable to calculate individual BMIs and thus cannot include such a
variable in the study.
28


Directions for Future Research
There are many ways in which strategies used in this study could be improved for
future research. A larger overall sample from which to analyze such variables would enable
far more in-depth research. Future research could also try to isolate different elements of
body dissatisfaction and its consequences. If such limitations were rectified, researchers
could identify which individual elements of BID, perhaps, are correlated with substance use
and risky sex and in what ways, as well as which are not. This could significantly add to the
existing literature and future preventative efforts to identify and treat MSM with such life-
threatening risk behaviors. .
Future research could also benefit from actively recruiting sufficient samples of all
subsets of MSM: gay, bisexual and heterosexual men (who endorse having had sex with a
man recently). This study was unable to collect large enough samples from each group and
was, thus, could not gain enough statistical power to analyze each individually. However,
such information would be valuable in attempting to assess if there are unique distinctions in
BID and sexual risk behavior when men are simply being objectified by other men, versus
men and women.
There are other variables that also need further exploration. This includes certain
constructs that could potentially coincide with BID, risky sex, and substance use, such as
depression, adventurism, and other personality characteristics. The results of this study
indicated that increased BID was positively correlated with assertion abilities when it comes
to sex. Being highly opposed to what much of the literature has previously illustrated (Littleton
et al., 2005; Steer & Tiggemann, 2008), this result requires replication. But, it may be that BID
in MSM has different correlates than BID in other populations. Recruiting participants in a
29


more structured environment to employ body scale drawings and assess BMIs could also
allow researchers to measure tendencies towards potential or pre-existing eating disorders.
This is a key element that connects with the variables of this study, yet was unable to be
properly assessed due to lack of resources.
Despite the lack of significance found in this study, prior research has illustrated that
the relationship between BID, substance use, and risky sexual behavior is a dynamic that
merits further exploration. Though this study was unable to prove such relationships with
confidence, the utilization of more refined and exhaustive data collection could further
enhance the field of HIV and AIDS research and preventative efforts.
30


APPENDIX A
GAY PRIDE SURVEY
THANK YOU FOR TAKING TIME TO FILL OUT THIS SURVEY!
THIS SURVEY IS ANONYMOUS.
PLEASE DO NOT
PUT YOUR NAME ON IT.
THIS SURVEY IS BEING DONE BY
THE UNIVERSITY OF COLORADO DENVER.
YOU WILL BE PAID $2.00 FOR COMPLETING THE SURVEY, PLUS WE WILL
DONATE $2.00 TO AN HIV/AIDS CHARITY. PARTICIPATION WILL TAKE 10-15 MINUTES.
31


Please answer each question below.
1. What is your age:_______.____years
2. Which best describes you:
White African-American Hispanic/Latino Asian-American Native American
Other___________
3. Circle the highest grade or year of school that you completed.
6 7 8 9 10 11 12 13 14 15 16 17+
4. Circle one of the following that is closest to your current yearly income.
$0 $15,000 $16 30,000 $31 $45,000 $46 $60, 000 Over $60,000
5. What is your current employment status:
Working Unemployed Student Receiving Disability Other
6. Which of the following best describes your relationship status at this time? (Circle all that
apply)
a) Not having sexual relations
b) Having sex but do not have an exclusive partner
c) In an exclusive relationship with one person (no outside sexual partners)
d) In an exclusive relationship with one person (with outside sexual partners)
7. How would you describe your sexual orientation? (circle one)
Gay Bisexual Heterosexual
If you are gay or bisexual, how out are you?
a) Definitely closeted (Not open about sexual orientation)
b) Closeted some of the time and Out some of the time
c) Definitely Out (Open about sexual orientation all of the time)
32


8. About how many people with HIV or AIDS have you known?
____________number of people
9. Have you been tested for HIV? YES NO
If you have been tested, do you know the results of your most recent test?
Positive Negative Dont Know
In the past year, how often have you done the following:
Never Seldom Occasionally Often
1. Read gay newspapers or magazines 1 2 3 4
2. Gone out to gay bars 1 2 3 4
3. Participated in gay social events 1 2 3 4
4. Attended gay cultural events 1 2 3 4
5. Visited gay-oriented Internet sites 1 2 3 4
Please circle or fill in your answer to the following:
1. Do you use condoms when you get into a relationship? YES NO
2. Do you find out about your sex partners HIV status before having sex? YES NO
33


Over the past 4 weeks, please rate how often have you felt this way:
Never Rarely Sometimes Often Always
1. Have you ever been so worried about your
shape that you feel you ought to diet?
1
2. Have you worried about your flesh not being
firm enough?
1
2
2
3. Has seeing a reflection (i.e., in a mirror or shop
window) made you feel you ought to diet?
1 2
4. Have you avoided situations where people could
see your body?
1 2
3 4 5
3 4 5
3 4 5
3 4 5
In the past 3 months, how many times have you done each of the following? Please write a
number in each space. If you did not do something, write a zero (0) in the space.
months
months
1.1 had sex after I had too much to drink.
2.1 had sex after I used drugs.
times in the past 3
times in the past 3
34


Please think carefully about the past 3 months, and fill in the spaces below. Please be sure
to write a number in every space. If you did not do a behavior, write a zero (0) in the space.
Give each answer your best estimate of how many times you have done the following things:
How many men have you had anal sex with in the past 3 months?
________Total # of men in past 3 months
How many women have you had vaginal or anal sex with in the past 3 months?
________Total # of women in past 3 months
How many times have you had ..
Anal sex, no condom used, my partner _______Times past 3 months
inserted his penis in me (I was bottom).
________# men past 3 months
Anal sex, no condom used, I inserted _______Times past 3 months
my penis in my partner (I was top).
________# men past 3 months
Anal sex, condom used, my partner _______Times past months
inserted his penis in me (I was bottom).
________# men past 3 months
Anal sex, condom used, I inserted _______Times past 3 months
my penis in my partner (I was top).
________# men past 3 months
Oral sex with ejaculation (cumming) in mouth, _____Times past 3 months
and no condom, my partner sucked my penis.
_______# men past 3 months
Oral sex with ejaculation (cumming) in mouth, _____Times past 3 months
and no condom, I sucked his penis.
_______# men past 3 months
35


Please circle your answer t6 the following questions:
1. Have you ever had a sexual disease (STD) such as syphilis, gonorrhea, or herpes?
YES NO
2. Have you ever used needles to inject (shoot-up) drugs?
YES NO
3. Has someone ever given you money, drugs, or a place to stay in exchange for sex?
YES NO
4. Have you ever given someone else money, drugs, or a place to stay in exchange for sex?
YES NO
Please rate your degree of confidence in your ability to do the following:
Absolutely Very Dont Know Very Absolutely
Certain Certain How Certain Uncertain Uncertain
1. Choose when and with whom to have sex.
1 2 3 4 5
2. Refuse to do something sexually which you
dont feel comfortable about.
1 2 3 4 5
3. Ask a potential partner to wait if
precautions are not available at the time.
1 2
4.
Control your sex urges while under the
influence of alcohol.
1
2
3 4 5
3 4
36


Please rate how often have you felt this way:
Never Rarely Sometimes Often Always
1. My self worth is very focused on my muscles look. 1 2 3 4 5
2.1 must get bigger muscles by any means necessary. 1 2 3 4 5
37


Please circle the choices that best apply:
Strongly Disagree Neither Agree Agree Strongly
Disagree 1. Physical appearance is an important element of masculinity in the gay community. 1 2 or Disagree 3 4 Agree 5
2. Well built men give the impression of masculinity as first sight. 1 2 3 4 5
3. A masculine man has a lot of sex. 1 2 3 4 5
4. Sexual performance is an important part of masculinity. 1 2 3 4 5
5. During the day, I think about how I look many times. 1 2 3 4 5
6.1 often worry about whether the clothes I am wearing make me look good. 1 2 3 4 5
7. I would be ashamed for people to know what I really weigh. 1 2 3 4 5
8. When Im not the size I think I should be, I feel ashamed. 1 2 3 4 5
9. I wish that I were more muscular. 1 2 3 4 5
10.1 think I would feel more confident if I had more muscle mass. 1 2 3 4 5
11.1 work hard to look muscular. 1 2 3 4 5
12.1 work out regularly each week. 1 2 3 4 5
13.1 use testosterone or deca durabolin to help pump up. 1 2 3 4 5
14.1 use other steroids to help pump my body up. 1 2 3 4 5
38


Please circle how much you have used the following in the past 3 MONTHS:
None Once or twice Several times At least every week
Alcohol 1
Marijuana 1
Poppers 1
Ecstasy (X) 1
Methamphetamine 1
(crystal or tina)
Cocaine 1
(powder or crack)
Ketamine 1
(special k)
Rophynol ("roofies") 1
GHB ("g) 1
Viagra, Cialis, or Levitra 1
Steroids 1
Other recreational drugs 1
4
4
4
4
4
2
2
2
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
3
3
3
4
4
4
4
4
4
4
Based on your sexual behavior over the past 12 months, how likely are you to get HIV?
Dont know Not at all likely Somewhat Likely Very Likely I am already HIV+
Please choose the feelings that best describe how you feel about the following parts of your
body:
Have Strong
Have
Have no
Have
Have Strong
39


Positive Feelings Moderate Positive Feelings feelings one way or the other Moderate Negative Feelings Negative Feelings
Weight 1 2 3 4 5
Body Build 1 2 3 4 5
Arms 1 2 3 4 5
Width of Shoulders 1 2 3 4 5
Body Hair 1 2 3 4 5
Sex Organs 1 2 3 4 5
Sex Drive 1 2 3 4 5
Please mark how much you agree or disagree with the statements.
Strongly Disagree Disagree Neither Disagree nor Agree Agree Strongly Agree
I am good at getting others to do my work. 1 2 3 4 5
I deserve special recognitioh. 1 2 3 4 5
I really enjoy beating the system. 1 2 3 4 5
It takes someone really special to understand and appreciate me. 1 2 3 4 5
I rarely get so angry that I lose control. 1 2 3 4 5
I put up a fight when someone asks me to do something I dont want to do. 1 2 3 4 5
People often disappoint me. 1 2 3 4 5
I like to show off. 1 2 3 4 5
I rarely stay in a sexual relationship with just one person for very long. 1 2 3 4 5
Thank you for taking the time to complete this survey!
40


APPENDIX B
IRB REQUEST FOR EXEMPTION
HSRC Request for Exemption
PROTOCOL #: 09-0430
CAMPUS BOX#: 120 TELEPHONE #: 303-556-6536 Fax#:
303-556-3377
Review Dates
Date of Initial Submission: May 29, 2009
Revision Date: June 8, 2009
Project Information
Project Title: Psychosocial factors, substance use, and sexual risk behavior
in gay and bisexual men
Research Area: Sexual Risk Behavior / Substance Use
Contact Information
Principal Investigator
Name: Eric Benotsch, Ph.D.
41


Employee or Student ID #: 000165670 Rank: Associate Professor
Department: Psychology
Campus Box or Mailing Address: 173
Phone #: 303-556-8566 Cell #:
E-Mail Address: eric.benotsch@ucdenver.edu
Advisor (required for students!
Name:
Employee ID #: Rank:
Department:
Campus Box or Mailing Address:
Phone #: Cell #:
E-Mail Address:
Co-lnvestiaators (please provide phone # and e-mail)
Name
Diana Luckman
Phone E-Mail
303-931- DIANA.LEVAS-
8974 LUCKMAN@email.ucdenver.edu
Primary Contact Tlf different from Principal investigator!
42


Name:
Employee or Student ID #:
Rank: Department:
Campus Box or Mailing Address:
Phone #: Cell #:
E-Mail Address:
Fundin
Do you have any funding for this study? Yes
El No
If yes, Funding Sponsor:
Sponsor Project #:
If yes, the grant provided must be provided
Note: I do not have external funding for the study. Incentives will be provided
from my ICR funds.
The Institution receiving funding is:
UCDHSC
Downtown Denver
campus
UCDHSC
Anschutz campus
Other (please list):
43


Performance Sites
List ALL sites where research will take place:
[X] UCDHSC
Downtown Denver
campus
UCDHSC
Anschutz campus
£3 Other (please list): Denver Gay Pride Festival 2009 (Downtown civic center
park area)
[X] Single Center
Non-Affiliated Sites
D Multi-center /
Protocol Information
Problem to be studied:
Men who have sex with men (MSM) are at heightened risk for HIV, STDs,
and substance use problems (CDC, 2003). In our past work, we have found that
conducting surveys at Gay Pride celebrations can yield large, useful data sets that
document risk trends in the gay community and help identify new areas for
intervention. These methods have yielded both publications and grant funding (e.g.,
Benotsch, Kalichman & Cage, 2002; Benotsch et al., 2005; Kalichman, Benotsch et
al., 2001).
In the present study, we will collect demographic data, and information
concerning recreational substance use, sexual behavior, gay acculturation, body
image, narcissism, altruism, self-control persistence, perceptions of vulnerability to
HIV, STD history and status, and estimates of the perceived risk associated with
various behaviors. A brief rationale for each of the major constructs assessed can
be found below.
44


Describe the research including questions, purpose, and methodology of the
research. This section should clearly describe what will happen in the study
and how these activities will answer study questions.
Denvers Gay Pride festival is a 2-day event. Two separate surveys will be
administered: one on Saturday, the second on Sunday. The data will be collected in
collaboration with the Gay, Lesbian, Bisexual, and Transgender Community Center
of Colorado (The Center). The Center is one of the largest and most respected
organizations devoted to LGBT issues in the state of Colorado.
The questionnaires used in the study assess the following constructs:
Questionnaire 1:
Measures:
Demographics. Gav Acculturation. Substance Use. Perceptions of Risk, and Sexual
Risk Behavior
Demographic information is crucial for describing the sample participants and
for identifying trends in risk behavior related to age, ethnicity, identification with
mainstream gay culture, etc. The demographic, substance use and sexual risk
behavior questions are comparable (or identical) to questions we have used on past
Gay Pride surveys conducted in Atlanta, Milwaukee, and Denver (Benotsch &
Nettles, 2007; Benotsch et al., 2002; 2006). These measures yield useful data
concerning risk behaviors. Consistent with our prior work, open response formats
will be used for the sexual behavior measures to reduce response bias and to
minimize measurement qrror (Benotsch, Mikytuck et al., 2006). Measures similar to
these have been found to be reliable in self-reported sexual behavior assessments
(Kauth et al., 1991) and to yield aggregate indices of risk that are comparable to
those obtained by finer-grained partner-by-partner sexual behavior assessments
(Pinkerton et al., 2007).
Body Image.
Previous research has found a link between body image disturbance, and
high-risk sexual behavior in heterosexual women (Littleton et al., 2005). Our
previous work was suggestive of links between body image disturbance and high-risk
sexual behavior in MSM (Browning et al., 2006). For this study, we will assess body
image in much greater detail. We will assess body image perceptions using items
adapted from McKinley & Hyde (1996), Halkitis et al. (2004), McCreary & Sasse,
2000, Franzoi, & Shields (1984) and Cooper et al. (1987), well-validated
assessments of problematic body image.
45


Narcissism
Narcissism is a personality trait we hypothesize will be associated with
pathological body image. Narcissism will be examined using items adapted from the
Schedule for Nonadaptive and Adaptive Personality (SNAP; Clark, 1993). The
SNAP is a factor analytically derived, self-report measure for the assessment of Axis
II personality disorders (Clark, 1993). All SNAP scales have demonstrated internal
consistencies and acceptable test-retest reliabilities (Simms, 2002).
Questionnaire 2:
Measures:
Demographics. Gav Acculturation. Substance Use. Perceptions of Risk, and Sexual
Risk Behavior
Demographic information is crucial for describing the sample participants and
for identifying trends in risk behavior related to age, ethnicity, identification with
mainstream gay culture, etc. The demographic, substance use and sexual risk
behavior questions are comparable (or identical) to questions we have used on past
Gay Pride surveys conducted in Atlanta, Milwaukee, and Denver (Benotsch &
Nettles, 2007; Benotsch et al., 2002; 2006). These measures yield useful data
concerning risk behaviors. Consistent with our prior work, open response formats
will be used for the sexual behavior measures to reduce response bias and to
minimize measurement error (Benotsch, Mikytuck et al., 2006). Measures similar to
these have been found to be reliable in self-reported sexual behavior assessments
(Kauth et al., 1991) and to yield aggregate indices of risk that are comparable to
those obtained by finer-grained partner-by-partner sexual behavior assessments
(Pinkerton et al., 2007). (Note: most of these items are identical to
questionnaire 1)
Non-medical use of prescription medications
Previous research has documented high rates of the use or abuse of
prescription medications in college students (McCabe & Boyd, 2005). Pharm
Parties are a cultural phenomenon where young adults come together to abuse or
trade prescription medication, acquired illicitly from peers, friends, or via the Internet
(Banta, C., 2005). Popular substances of abuse at these parties include pain
medications (e.g., Vicodin), medications used for the treatment of attention-deficit
disorder (e.g., Ritalin), arid medications used for anxiety (e.g., Xanax). Some of
these medications can be purchased without a prescription on the Internet, and
many are among the most commonly-prescribed medications in the United States.
The relative availability of these prescription medications leads to the potential for
46


abuse. Illicit use of prescription medication may be particularly dangerous when
used in combination with traditional drugs of abuse such as alcohol, ecstasy,
methamphetamine, etc. McCabe and colleagues found that the prevalence of
lifetime illicit drug use of pain medication was 17% for college-age men and 16% for
college-age women. Other commonly abused medications included stimulant
medications (5.4%), sedative/anxiety medication (2.9%), and sleeping medication
(2.0%). (McCabe, Teter, Boyd, 2005). In my labs work on this campus, 48% of
students who participated in our research reported non-medical use of prescription
drugs at some point in their lifetime (Cejka et al., 2008). Gay and bisexual men have
elevated rates of substance use, and it is well-documented that substance use /
abuse is associated with higher rates of sexual risk behavior (Benotsch, Kalichman,
& Kelly, 1999; Benotsch, Seeley et al., 2006; Benotsch, Mikytuck et al., 2006; CDC,
2003). To the best of our knowledge, there is no literature documenting the
prevalence of the non-medical use of prescription medications among MSM. In this
study, we will administer a shortened version of an assessment of this behavior that
we have used in previous work (Cejka et al., 2008).
HIV Altruism / Social Consciousness
HIV altruism is a construct associated with higher levels of consistent condom
use among HIV-positive persons. This scale has shown adequate internal
consistency (a = 0.83) and predictive utility in prior work (ODell et al., 2008). We
intend to explore whether altruism is also associated with greater steps to protect
sexual partners among gay and bisexual men, regardless of their HIV status. We
are supplementing questions from the HIV altruism scale with items from the
Assessment of Global Social Responsibility scale, a previously validated scale of
social consciousness (Starrett, 1996).
Persistence
For populations at high risk for HIV, the general recommendation from public
health officials has been to maintain abstinence or use condoms 100% of the time
during sexual activity. Despite the obvious discipline following such
recommendations would require, relatively little research has examined the role of
self-control and persistence as a correlate of safer sex. For this study, we will
assess this construct with the persistence subscale of the State Self-Control Scale
(Tangney, Baumeister, & Boone, 2004).
Recruitment: Describe from where and how the participants or records will be
identified.
We will rent a vendor booth which will be located on the Gay Pride grounds
(Civic Center Plaza). Participants will be recruited from the vicinity of our booth.
Both areas will be staffed by the P.I., and 5 students (UCD clinical psychology
47


graduate students and/or advanced undergraduate students). As men pass by, they
will be invited to participate in an anonymous survey.
Potential participants will be told that participation is voluntary and that the
information they provide, should they choose to participate, will be used for research
purposes and to better understand the health and health behaviors of men who have
sex with men. Only participants age 18 or over will be eligible to participate.
A sample script for recruiters is as follows:
"Hello. Do you mind if I talk to you for a minute? We're administering a survey as
part of a research project that examines health behaviors of men who have sex with
men. The survey is completely voluntary, anonymous, and takes about 10-15
minutes to complete. We believe the information will help us plan for the health
needs of MSM in Colorado. Would you be willing to complete a survey for us?"
If the participant agrees to participate, staff will provide them with a clipboard
with the survey being administered. We will insure that questionnaire administration
occur in a private setting within the same venue (e.g., removed from other individuals
who may be present). We will answer any questions participants have. We will offer
a $2.00 cash incentive for participation. In addition, a $2.00 donation will be made
on the participants behalf to one of two LGBT/HIV-related charities. Participants will
have the option to choose to donate their funds to: (a) The Positive Project, a
Denver based non-profit organization that seeks to reduce stigma associated with
HIV and to improve the lives of HIV-positive persons, or (b) The Elton John AIDS
Project, an international non-profit organization that funds innovative HIV prevention
programs. In our past work, we have found that giving participants the opportunity to
help support a worthy cause is a useful additional incentive for participation. When
weve used this procedure in the past, as many as 40% of participants have chosen
to donate their entire ($4.00) incentive to charity. The financial aspects of the
protocol (cash payment, charitable donation) have been approved by the UCD
controller (Kim Huber) and the Vice Chancellor for Administration and Finance
(Teresa Berryman). As an additional incentive strategy, we will provide free
condoms and lube packets to interested participants. We will also provide
informational brochures (English and Spanish) containing information about safer
sex and substance use.
Using this incentive structure in the past, we have found that 60% or more of
participants have been willing to complete a 10-11 page questionnaire. The present
questionnaires are a bit shorter (8-pages) which may increase participation. Based
on trial runs, we anticipate that participants will be able to complete the questionnaire
in 10-15 minutes.
48


Participant Population: Describe the target population.
The target population is MSM age 18 and over attending the 2009 Gay Pride
celebration in Denver, CO. The PI has successfully recruited over 1500 MSM to
complete surveys at Gay Pride celebrations in Atlanta, GA; Milwaukee, Wl; and
Denver, CO, with no adverse events reported. MSM in the United States have
become accustomed to completing brief anonymous health-related surveys.
Privacy and Confidentiality: Describe what information will be collected, how it
will be gathered, who will have access to it, and how it will be protected.
A number of steps will be taken to insure protection of research participants
to minimize any negative emotional or social consequences of participation, and
protection of confidentiality. Because of the sensitive nature of the survey and
potential legal ramifications of describing illegal activity, measures will be completed
anonymously. Names or other forms of identifying information will not be collected at
any time. Data collected will be kept secure and without identifying information.
Participants will have the opportunity to ask questions of study personnel and will be
free to withdraw from the study at any time. Data will be collected by the P.l. and
senior UCD students well versed in the emotional support of at-risk populations.
Participants will have the option to decline to participate or to decline to answer a
question they deem too personal.
The P.l. will be present and available to answer any questions. Participants
will also be provided with the phone number to call the principal investigator if they
have questions at a later time. The PI is a clinical psychologist with 11 years
experience working with gay men on issues related to HIV prevention. The PI has
extensive experience conducting HIV-related research, has been a P.l. or co-
investigator on 12 federal or state-funded research grants, and has co-authored
more than 50 publications in this field. The PI has also completed relevant training in
HIV prevention, including a 2-year postdoctoral fellowship in HIV prevention research
and the National Institute of Healths ethics course. The PI will provide ongoing
supervision and monitoring of the project to minimize risks to participants and insure
ethical research conduct. Data will be kept secure in locked filing cabinets in the Pis
lab. Electronic data will be stored on password-protected computers with encrypted
hard drives.
As a service to participants (and non-participants attending Gay Pride), we will
provide informational materials about use and abuse of commonly used recreational
drugs and safer sex behavior.
49


Will any special populations be involved?
Prisoners ...............
Yes No
Decisionally Challenged...
Pregnant Women/Fetuses
Yes No
Yes No
Number of subjects (or records, specimens, etc.): Up to 450 for each
questionnaire (up to 900 total) N/A: Explain
Age range: 18 and older (no upper limit) N/A: Explain
Expected date of completion: May 2011 (including analysis and publication)
I f the research extends beyond the expected date of completion then the researcher
must notify HSRC.
Attached is a copy of material that will be given to participants. Check and
include all that apply.
Advertisement Flyer Telephone script
Letter Information Sheet Questionnaire
Note: We will not use media advertisements in this study. However, signs on
the vender booth itself will be displayed advertising the opportunity to participate
in a short survey. The signs will indicate our affiliation with UCD and indicate that
men can complete a brief health-related survey.
Text of signs will read as follows:
Mens Health Research Survey (large print)
10 minutes of your time can help the community!
Please answer the following additional questions about the research.
50


1. Will the research be conducted in established or commonly accepted
educational settings?
Yes- answer question below

No-proceed to # 2
A. Will the researchers use their current students or trainees as
subjects? Yes No
If yes, explain what additional measures will be taken to ensure that
participants do not feel pressured or coerced during the research.
2. Will existing data, documents, or records be used?
I I Yes-answer questions below
No -proceed to # 3
A. What was the time period for source data collection?
From to
B. State the purpose for the initial collection and who collected it.
C. Is the source publicly available? Yes-state where:
No-answer questions below
1. Is the information recorded in such a manner that subjects cannot be
identified, directly or through identifying links? Yes No*
If no, the protocol does not qualify for exemption. Submit as an
Expedited Protocol.
In order to qualify for exempt status, records cannot be identified,
directly or through identifying links.
51


CHECK THE BOX NEXT TO EACH POTENTIAL IDENTIFIER YOU WILL
BE USING FOR THIS RESEARCH
Name/lnitials
Address
City
County
Precinct
Zip Code
Telephone Number
Fax Number
E-Mail Address
Social Security Number
Unique ID Numbers: Student ID, Medical Record Number,
Account Number, etc.
Certificate/license Number
Vehicle Identifiers
Device Identifiers
Web Universal Resource Locators (URL)
Internet Protocol Address Numbers
Biometric Identifiers (including finger or voice prints)
Full Face Photographs and Comparable Images
Any Other Unique Identifying number, characteristic or code
All dates (except year) that are directly related to an
individual (e.g. date of birth, graduation date)
2. Is a master list or spreadsheet used to identify records of
interest or to track which records have been extracted?
Yes No
Describe how the tracking will occur:
If lin'k exists, the protocol does not qualify for exemption.
Submit as an Expedited Protocol.
3. Will existing biological specimens be used?
Yes -answer questions below ^ No -proceed to # 4
A. What was the time period for biological specimen collection?
52


From
to
B. State the purpose for the initial collection, who collected it, and whether
consent was used to obtain it.
C. Is the source publicly available? Yes- state where:
I I No-answer questions below
1. Can the specimens be linked back to a person through direct or
indirect identifiers?
Yes No
2. If yes, is there an agreement in place that prohibits the release of
identifiers? '
Yes DNo
If yes, submit copy of agreement.
In order to qualify for exempt status, specimens cannot be identified,
directly or through identifying links.
CHECK THE BOX NEXT TO EACH POTENTIAL IDENTIFIER YOU WILL
BE USING FOR THIS RESEARCH
Name/lnitials
Address
City
County
Precinct
Zip Code
Telephone Number
Fax Number
53


E-Mail Address
Social Security Number
ED Unique ID Numbers: Student ID, Medical Record Number,
Account Number, etc.
Certificate/license Number
Vehicle Identifiers
Device Identifiers
Web Universal Resource Locators (URL)
Internet Protocol Address Numbers
Biometric Identifiers (including finger or voice prints)
Full Face Photographs and Comparable Images
Any Other Unique Identifying number, characteristic or code
All dates (except year) that are directly related to an
individual (e.g. date of birth, graduation date)
4. Will surveys/interviews/tests be used?
I I No- proceed to # 5

Yes- answer questions below
A. Is data collected from participants recorded in such a way that a person can
be identified directly or indirectly? SUBMIT all
Surveys/Questionnaires/Tests and Invitation to Participate.
C]Yes E3 No
CHECK THE BOX NEXT TO EACH POTENTIAL IDENTIFIER YOU WILL
BE USING FOR THIS RESEARCH
Name/lnitials
Address
City
County.
Precinct
Zip Code
Telephone Number
Fax Number
E-Mail Address
Social Security Number
Unique ID Numbers: Student ID, Medical Record Number,
Account Number, etc.
Certificate/license Number
Vehicle Identifiers
54


Device Identifiers
Web Universal Resource Locators (URL)
Internet Protocol Address Numbers
Biometric Identifiers (including finger or voice prints)
Full Face Photographs and Comparable Images
Any Other Unique Identifying number, characteristic or
code
All dates (except year) that are directly related to an
individual (e.g. date of birth, graduation date)
B. Could disclosure of the survey responses place the participant at risk of
criminal or civil liability or be damaging to the subjects financial standing,
employability or reputation?
IE Yes No
If you answer, "yes" to BOTH 4A and 4B, protocol does not qualify for
exemption. Submit as an Expedited protocol.
55


References
Banta, C. (2005). Trading for a high: An inside look at pharming party" the
newest venue for teenage prescription-drug abuse. Newsweek, August 1, 2005.
Benotsch, E.G., Kalichman, S., & Cage, M. (2002). Men who have met sex
partners via the Internet: Prevalence, predictors, and implications for HIV
prevention. Archives of Sexual Behavior, 31, 177-183.
Benotsch, E.G., Kalichman, S.C., & Kelly, J.A. (1999). Sexual compulsivity
and substance use in HIV seropositive men who have sex with men: Prevalence
and predictors of high-risk behaviors. Addictive Behaviors, 24, 857-868.
Benotsch EG, Mikytuck J, Ragsdale K, Pinkerton SD. Sexual risk and HIV
acquisition among MSM travelers to Key West, Florida: A mathematical modeling
analysis. AIDS Patient Care STDS 2006;20:549-556.
Benotsch, E.G., & Nettles, C.D. (2007). Internet use to find sexual
partners, sexual risk, and strategies to reduce risk among men who have sex
with men. Poster presented at the 65th annual meeting of the American
Psychosomatic Society, Budapest, Hungary.
Benotsch, E.G., Nettles, C.D., & Kalichman, S.C. (2005). Methamphetamine
use, sensation seeking, and high-risk sexual behavior among men who have sex
with men. Poster presented at the 26th annual meeting of the Society of Behavioral
Medicine, Boston, MA.
Benotsch, E.G., Nettles, C.D., & Uban, K. (2006). Methamphetamine use and
sexual risk behavior in aav and bisexual men. Poster presented at the 18th annual
meeting of the Association for Psychological Science. New York, NY.
Benotsch, E.G., Seeley, S., Mikytuck, J., Pinkerton, S.D., Nettles, C.D., &
Ragsdale, K. (2006). Substance use, medications for sexual facilitation, and sexual
risk behavior among traveling men who have sex with men. Sexually Transmitted
Diseases, 33, 706-711.
Browning, M., Rosen, A., Benotsch, E.G., Nettles, C.D., Uban, K., & Martin,
K. (2006). Body image and sexual risk behaviors in men who have sex with men.
Poster presented at the 64th annual meeting of the American Psychosomatic Society,
Denver, CO.
CDC (2003). Fact Sheet: Need for Sustained HIV prevention among Men
who have sex with men. Available on the World Wide Web at:

Cejka, A., Benotsch, E.G., Allen, E., & Case, K. (2008). Non-medical use of
prescription medications among young adults in the United States. Poster presented
at the 10th International Congress of Behavioral Medicine, Tokyo, Japan.
Clark, L. A. (1993). Schedule for Nonadaptive and Adaptive Personality
manual for
administration, scoring, and interpretation. Minneapolis, MN: University of Minnesota
Press.
56


Cooper, P., Taylor, M., Cooper, Z., Fairburn, C. (1987) The Development and
Validation of the Body
Shape Questionnaire. International Journal of Eating Disorders, 6(4), 485-494.
Franzoi, S., & Shields, S. (1984). The Body Esteem Scale: Multidimensional
Structure and Sex Differences in a College Population. Journal of Personality
Assessment, 48(2), 173-178.
Halkitis, P., Green, K., & Wilton, L. (2004). Masculinity, Body Image, and
Sexual Behavior in HIV-
Seropositive Gay Men: A Two-Phase Formative Behavioral Investigation Using the
Internet. International Journal of Mens Health, 3(1), 27-42.
Kauth MR, St Lawrence JS, Kelly J A. Reliability of retrospective
assessments of sexual hiv risk behavior: A comparison of biweekly, three-month,
and twelve-month self-reports. AIDS Educ Prev 1991;3:207-214.
McCabe, Sean Esteban, Boyd, Carol J. (2005) Sources of prescription drugs
for illicit use Addictive behaviors 30 1342-1350, Science Direct, www. Science
direct.com
McCabe. Sean Esteban, Teter, Christian J., Boyd, Carol J. (2005) Illicit use of
prescription pain medication among college students. Addictive behaviors 30 1342-
1350, Science Direct, www. Science direct.com.
McKinley, N., & Hyde, J. (1996). The Objectified Body Consciousness Scale.
Psychology of Women Quarterly, 20,181-215.
McCreary, D., & Sasse, D. (2000). An Exploration of the Drive for Muscularity
in Adolescent Boys and
Girls. Journal of American College Health, 48, 297-304.
ODell, B.L., Rosser, B.R.S., Miner, M.H., & Jacoby, S.M. (2008). HIV
prevention altruism and sexual risk behavior in HIV-positive men who have sex with
men. AIDS & Behavior, 12, 713-720.
Pinkerton SD, Benotsch EG, & Mikytuck JM. When do simpler sexual
behavior data collection techniques suffice? An analysis of consequent uncertainty in
HIV acquisition risk estimates. Eval Rev 2007;31:401-412.
Simms, L. J. (2002). Development, reliability, and validity of a computerized
adaptive version of the schedule for nonadaptive and adaptive personality [Thesis].
Retrieved 6/8/2006 from
httD://www.psvch.umn.edu/psvlabs/catcentral/pdf%20files/si02-01 .pdf.
Starrett, R. H. (1996). Assessment of global social responsibility,
Psychological Reports, 78, 535-554.
Tangney, J.P., Baumeister, R.F., & Boone, A.L. (2004). High self-control
predicts good adjustment, less pathology, better grades, and interpersonal success.
Journal of Personality, 72, 271-323.
57


Exempt Categories
Select one or more of the following categories for exemption of this project.
(1) Research conducted in established or commonly accepted
educational settings, involving normal educational practices, such as:
(i) research on regular and special education instructional strategies,
or
(ii) research on the effectiveness of or the comparison among
instructional techniques, curricula, or classroom management
methods.
[X] (2) Research involving the use of educational tests (cognitive, diagnostic,
aptitude, achievement), survey procedures, interview procedures or
observation of public behavior, unless:
(i) information obtained is recorded in such a manner that human
subjects can be identified, directly or through identifiers linked to
the subjects; and
(ii) any disclosure of the human subjects' responses outside the
research could reasonably place the subjects at risk of criminal or
civil liability or be damaging to the subjects' financial standing,
employability, or reputation.
(3) Research involving the use of educational tests (cognitive, diagnostic,
aptitude, achievement), survey procedures, interview procedures, or
observation of public behavior that is not exempt under paragraph (b)(2)
of this section, if:
(i) the human subjects are elected or appointed public officials or
candidates for public office; or
(ii) Federal statute(s) require(s) without exception that the
confidentiality of the personally identifiable information will be
maintained throughout the research and thereafter.
(4) Research involving the collection or study of existing data, documents,
records, pathological specimens, or diagnostic specimens where:
Yes No


Sources are publicly available.
The information is recorded by the investigator in such a
manner that subjects cannot be identified, directly or
58


through identifiers linked to the subjects.
Coded or Linked data at site of origin is not acceptable.
(5) Research and demonstration projects which are conducted by or
subject to the approval of Department or Agency heads, and which are
designed to study, evaluate, or otherwise examine:
(i) Public benefit or service programs;
(ii) procedures for obtaining benefits or services under those
programs;
(iii) possible changes in or alternatives to those programs or
procedures; or
(iv) possible changes in methods or levels of payment for benefits or
services under those programs.
(6) Taste and food quality evaluation and consumer acceptance studies
(i) if wholesome foods without additives are consumed or
(ii) if a food is consumed that contains a food ingredient at or below
the level and for a use found to be safe, or agricultural chemical or
environmental contaminant at or below the level found to be safe,
by the Food and Drug Administration or approved by the
Environmental Protection Agency or the Food Safety and
Inspection Service of the U.S. Department of Agriculture.
If vour project does not fit one of the six (6) Exempt categories above and you
are submitting vour project to determine whether the activities are considered
human subject research please indicate below:
Submitting project for determination of Not Human Subjects Research
Acknowledgement
Submission of a proposal to the HSRC requires that the principal investigator and
advisor (if PI is a student) sign this page indicating they have read the definitions
of scientific misconducf'and conflict of interest given below and agree to the
continuing responsibility to HSRC statement.
59


Scientific Misconduct Scientific Misconduct shall be considered to include:
1. Fabrication, falsification, plagiarism or other unaccepted practices in proposing,
carrying out or reporting results from research;
2. Material failure to comply with Federal requirements for the protection of human
subjects, researchers and/or the Public;
3. Failure to meet other material legal requirements governing research;
4. Failure to comply with established standards regarding author names on
publications;
5. Failure to adhere to issues of patient confidentiality as provided in the subject
consent form, the study protocol, and as outlined in the Code of Federal
Regulations (45 CFR 46)
Investigators Continuing Responsibility to HSRC
Once the protocol has been deemed as exempt it is the Principal Investigators (PI)
responsibility to report any changes in the research activity prior to implementing the
changes, to determine whether the proposed changes continue to meet criteria for
exemption.
Acknowledgment
I have read the definitions of Scientific Misconduct and listed all potential
Conflicts of Interest. I have read the Investigators Continuing Responsibilities
to HSRC. I understand the definitions of Scientific Misconduct and Conflicts of
Interest and my continuing responsibilities to HSRC. My signature below
attests to my agreement to conduct this research study in such a manner that
acts of scientific misconduct and conflicts of interest will not be committed
and that I will comply with the continuing responsibilities to HSRC.
Signature of Principal Investigator Date Signature of Advisor
Date
(if applicable)
60


HSRC Use Only____________________________________
Determination of the Human Subject Research Committee
Qualifies for Exemption under 45 CFR 46.101
Qualifies as Not Human Subject Research
Resubmit: Expedited or Full Board
HSRC Chair or Designee
Date
Tony Robinson
Mary Geda
61


BIBLIOGRAPHY
Barbara, A.M. (2002). Substance Abuse Treatment with Lesbian, Gay, and Bisexual
People: A Qualitative Study of Service Providers. Journal of Gay & Lesbian Social
Services, 14(4), 1-17.
Baron, M.R., & Kenny, D.A. (1986). The Moderator-Mediator Variable Distinction in Social
Psychological Research: Conceptual, Strategic, and Statistical Considerations.
Journal of Personality and Social Psychology, 51 (6), 1173-1182.
Benotsch, E.G., Mikytuck, J., Ragsdale, K., & Pinkerton, S.D. (2006). Sexual risk and HIV
acquisition among MSM travelers to Key West, Florida: A mathematical modeling
analysis. AIDS Patient Care & STDS, 20, 549-556.
Browning, M., Rosen, A., Benotsch, E., Nettles, C., Uban, K., & Martin, K. (2006, March).
Body Image and Sexual Risk Behavior in Men who have Sex with Men. Poster
session presented at the 64th annual meeting of the American Psychosomatic
Society, Denver, CO.
Bryant, K. (2006). Expanding Research on the Role of Alcohol Consumption and Related
62


Risks in the Prevention and Treatment of HIV/ AIDS. Substance Use and Misuse, 41,
1465-1507.
Cabaj, R.P. (2000). Substance Abuse, Internalized Homophobia, and Gay Men and
Lesbians: Psychodynamic Issues and Clinical Complications. Journal of Gay and
Lesbian Psychotherapy, 3(3/4), 5-24.
Cafri, G., Van den Berg, P., & Thompson, J.K. (2006). Pursuit of Muscularity in Adolescent
Boys: Relations Among Biopsychosocial Variables and Clinical Outcomes. Journal
of Clinical Child and Adolescent Psychology, 35(2), 283-291.
Chaney, M.P. (2008). Muscle Dysmorphia, Self-esteem, and Loneliness among Gay and
Bisexual Men. International Journal of Mens Health, 7(2), 157-170.
Cochran, S.D., Ackerman, D., Mays, V.M., & Ross, M.W. (2004). Prevalence of non-
medical drug use and dependence among homosexually active men and women in
the US population. Addiction, 99, 989-998.
Conner, M., Johnson, C., & Grogan, S. (2004). Gender, Sexuality, Body Image, and Eating
Behaviors. Journal of Health Psychology, 9(4), 505-515.
Cooper, P., Taylor, M., Cooper, Z., Fairburn, C. (1987) The Development and Validation of
the Body Shape Questionnaire. International Journal of Eating Disorders, 6(4),
63


485-494.
Duggan, S. & McCreary, D. (2004). Body Image, Eating Disorders, and the Drive for
Muscularity in Gay and Heterosexual Men: The Influence of Media images. The
Journal of Homosexuality, 47(3/4), 45-58.
Franzoi, S., & Shields, S. (1984). The Body Esteem Scale: Multidimensional Structure and
Sex Differences in a College Population. Journal of Personality Assessment, 48(2),
173-178.
Gil, S. (2007). Body Image, well-being and sexual satisfaction: a comparison between
heterosexual and gay men. Sexual and Relationship Therapy, 22(2), 237-244.
Gillen, M.M., Lefkowitz, E.S., & Shearer, C.L. (2006). Does Body Image Play a Role In
Risky Sexual Behavior and Attitudes? Journal of Youth and Adolescence, 35(2), 243-
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