Sexual identity, sexual behavior, and drug use behaviors among people who use drugs in the rural U.S.

Wiley D. Jenkins; Lauren B. Beach; John Schneider; Samuel R. Friedman; Mai T. Pho; Suzan Walters; Jerel Ezell; April M. Young; Caitie Hennessy; William C. Miller; Vivian F. Go; Christina Sun; David W. Seal; Ryan P. Westergaard; Heidi M. Crane; Rob J. Fredericksen; Stephanie A. Ruderman; Scott Fletcher; Jimmy Ma; J. A. Delaney; Karma Plaisance; Judith Feinberg; Gordon S. Smith; P. Todd Korthuis; Thomas J. Stopka; Peter D. Friedmann; William Zule; Mike Winer

doi:10.1016/j.josat.2025.209629

Sexual identity, sexual behavior, and drug use behaviors among people who use drugs in the rural U.S.

Wiley D. Jenkins
, Lauren B. Beach
, John Schneider
, Samuel R. Friedman
, Mai T. Pho
, Suzan Walters
, Jerel Ezell
, April M. Young
, Caitie Hennessy
, William C. Miller
, Vivian F. Go
, Christina Sun
, David W. Seal
, Ryan P. Westergaard
, Heidi M. Crane
, Rob J. Fredericksen
, Stephanie A. Ruderman
, Scott Fletcher
, Jimmy Ma
, J. A. Delaney

Karma Plaisance, Judith Feinberg, Gordon S. Smith, P. Todd Korthuis, Thomas J. Stopka, Peter D. Friedmann, William Zule, Mike Winer

Research output: Contribution to journal › Article › peer-review

1 Scopus citations

Abstract

Introduction: People who use drugs (PWUD) are at risk of HIV infection, but the frequency and distribution of transmission-associated behaviors within rural communities is not well understood. Further, while interventions designed to more explicitly affirm individuals' sexual orientation and behaviors may be more effective, descriptions of behavior variability by orientation are lacking. We sought to describe how disease transmission behaviors and overdose risk vary by sexual orientation and activity among rural PWUD. Methods: From 01/2018–03/2020, rural PWUD participating in the Rural Opioid Initiative were surveyed across 8 sites. Collected data included: demographics; experiences with drug use, overdose, and healthcare; stigma; gender identity; and sexual orientation and partners. Participants were categorized as: monosexual by orientation and behavior (Mono-only), monosexual by orientation but behaviorally bisexual (Mono/Bi), and bisexual by orientation (Bi+). Analyses included descriptive summaries, bivariate examination (chi-square), and logistic regression (relative risk [RR] and 95 % confidence interval [CI]). Results: The 1455 participants were 84.8 % Mono-only, 3.2 % Mono/Bi, and 12.0 % Bi+. Compared to Mono-only men, Mono/Bi and Bi+ men had greater risk of transactional sex (RR = 9.71, CI = 6.66–14.2 and RR = 5.09, CI = 2.79–9.27, respectively) and sharing syringes for injection (RR = 1.58, CI = 1.06–2.35 and RR = 1.85, CI = 1.38–2.47). Compared to Mono-only women, Mono-Bi and Bi+ women had greater risk of transactional sex (RR = 4.47, CI = 2.68–7.47 and RR = 2.63, CI = 1.81–3.81); and Bi+ women had greater risk of sharing syringes for injection (RR = 1.49, CI = 1.23–1.81), sharing syringes to mix drugs (RR = 1.44, CI = 1.23–1.69), and experiencing an overdose (RR = 1.32, CI = 1.12–1.56). Bi+ men and women both more frequently reported selling sex as a source of income (versus Mono-only, both p < 0.050) and measures of perceived stigma (all p < 0.050). Conclusions: Rural PWUD who are bisexual by orientation or behavior are significantly more likely to engage in behaviors associated with infectious disease transmission and to experience stigma and drug overdose. Given the growing recognition of bisexuality as a distinct orientation that warrants individualized consideration, interventions that are specifically acknowledging and affirming to the circumstances of this group are needed.

Original language	English
Article number	209629
Journal	Journal of substance use and addiction treatment
Volume	171
DOIs	https://doi.org/10.1016/j.josat.2025.209629
State	Published - Apr 2025

Bibliographical note

Publisher Copyright:
© 2025 Elsevier Inc.

Funding

This publication is based upon data collected and/or methods developed as part of the Rural Opioid Initiative (ROI), a multi-site study with the goal of better characterizing the rural opioid epidemic and its consequences and a common protocol that was developed collaboratively by investigators at eight research institutions and at the National Institute on Drug Abuse (NIDA), the Appalachian Regional Commission (ARC), the Centers for Disease Control and Prevention (CDC), and the Substance Abuse and Mental Health Services Administration (SAMHSA). Research presented in this manuscript is the result of secondary data harmonization and analysis and was supported by grant U24DA048538 from NIDA. Primary data collection was supported by grants UG3DA044829/UH3DA044829, UG3DA044798/UH3DA044798, UG3DA044830/UH3DA044830, UG3DA044823/UH3DA044823, UH3DA044822/UH3DA044822, UG3DA044831/UH3DA044831, UG3DA044825, UG3DA044826/UH3DA044826, U24DA044801, and UL1TR002369 co-funded by NIDA, ARC, CDC, and SAMHSA. The authors thank the other ROI investigators and their teams, community and state partners, and the participants of the individual ROI studies for their valuable contributions. A full list of participating ROI institutions and other resources can be found at http://ruralopioidinitiative.org. This publication is based upon data collected and/or methods developed as part of the Rural Opioid Initiative (ROI), a multi-site study with the goal of better characterizing the rural opioid epidemic and its consequences and a common protocol that was developed collaboratively by investigators at eight research institutions and at the National Institute on Drug Abuse (NIDA), the Appalachian Regional Commission (ARC), the Centers for Disease Control and Prevention (CDC), and the Substance Abuse and Mental Health Services Administration (SAMHSA). Research presented in this manuscript is the result of secondary data harmonization and analysis and was supported by grant U24DA048538 from NIDA . Primary data collection was supported by grants UG3DA044829/UH3DA044829 , UG3DA044798/UH3DA044798 , UG3DA044830/UH3DA044830 , UG3DA044823/UH3DA044823 , UH3DA044822/UH3DA044822 , UG3DA044831/UH3DA044831 , UG3DA044825 , UG3DA044826/UH3DA044826 , U24DA044801 , and UL1TR002369 co-funded by NIDA , ARC , CDC , and SAMHSA .

Funders	Funder number
Centers for Disease Control and Prevention
Automotive Research and Testing Center
Appalachian Regional Commission
Rural Opioid Initiative
Substance Abuse and Mental Health Services Administration	U24DA048538
Author National Institute on Drug Abuse DA031791 Mark J Ferris National Institute on Drug Abuse DA006634 Mark J Ferris National Institute on Alcohol Abuse and Alcoholism AA026117 Mark J Ferris National Institute on Alcohol Abuse and Alcoholism AA028162 Elizabeth G Pitts National Institute of General Medical Sciences GM102773 Elizabeth G Pitts Peter McManus Charitable Trust Mark J Ferris National Institute on Drug Abuse	UG3DA044829/UH3DA044829, UL1TR002369, UH3DA044822/UH3DA044822, UG3DA044798/UH3DA044798, UG3DA044826/UH3DA044826, UG3DA044823/UH3DA044823, UG3DA044831/UH3DA044831, UG3DA044830/UH3DA044830, UG3DA044825, U24DA044801

UN SDGs

This output contributes to the following UN Sustainable Development Goals (SDGs)

SDG 3 Good Health and Well-being

Keywords

Infectious Disease
Overdose
People who use drugs
Rural

ASJC Scopus subject areas

Medicine (miscellaneous)
Psychiatric Mental Health
Psychiatry and Mental health

Access to Document

10.1016/j.josat.2025.209629

Cite this

Jenkins, W. D., Beach, L. B., Schneider, J., Friedman, S. R., Pho, M. T., Walters, S., Ezell, J., Young, A. M., Hennessy, C., Miller, W. C., Go, V. F., Sun, C., Seal, D. W., Westergaard, R. P., Crane, H. M., Fredericksen, R. J., Ruderman, S. A., Fletcher, S., Ma, J., ... Winer, M. (2025). Sexual identity, sexual behavior, and drug use behaviors among people who use drugs in the rural U.S. Journal of substance use and addiction treatment, 171, Article 209629. https://doi.org/10.1016/j.josat.2025.209629

@article{0b1011f6d8484f438d6a3116bee51ead,

title = "Sexual identity, sexual behavior, and drug use behaviors among people who use drugs in the rural U.S.",

abstract = "Introduction: People who use drugs (PWUD) are at risk of HIV infection, but the frequency and distribution of transmission-associated behaviors within rural communities is not well understood. Further, while interventions designed to more explicitly affirm individuals' sexual orientation and behaviors may be more effective, descriptions of behavior variability by orientation are lacking. We sought to describe how disease transmission behaviors and overdose risk vary by sexual orientation and activity among rural PWUD. Methods: From 01/2018–03/2020, rural PWUD participating in the Rural Opioid Initiative were surveyed across 8 sites. Collected data included: demographics; experiences with drug use, overdose, and healthcare; stigma; gender identity; and sexual orientation and partners. Participants were categorized as: monosexual by orientation and behavior (Mono-only), monosexual by orientation but behaviorally bisexual (Mono/Bi), and bisexual by orientation (Bi+). Analyses included descriptive summaries, bivariate examination (chi-square), and logistic regression (relative risk [RR] and 95 \% confidence interval [CI]). Results: The 1455 participants were 84.8 \% Mono-only, 3.2 \% Mono/Bi, and 12.0 \% Bi+. Compared to Mono-only men, Mono/Bi and Bi+ men had greater risk of transactional sex (RR = 9.71, CI = 6.66–14.2 and RR = 5.09, CI = 2.79–9.27, respectively) and sharing syringes for injection (RR = 1.58, CI = 1.06–2.35 and RR = 1.85, CI = 1.38–2.47). Compared to Mono-only women, Mono-Bi and Bi+ women had greater risk of transactional sex (RR = 4.47, CI = 2.68–7.47 and RR = 2.63, CI = 1.81–3.81); and Bi+ women had greater risk of sharing syringes for injection (RR = 1.49, CI = 1.23–1.81), sharing syringes to mix drugs (RR = 1.44, CI = 1.23–1.69), and experiencing an overdose (RR = 1.32, CI = 1.12–1.56). Bi+ men and women both more frequently reported selling sex as a source of income (versus Mono-only, both p < 0.050) and measures of perceived stigma (all p < 0.050). Conclusions: Rural PWUD who are bisexual by orientation or behavior are significantly more likely to engage in behaviors associated with infectious disease transmission and to experience stigma and drug overdose. Given the growing recognition of bisexuality as a distinct orientation that warrants individualized consideration, interventions that are specifically acknowledging and affirming to the circumstances of this group are needed.",

keywords = "Infectious Disease, Overdose, People who use drugs, Rural",

author = "Jenkins, \{Wiley D.\} and Beach, \{Lauren B.\} and John Schneider and Friedman, \{Samuel R.\} and Pho, \{Mai T.\} and Suzan Walters and Jerel Ezell and Young, \{April M.\} and Caitie Hennessy and Miller, \{William C.\} and Go, \{Vivian F.\} and Christina Sun and Seal, \{David W.\} and Westergaard, \{Ryan P.\} and Crane, \{Heidi M.\} and Fredericksen, \{Rob J.\} and Ruderman, \{Stephanie A.\} and Scott Fletcher and Jimmy Ma and Delaney, \{J. A.\} and Karma Plaisance and Judith Feinberg and Smith, \{Gordon S.\} and Korthuis, \{P. Todd\} and Stopka, \{Thomas J.\} and Friedmann, \{Peter D.\} and William Zule and Mike Winer",

note = "Publisher Copyright: {\textcopyright} 2025 Elsevier Inc.",

year = "2025",

month = apr,

doi = "10.1016/j.josat.2025.209629",

language = "English",

volume = "171",

}

Jenkins, WD, Beach, LB, Schneider, J, Friedman, SR, Pho, MT, Walters, S, Ezell, J, Young, AM, Hennessy, C, Miller, WC, Go, VF, Sun, C, Seal, DW, Westergaard, RP, Crane, HM, Fredericksen, RJ, Ruderman, SA, Fletcher, S, Ma, J, Delaney, JA, Plaisance, K, Feinberg, J, Smith, GS, Korthuis, PT, Stopka, TJ, Friedmann, PD, Zule, W & Winer, M 2025, 'Sexual identity, sexual behavior, and drug use behaviors among people who use drugs in the rural U.S.', Journal of substance use and addiction treatment, vol. 171, 209629. https://doi.org/10.1016/j.josat.2025.209629

TY - JOUR

T1 - Sexual identity, sexual behavior, and drug use behaviors among people who use drugs in the rural U.S.

AU - Jenkins, Wiley D.

AU - Beach, Lauren B.

AU - Schneider, John

AU - Friedman, Samuel R.

AU - Pho, Mai T.

AU - Walters, Suzan

AU - Ezell, Jerel

AU - Young, April M.

AU - Hennessy, Caitie

AU - Miller, William C.

AU - Go, Vivian F.

AU - Sun, Christina

AU - Seal, David W.

AU - Westergaard, Ryan P.

AU - Crane, Heidi M.

AU - Fredericksen, Rob J.

AU - Ruderman, Stephanie A.

AU - Fletcher, Scott

AU - Ma, Jimmy

AU - Delaney, J. A.

AU - Plaisance, Karma

AU - Feinberg, Judith

AU - Smith, Gordon S.

AU - Korthuis, P. Todd

AU - Stopka, Thomas J.

AU - Friedmann, Peter D.

AU - Zule, William

AU - Winer, Mike

PY - 2025/4

Y1 - 2025/4

N2 - Introduction: People who use drugs (PWUD) are at risk of HIV infection, but the frequency and distribution of transmission-associated behaviors within rural communities is not well understood. Further, while interventions designed to more explicitly affirm individuals' sexual orientation and behaviors may be more effective, descriptions of behavior variability by orientation are lacking. We sought to describe how disease transmission behaviors and overdose risk vary by sexual orientation and activity among rural PWUD. Methods: From 01/2018–03/2020, rural PWUD participating in the Rural Opioid Initiative were surveyed across 8 sites. Collected data included: demographics; experiences with drug use, overdose, and healthcare; stigma; gender identity; and sexual orientation and partners. Participants were categorized as: monosexual by orientation and behavior (Mono-only), monosexual by orientation but behaviorally bisexual (Mono/Bi), and bisexual by orientation (Bi+). Analyses included descriptive summaries, bivariate examination (chi-square), and logistic regression (relative risk [RR] and 95 % confidence interval [CI]). Results: The 1455 participants were 84.8 % Mono-only, 3.2 % Mono/Bi, and 12.0 % Bi+. Compared to Mono-only men, Mono/Bi and Bi+ men had greater risk of transactional sex (RR = 9.71, CI = 6.66–14.2 and RR = 5.09, CI = 2.79–9.27, respectively) and sharing syringes for injection (RR = 1.58, CI = 1.06–2.35 and RR = 1.85, CI = 1.38–2.47). Compared to Mono-only women, Mono-Bi and Bi+ women had greater risk of transactional sex (RR = 4.47, CI = 2.68–7.47 and RR = 2.63, CI = 1.81–3.81); and Bi+ women had greater risk of sharing syringes for injection (RR = 1.49, CI = 1.23–1.81), sharing syringes to mix drugs (RR = 1.44, CI = 1.23–1.69), and experiencing an overdose (RR = 1.32, CI = 1.12–1.56). Bi+ men and women both more frequently reported selling sex as a source of income (versus Mono-only, both p < 0.050) and measures of perceived stigma (all p < 0.050). Conclusions: Rural PWUD who are bisexual by orientation or behavior are significantly more likely to engage in behaviors associated with infectious disease transmission and to experience stigma and drug overdose. Given the growing recognition of bisexuality as a distinct orientation that warrants individualized consideration, interventions that are specifically acknowledging and affirming to the circumstances of this group are needed.

AB - Introduction: People who use drugs (PWUD) are at risk of HIV infection, but the frequency and distribution of transmission-associated behaviors within rural communities is not well understood. Further, while interventions designed to more explicitly affirm individuals' sexual orientation and behaviors may be more effective, descriptions of behavior variability by orientation are lacking. We sought to describe how disease transmission behaviors and overdose risk vary by sexual orientation and activity among rural PWUD. Methods: From 01/2018–03/2020, rural PWUD participating in the Rural Opioid Initiative were surveyed across 8 sites. Collected data included: demographics; experiences with drug use, overdose, and healthcare; stigma; gender identity; and sexual orientation and partners. Participants were categorized as: monosexual by orientation and behavior (Mono-only), monosexual by orientation but behaviorally bisexual (Mono/Bi), and bisexual by orientation (Bi+). Analyses included descriptive summaries, bivariate examination (chi-square), and logistic regression (relative risk [RR] and 95 % confidence interval [CI]). Results: The 1455 participants were 84.8 % Mono-only, 3.2 % Mono/Bi, and 12.0 % Bi+. Compared to Mono-only men, Mono/Bi and Bi+ men had greater risk of transactional sex (RR = 9.71, CI = 6.66–14.2 and RR = 5.09, CI = 2.79–9.27, respectively) and sharing syringes for injection (RR = 1.58, CI = 1.06–2.35 and RR = 1.85, CI = 1.38–2.47). Compared to Mono-only women, Mono-Bi and Bi+ women had greater risk of transactional sex (RR = 4.47, CI = 2.68–7.47 and RR = 2.63, CI = 1.81–3.81); and Bi+ women had greater risk of sharing syringes for injection (RR = 1.49, CI = 1.23–1.81), sharing syringes to mix drugs (RR = 1.44, CI = 1.23–1.69), and experiencing an overdose (RR = 1.32, CI = 1.12–1.56). Bi+ men and women both more frequently reported selling sex as a source of income (versus Mono-only, both p < 0.050) and measures of perceived stigma (all p < 0.050). Conclusions: Rural PWUD who are bisexual by orientation or behavior are significantly more likely to engage in behaviors associated with infectious disease transmission and to experience stigma and drug overdose. Given the growing recognition of bisexuality as a distinct orientation that warrants individualized consideration, interventions that are specifically acknowledging and affirming to the circumstances of this group are needed.

KW - Infectious Disease

KW - Overdose

KW - People who use drugs

KW - Rural

UR - https://www.scopus.com/pages/publications/85217810002

UR - https://www.scopus.com/pages/publications/85217810002#tab=citedBy

U2 - 10.1016/j.josat.2025.209629

DO - 10.1016/j.josat.2025.209629

M3 - Article

AN - SCOPUS:85217810002

SN - 2949-8767

VL - 171

JO - Journal of substance use and addiction treatment

JF - Journal of substance use and addiction treatment

M1 - 209629

ER -

Sexual identity, sexual behavior, and drug use behaviors among people who use drugs in the rural U.S.

Abstract

Bibliographical note

Funding

UN SDGs

Keywords

ASJC Scopus subject areas

Access to Document

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