Self-esteem and HIV risk practices among young adult ecstasy users.
Abstract: This study examines the role that self-esteem plays in HIV-related risk taking among users of the drug, Ecstasy. The first part of the analysis focuses on the relationship of self-esteem to HIV risk-taking. The second part examines predictors of self-esteem in this population. Conducted between 2002 and 2004, the research is based on a sample of 283 young adult Ecstasy users who completed approximately two-hour-long, face-to-face interviews via computer-assisted structured interviews. Study participants were recruited in the Atlanta, Georgia metropolitan area using targeted sampling and ethnographic mapping. Results indicated that self-esteem is associated with a variety of risky practices, including: the number of sex partners that people had, individuals' likelihood of having multiple sex partners, the number of different illegal drugs people used, and their condom use self-efficacy. The multivariate analysis conducted to ascertain the factors that impact participants' levels of self-esteem yielded six factors: educational attainment (positive), coming from a family-of-origin whose members got along well (positive), the extent of alcohol problems (negative), the number of positive effects experienced as a result of Ecstasy use (positive), the number of negative effects experienced as a result of Ecstasy use (negative), and the extent of experiencing symptoms of post-traumatic stress disorder (negative).

Keywords--drug use/abuse, Ecstasy use, HIV risk behaviors, self-esteem, young adults
Subject: Drug abuse (Risk factors)
Alcoholism (Risk factors)
Teenagers (Sexual behavior)
Youth (Sexual behavior)
Post-traumatic stress disorder (Risk factors)
HIV (Viruses) (Risk factors)
Condoms
Authors: Klein, Hugh
Elifson, Kirk W.
Sterk, Claire E.
Pub Date: 12/01/2010
Publication: Name: Journal of Psychoactive Drugs Publisher: Taylor & Francis Ltd. Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2010 Taylor & Francis Ltd. ISSN: 0279-1072
Issue: Date: Dec, 2010 Source Volume: 42 Source Issue: 4
Product: Product Code: E121930 Youth; 3069770 Prophylactics & Diaphragms NAICS Code: 326299 All Other Rubber Product Manufacturing SIC Code: 3069 Fabricated rubber products, not elsewhere classified
Accession Number: 287390944
Full Text: In the United States, use of the drug known colloquially as Ecstasy or MDMA (3,4-methylenedioxymethamphetamine) appears to be most popular among adolescents, young adults, and men who have sex with men (NIDA 2006, 2001). Historically, Ecstasy use been associated with partying and the "club scene" among members of these populations. Traditionally, its use among young people was associated with so-called raves, which are "underground" music and dance events (Hammersley, Khan & Ditton 2002; Hitzler 2002). However, in recent years Ecstasy use appears to have been moving out of the club scene (where it still remains popular today) and into new environments (NIDA 2006, 2001; Eiserman, Diamond & Schensul 2005; Boeri, Sterk & Elifson 2004). Nowadays Ecstasy is used by a broader array of people in social settings beyond raves, such as at home, at social gatherings, nonrave music events, and settings where alcohol and other drugs are used (Bahora, Sterk & Elifson 2009; Sterk, Theall & Elifson 2006; Boeri, Sterk & Elifson 2004).

As a result of its proliferation, researchers have begun to assess the social and health risks associated with the continued use of this drug, including those associated with HIV (Theall, Elifson & Sterk 2006). Some authors have noted that the use of Ecstasy creates a profound increase in sexual desire in its users (Zemishlany, Aizenberg & Weizman 200 I), whereas others have highlighted the fact that Ecstasy use leads many users to feel emotionally closer to their sexual partners while high on Ecstasy (Buffum & Moser 1986; Theall, Elifson & Sterk 2006). Moreover, as one of its principal drug effects, Ecstasy leads many users to want to touch others, to experience other people in a tactile manner, and to have sexual contact with them (Theall, Elifson & Sterk 2006). It therefore stands to reason that a drug (like Ecstasy) that is used specifically because of its perceived/anticipated sex-enhancing effects may cause users to practice unsafe sex, due to having sexual relations while under the influence of the drug. Indeed, numerous studies have established just such a link between Ecstasy use and involvement in risky sexual practices (Breen et al. 2006; Colfax & Guzman 2006; Novoa et al. 2005).

A substantial body of literature focusing on HIV risk among Ecstasy users has been based on samples of men who have sex with men. Its use in this population has been linked to a variety of HIV-related risk practices (e.g., having unprotected sex, having sex with multiple partners, having sexual relations while under the influence of Ecstasy and other drugs) (Lee et al. 2003; Klitzman et al. 2002; Mattison et al. 2001 ; Klitzman & Pope 2000), and its use typically appears to co-occur alongside the consumption of a variety of other drugs (Boeri et al. 2008; Sterk, Theall & Elifson 2006; Lee et al. 2003). Generally speaking, however, the extent to which Ecstasy use is related to engaging in HIV-related risk behaviors has not been studied in-depth among persons who are not gay males.

Also not well documented in the scientific literature is the role that self-esteem may play in the Ecstasy use/HIV risk nexus. Common sense dictates that people who feel good about themselves will be more likely to take care of themselves and to make wise decisions about their health when compared to persons whose self-esteem is not as high. Previous research on the subject of self-esteem and drug use/abuse has been relatively sparse, although most published studies have shown a link between low self-esteem and greater drug use/abuse, with these studies typically viewing self-esteem as a mediating variable. For example, in a study of homeless women, Stein, Burden, and Nyamathi (2002) reported that greater self-esteem was associated with fewer substance abuse problems. Similar findings were also obtained by Tucker and colleagues (2005) in their research on homeless women. In a study comparing rural pregnant cocaine users and nonusers, Behnke and colleagues (1997) found that cocaine users were more likely to suffer from lower self-esteem than nonusers. Lower levels of self-esteem have also been associated with greater intensity of methamphetamine use (Semple, Grant & Patterson 2005) and with more alcohol consumption (Gullette & Lyons 2006) in other studies. It is worth noting that none of these studies specifically addressed the relationship of self-esteem to Ecstasy use.

Regarding the link between self-esteem and HIV risk, studies of gay and/or bisexual men have shown that lower self-esteem or episodes in which an individual's self-esteem is injured are associated with greater involvement in risky sexual behaviors and sexual compulsivity (Rosario, Schrimshaw & Hunter 2006; Semple, Zians, Grant, & Patterson, 2006; Preston, D' Augelli, Kassab, Cain, Schulze, & Starks, 2004; Martin & Knox 1997). In a study of HIV risk practices among transgendered persons, Clements and colleagues (1999) noted that low self-esteem was among the most commonly cited reasons why transgendered persons have difficulty adopting and maintaining lowered-risk behaviors. Research based on a study of "at risk" women revealed a link between lower self-esteem and greater involvement in HIV risk behaviors (Sterk, Klein & Elifson 2004), as did another study that was conducted with a college student research sample (Gullette & Lyons 2006). Studies based on substance-abusing populations have also shown an association between lower self-esteem and greater involvement in sexual risk taking (Lejuez et al. 2004; Semple, Grant & Patterson 2005). Notably minimal among these published studies are research findings based on samples comprised of young adults.

The present study examines the relationship of self-esteem and HIV risk practices in a population of young adult Ecstasy users. The first part of the analysis focuses on determining whether there is an association between low self-esteem and greater involvement in risk behaviors in this population. In the second part of the analysis, we examine the predictors of low self-esteem in this population. This is an important part of the analysis because findings obtained here may be used to develop an informed intervention or prevention program.

METHODS

Procedures

A cross-sectional study was conducted from August 2002 until August 2004 in Atlanta, Georgia among 283 Ecstasy users between the ages of 18 and 25. The principal goals of this study were to examine life issues and challenges, substance use and abuse, psychological and psychosocial functioning, and a variety of HIV-related risk behaviors among young adult Ecstasy users.

In order to participate in the study, several eligibility criteria had to be met. Study participants had to be between 18 and 25 years of age, capable of conducting their interviews in English, not be in a substance abuse treatment program or any other institutional setting at the time of enrollment in the study, and not be intoxicated or otherwise impaired cognitively at the time of their interview. To make sure that recurrent users (as distinguished from first-time or experimental users) of Ecstasy comprised the study sample, all persons had to report having used Ecstasy on at least three different days during the preceding 90 days. Lab testing verification of the actual drug content of the Ecstasy consumed by study participants was not undertaken.

The initial recruitment was based largely on targeted sampling, including ethnographic mapping (Sterk 1999; Watters & Biernacki 1989). The targeted neighborhoods were chosen because of their concentration of Ecstasy users. These communities were "hot spots" of local drug activity characterized by frequent drug sales and widespread drug use. Within these community hot spots, the outreach workers targeted places where Ecstasy users were known to gather (e.g., clubs, public parks), so as to maximize their recruitment efforts. In addition, passive recruitment was used to advertise the study and bolster recruitment possibilities. The latter approach, which accounted for approximately one-quarter of the study participants who eventually enrolled, involved the posting of flyers in local clubs and venues, colleges and universities, coffee shops, and various on-the-street locations.

Prior to conducting interviews, all eligible persons were provided with appropriate information to facilitate the informed consent process. Institutional Review Board approvals for this study and all related research protocols were obtained from Emory University and Georgia State University. On average, interviews took two hours to complete. Face-to-face interviews were conducted by trained interviewers using a computer-assisted interview. At the completion of the interview, people were paid $25 for their participation.

Measures

A structured questionnaire designed specifically for this study was used for data collection. It was created based on existing validated instruments that are widely known and used in the field (GAIN, Dennis et al. 1995; Risk Behavior Assessment, Needle et al. 1995; ASI, McLellan et al. 1985), as well as on a formative research study conducted by the present authors using a similar population of Ecstasy users.

The main variable of interest in these analyses assessed respondents' self-esteem, using Rosenberg's (1965) well-known self-esteem scale. This 10-item scale was found to be reliable (Cronbach's alpha = 0.88) and higher scores indicated greater levels of self-esteem.

Outcome measures used in the first part of the analysis included: number of sex partners during the past 30 days (continuous measure), whether or not an individual reported having multiple sex partners during the preceding 30 days (dichotomous measure), the number of different types of illegal drugs the person reported having used during the previous 30 days (continuous measure), proportion of all sex acts involving the use of protection (including oral, vaginal, and anal sex with steady partners, casual partners, and persons known to the respondent for less than 24 hours), and condom use self-efficacy (scale measure, Cronbach's alpha = 0.80). Condom use self-efficacy was included in these analyses because of its strong relationship to and predictive value with regard to actual condom use. Although relevant as a potential outcome measure, injection drug behaviors were not examined (and are not included in Table 1) due to their very low prevalence among the members of this particular study population.

Several types of predictor variables were considered and included as independent variables in these analyses because of previous research findings documenting their relevance to the subject matter at hand. Demographic characteristics included in these analyses were gender (male versus female), age (continuous measure), race/ethnicity (two measures, one comparing Caucasians to non-Caucasians and one comparing African Americans to non-African Americans), educational attainment (continuous measure), income (continuous measure), religiosity (continuous scale measure, Cronbach's alpha = 0.75), marital status (two measures, one comparing single versus other-than-single persons and the other comparing "involved" versus other-than-involved persons), and sexual orientation (coded as heterosexual versus other-than-heterosexual). Background experiences and characteristics were also considered, including measures of the number of persons the respondent knew who were HIV-positive or who had AIDS or who had died from AIDS (three continuous measures), age of first sexual experience (continuous measure), asking one's main and most recent casual sex partners about HIV/AIDS (two yes/no measures), the extent to which the person's family-of-origin got along (ordinal measure), and the extent to which the person's family-of-origin communicated with one another (continuous scale measure, Cronbach 's alpha = 0.75). Several substance use/abuse items were also used in these analyses, including a number of items specific to the Ecstasy use experience. These measures were: using Ecstasy for its touch-enhancing properties (continuous scale measure, Cronbach's alpha = 0.80), ever going on an Ecstasy binge (yes/no), the extent of recently experiencing negative consequences as a result of Ecstasy use (continuous scale measure, Cronbach's alpha = 0.73), recently experiencing positive effects as a result of Ecstasy use (continuous scale measure, Cronbach's alpha = 0.79), age of first drug use (continuous measure), number of alcohol-related problems experienced during past 30 days (continuous scale measure, Cronbach's alpha = 0.83), and ever been in drug treatment (yes/no). In addition to self-esteem, a few other measures of psychological and psychosocial functioning were also examined, including handling disagreements in a (dys)functional way (continuous scale measure, Cronbach's alpha = 0.80), impulsivity (continuous scale measure, Cronbach's alpha = 0.77), and post-traumatic stress disorder (PTSD) (continuous scale measure, Cronbach's alpha = 0.94).

Analysis

The analysis for the current research was undertaken in two substantively similar stages, but with different outcomes being considered. In the first part, the aim was to ascertain whether or not self-esteem was related to risky behaviors. In the second part, the aim was to determine what factors were predictive of study participants' levels of self-esteem. Initially, in Part 1, separate bivariate analyses were conducted to determine whether self-esteem was related to the various outcome measures under consideration (i.e., number of sex partners, whether or not the person reported having had multiple sex partners, the proportion of all sex acts involving the use of protection, condom use self-efficacy, and polydrug abuse). Coinciding with these analyses, additional Part 1 bivariate analyses were undertaken to ascertain what other variables were related to risky behaviors and, therefore, ought to be entered into multivariate equations. For testing the bivariate relationships, whenever the predictor variable was dichotomous, Student's t tests were used. Whenever the independent variable was categorical in nature or ordinal with fewer than five categories, analysis of variance was used. Whenever the independent variable was continuous in nature, simple regression was used. Multivariate logistic regression was used for the analysis of whether or not the person had been with multiple sex partners; multiple regression was used for all other outcomes here. The Part 2 analysis was undertaken in a similar fashion, but using level of self-esteem as the dependent variable.

Items that were found to be statistically significant (p < .05) or marginally significant (.10 > p > .05) predictors in these bivariate analyses were selected for entry into the multivariate prediction model. Only statistically significant contributors were retained in the final equations. Throughout all of these analyses, results are reported as statistically significant whenever p < .05.

RESULTS

Sample Characteristics

The majority of the people taking part in this study (70.0%) were male. Most were either Caucasian (49.8%) or African American (37.1 %). The mean age was 20.9 years (median = 20, SD = 2.3). Overall, this sample was fairly well educated, with 38.2% of the respondents having had at least some college training. In contrast, nearly one-quarter of the people who took part in it (24.0%) had not completed high school or the equivalent, and an additional 37.8% had a high school diploma. Approximately one-quarter of the study participants (24.7%) were employed on a full-time basis; slightly more (30.4%) were employed on a part-time basis; and approximately one-quarter of them (25.4%) were unemployed at the time they took part in the study. Slightly more than half of the respondents (58.4%) were "involved" with someone and 39.9% self-reported as being single, never having married before. Although most of the people participating in the study self-identified as being heterosexual (76.7%), a substantial proportion of them (23.3%) did not.

Part 1: Is Self-Esteem Related to Involvement in Risky Practices?

Table 1 presents the findings pertaining to self-esteem as a predictor of various risky practices. In the table, standardized coefficients are presented to facilitate comparisons of effects sizes. For most of the outcome measures shown, self-esteem was found to be a statistically significant multivariate predictor of involvement in HIV risk. This was true even when we controlled for the effects of race/ethnicity, marital/relationship status, sexual orientation, age, and gender. Interestingly, and somewhat to our surprise, the directionality of this relationship was not consistent from dependent measure to dependent measure. Contrary to expectations, higher levels of self-esteem were associated with more illegal drug usage (p < .01) and having had fewer sexual partners (p < .05). In contrast, consistent with expectations, higher levels of self-esteem were found to be related to experiencing fewer negative consequences as a result of one's Ecstasy use (p < .001), demonstrating fewer symptoms of Ecstasy dependence (p < .001), fewer alcohol problems (p < .01), and greater levels of condom use self-efficacy (p < .001). As the table shows, self-esteem was not found to be related to condom use or to the frequency of sexual risk taking once the effects of race/ethnicity, marital/relationship status, sexual orientation, age, and gender were controlled.

Part 2: What Factors Are Predictive of Self-Esteem?

Table 2 presents the findings obtained for the multivariate prediction model for respondents' level of self-esteem. In all, six statistically significant predictors were identified, and together they explained 21.2% of the total variance. Greater educational attainment was associated with higher levels of self-esteem (p < .05). In addition, the more congenial the relationship within the person's family-of-origin while he/she was growing up, the higher his/her self-esteem was likely to be in adulthood (p < .01). Higher self-esteem was also associated with the number of recently-experienced positive effects resulting from one's Ecstasy use (p < .05). Conversely, the fewer negative consequences that people reported experiencing as a result of their recent Ecstasy use, the higher their levels of self-esteem typically were (p < .01). Also, the more alcohol-related problems the person had been experiencing during the recent past, the lower his/her self-esteem was likely to be (p < .01). Finally, the more symptoms of post-traumatic stress disorder people experienced, the lower their levels of self-esteem were (p < .01).

DISCUSSION

Potential Limitations of This Research

Before discussing our main conclusions, we would like to acknowledge three potential limitations of this research. First, the data collected as part of this study of young adult Ecstasy users were all based on uncorroborated self-reports. Therefore, the extent to which respondents underreported or overreported their involvement in risky behaviors is unknown. In all likelihood, the self-reported data can be trusted, as numerous authors have noted that persons in their research studies (which, like the present study, have included fairly large numbers of substance abusers) have provided accurate information about their behaviors (Jackson et al. 2004; Higgins et al. 1995; Anglin, Hser & Chou 1993; Nurco 1985).

A second possible limitation pertains to recall bias. Respondents were asked to report about their beliefs, attitudes, and behaviors during the past 30 days, the past 90 days, and the past year, depending upon the measure in question. These time frames were chosen specifically (1) to incorporate a large enough amount of time in the risk behavior questions' time frames so as to facilitate meaningful variability from person to person, and (2) to minimize recall bias. The exact extent to which recall bias affected the data cannot be assessed, although other researchers collecting data similar to that captured in this study have reported that recall bias is sufficiently minimal that its impact upon study findings is likely to be small (Jaccard & Wan 1995).

A third possible limitation of these data comes from the sampling strategy used. All interviews were conducted in the Atlanta, Georgia metropolitan area. There may very well be local or regional influences or subcultural differences between these respondents and those residing elsewhere that could affect the generalizability of the data. Additionally, the chain referral sampling approach used to identify study participants is not a random sampling strategy, and there may be inherent biases in who was/not identified as a potential study participant in this research. A good discussion of the issues pertinent to this issue may be found in Heckathorn (1997), along with strategies that can be employed to minimize any bias that could result from the use of a chain-referral sampling approach.

Conclusions

Despite these potential limitations, we believe that the present research makes several scientific contributions. First, this study demonstrated that self-esteem does appear to be related to HIV risk practices among users of Ecstasy. In most but not all instances, higher self-esteem was associated with lower involvement in HIV risk. However, the specific nature of this relationship is complex and not always consistent with expectations. For example, contrary to expectations, and contrary to most of the published literature reporting on the relationship between self-esteem and condom use (see, for example, Rosario, Schrimshaw & Hunter 2006; Semple, Grant & Patterson 2005), the present study found no association between self-esteem and condom use in the multivariate analysis. It is noteworthy that self-esteem was one of the major predictors of condom use self-efficacy, though, and that condom use self-efficacy was found to be the strongest predictor of sexual protection rates in this sample. Therefore, it should be noted that, in this study of young adult Ecstasy users, self-esteem is likely to have had an indirect effect on condom use, operating through its influence on condom use self-efficacy.

Also contrary to expectations, we discovered that higher levels of self-esteem corresponded with more illegal drug usage (total quantity-frequency summed across all illegal drug types examined) and having had a smaller overall number of sex partners. Atypical findings like these regarding self-esteem and HIV risk have led some researchers to seek answers to the underlying question of why--seemingly counterintuitively--higher self-esteem may correspond with greater rather than lesser involvement in HIV risk for many persons. Research on this subject has revealed several processes that may be at work. First, some studies have shown that many persons with higher levels of self-esteem engage in rationalization processes that enable them to justify to themselves their own high-risk behaviors (Boney-McCoy, Gibbons & Gerrard 1999; Smith, Gerrard & Gibbons 1997). Smith, Gerrard, and Gibbons (1997) referred to these processes as self-serving cognitive strategies. In other work, a similar behavioral phenomenon has been referred to as compensatory self-enhancement (Gerrard et al. 2000). Second, other authors (McNair, Carte & Williams 1998) have discovered that persons with low levels of self-esteem are more likely than persons with higher levels of self-esteem to perceive their behaviors as risky. This, in turn, enables persons who are high in self-esteem to continue to engage in risky behaviors while those who are lower in self-esteem avoid practicing those same behaviors. Third, other research has found that persons with higher levels of self-esteem worried less about acquiring HIV, thereby enhancing their likelihood of becoming involved in risky behaviors (Abel & Chambers 2004). The bottom line seems to be this: when higher self-esteem is associated with greater, rather than lesser, involvement in HIV risk (as was the case in some instances in the current study), this relationship appears to be the result of cognitive processes that make it possible for high self-esteem persons to minimize their self-perception of risk whereas their low self-esteem counterparts do the opposite.

In contrast to the preceding unexpected findings, we discovered that higher levels of self-esteem corresponded with higher levels of condom use self-efficacy--a finding that we anticipated prior to undertaking this study. This is consistent with previous research, most of which was based on female populations (Sterk, Klein & Elifson 2003; McCree et al. 1999), and it contributes to the field by documenting yet another population--namely, young adult Ecstasy users--for whom higher self-esteem serves as a protective mechanism against HIV risk-taking.

Additionally, as predicted before undertaking the research, this study found that higher levels of self-esteem were related to experiencing fewer negative effects of one's Ecstasy use, experiencing fewer dependency symptoms as a result of using Ecstasy, and fewer alcohol-related problems. These findings are similar to those obtained by other researchers whose work has shown an inverse relationship between self-esteem and drug abuse problems (or a direct relationship between self-esteem and treatment-related outcomes) (Dekel, Benbenishty & Arnram 2004; Mann et al. 2004; Dodge & Potocky 2000; Nyamathi et al. 1999). Moreover, our findings complement the approach taken by community-based treatment programs like SISTAS (Sisters In Support Together Against Substances), which incorporate self-esteem building components into their anti-substance abuse curriculum (McCurtis-Witherspoon & Williams-Richardson 2006). The present study contributes to this body of research by demonstrating the importance of self-esteem for one other population of substance abusers--namely, young adult Ecstasy users--for whom HIV risk appears to be related (albeit not in a straightforward manner) to self-esteem levels.

Having established that self-esteem is, indeed, related to HIV risk taking among young adults who use Ecstasy, we then turned our attention to identifying the factors that underlie their levels of self-esteem. In all, six such factors were identified and these merit additional discussion. First, we learned that greater educational attainment was associated with higher self-esteem. This association has been reported in the scholarly literature previously (Jackson & Mustillo 200 1). Although it is almost certainly beyond the scope of most-community-based HIV intervention projects to address education-related issues in any detailed way, there are steps that they could take in an effort to bolster drug abusers' self-esteem. For example, such programs might encourage young adults who did not complete high school or its equivalent to do so, and they could provide project participants with information about G.E.D. preparation courses in the local area. For persons who completed high school, interventionists might wish to broach the subject of attending college or a community college, and discuss the benefits of entering a higher education institution. Other authors have written about the benefits of attaining higher educational attainment vis-a-vis self-esteem (Murrell, Salsman & Meeks 2003) and our findings complement and support their research.

This study also found a positive relationship between the extent to which the members of a person's family-of-origin got along with one another during their formative years and their levels of self-esteem in young adulthood. Other researchers have found similar associations in their studies of persons of Mexican descent (Russell, Salazar & Negrete 2000) as well as in a very large meta-analytical study of American adults (Busby, Gardner & Taniguchi 2005). When one considers the central and critical role that the family plays in people's early socialization experiences, it is not at all surprising that good family relationships would correspond with developing a lasting positive sense of self and an enduring good feeling about oneself. From an intervention standpoint, one extension/extrapolation of this finding would be to work with young adult Ecstasy users who have poor family relationships to develop better, more supportive interactions with their family members. Encouraging people who need such services to consult family therapists would be one way to accomplish this. Bringing key family members into the intervention process and providing them with skills-building exercises that can teach them more effective communication strategies, how to build or reestablish trust in one another, and how to be more supportive of one another would be possible too. Some work on this subject has already been done. For example, one intervention-based project (Substance Use Prevention Education Resource/Self-Esteem Through Arts and Recreation Sessions-a.k.a. SUPER STARS) worked with at risk youths and their parents, and reported that the program was successful at improving youths' self-esteem and their family relationships (Emshoff et al. 1996). In another study focusing on family functioning in families with at least one person aged 13 to 16, Farrell and Barnes (1993) found that the more cohesive a family was, the better the individual family members fared psychologically, including functioning in terms of their self-esteem.

Three of the items that were found to be important predictors of self-esteem in the present study's multivariate analysis were substance use/abuse-related. The more problems that people experienced as a result of their alcohol use, the lower their self-esteem tended to be. Consistent with this, the fewer the negative effects they had been experiencing as a result of their Ecstasy use and the more positive effects they had been experiencing as a result of their Ecstasy use, the greater their self-esteem was reported to be. Similar findings, particularly those regarding the alcohol problems/self-esteem nexus, have been reported in the scholarly literature (Aros et al. 2006; Lewis & O'Neill 2000). The implication of these particular findings is straightforward: young adult Ecstasy users in general, and especially those whose substance use is causing them to experience problems in their lives, would be likely to derive at least some self-esteem-related benefit by receiving help, notably in the form of substance abuse counseling and/or treatment. Intervention programs working with this population would be wise to have good collaborative relationships established with local drug treatment programs, so that willing participants can be offered a treatment slot on demand. By removing the adverse effects of substance abuse on their daily lives, it is likely that many of these persons would come to feel better about themselves. That, our other findings suggest, may very well lead to HIV risk-related benefits as well.

Finally, we would like to address the remaining finding--namely, that persons who were suffering from symptoms of post-traumatic stress disorder scored lower in self-esteem than their peers who were not experiencing PTSD (or who were not experiencing as many symptoms). Many studies have documented the long-lasting nature of PTSD and the myriad ways in which it adversely affects people's lives, including research showing it to lead to diminished self-esteem (Adams & Boscarino 2006; Christensen, Cohan & Stein 2004; Hyman, Gold & Cott 2003). The present research demonstrates that this relationship applies to young adult Ecstasy users as well. It highlights the need to provide persons experiencing symptoms of PTSD with mental health counseling, to help them deal with and resolve their lingering trauma issues. This finding suggests that community-based intervention programs working with young adults who use Ecstasy should provide their clientele with referrals to mental health providers, as well as encourage those whose questionnaire responses indicate a specific need for counseling to seek it. Common sense and research findings alike support this recommendation, as published studies have shown that cognitive trauma therapy can alleviate the symptoms of PTSD and also have a positive impact on self-esteem (Kubany et al. 2004; Kubany 1997). Group counseling approaches have also been shown to facilitate recovery from PTSD while simultaneously improving people's levels of self-esteem (Sinclair et al. 1995).

In conclusion, the present research, which was based on a community study of young adult Ecstasy users, found that there was an association between self-esteem and involvement in HIV risk practices. Depending upon which specific risk outcome was examined, sometimes this relationship was direct and sometimes it was inverse. Further research is warranted to examine more carefully the role that low (or high) self-esteem plays in leading drug users to engage in risky behaviors. The present study also identified several factors that were associated with, and perhaps causal of, Ecstasy users' levels of self-esteem. Included among these factors were educational attainment, the quality of relationships in people's families-of-origin, the extent to which alcohol abuse caused problems in their lives, the extent to which Ecstasy use led to positive and/or negative consequences, and post-traumatic stress disorder experiences. These findings led the authors to conclude that intervention programs working with young adult Ecstasy users ought to emphasize continuing education, improving family interactions and relationships, the need to enter drug treatment, and the need to seek out mental health counseling/treatment services.

http://dx.doi.org/10.1080/02791072.2010.10400707

REFERENCES

Abel, E. & Chambers, K.B. 2004. Factors that influence vulnerability to STDs and HIV/AIDS among Hispanic women. Health Care for Women International 25: 761-80.

Adams, R.E. & Boscarino, J.A. 2006. Predictors of PTSD and delayed PTSD after disaster: The impact of exposure and psychosocial resources. Journal of Nervous and Mental Disease 194: 485-93.

Anglin, M.D.; Hser, Y. & Chou, C. 1993. Reliability and validity of retrospective behavioral self-report by narcotics addicts. Evaluation Review 17 : 91-103.

Aros, S.; Mills, J.L.; Torres, C.; Henriquez, C.; Fuentes, A.; Capurro, T.; Mena, M.; Conley, M.; Cox, C.; Signore, C.; Klebanoff, M. & Carrorla, F. 2006. Prospective identification of pregnant women drinking four or more standard drinks ([greater than or equal to] 48g) of alcohol per day. Substance Use and Misuse 41: 183-97.

Bahora, M.; Sterk, C.E. & Elifson, K.W. 2009. Understanding recreational Ecstasy use in the United States: A qualitative inquiry. International Journal of Drug Policy 20: 62-69.

Behnke, M.; Eyler, F.D.; Woods, N.S.; Wobie, K. & Conlon, M. 1997. Rural pregnant cocaine users: An in-depth sociodemographic comparison. Journal of Drug Issues 27: 501-24.

Boeri, M.W.; Sterk, C.E.; Bahora, M. & Elifson, K.W. 2008. Poly-drug use among Ecstasy users: Separate, synergistic, and indiscriminate patterns. Journal of Drug Issues 38: 517-42.

Boeri, M.W.; Sterk, C.E. & Elifson, K.W. 2004. Rolling beyond raves: Ecstasy use outside the rave setting. Journal of Drug Issues 34: 831-60.

Boney-McCoy, S., Gibbons, F.X. & Gerrard, M. 1999. Self-esteem, compensatory self-enhancement, and the consideration of health risk. Personality and Social Psychology Bulletin 25: 954-65.

Breen, C.; Degenhardt, L.; Kinner, S.; Bruno, R.; Jenkinson, R.; Matthews, A. & Newman, J. 2006. Alcohol use and risk taking among regular Ecstasy users. Substance Use and Misuse 41: 1095-1109.

Buffum, J. & Moser, C. 1986. MDMA and human sexual function. Journal of Psychoactive Drugs 18: 355-59.

Busby, D.M.; Gardner, B.C. & Taniguchi, N. 2005. The family of origin parachute model: Landing safely in adult romantic relationships. Family Relations 54: 254-64.

Christensen, P.N.; Cohan, S.L. & Stein, M.B. 2004. The relationship between interpersonal perception and post-traumatic stress disorder related functional impairment: A social relations model analysis. Cognitive Behaviour Therapy 33: 151-60.

Clements, K.; Wilkinson, W.; Kitano, K. & Marx, R. 1999. HIV prevention and health service needs of the transgender community in San Francisco. International Journal of Transgenderism 3: 1-2.

Colfax, G. & Guzman, R. 2006. Club drugs and HIV infection: A review. Clinical Infectious Diseases 42: 1463-69.

Dekel, R.; Benbenishty, R. & Amram, Y. 2004. Therapeutic communities for drug addicts: Prediction of long-term outcomes. Addictive Behaviors 29: 1833-37.

Dennis, M.L.; Rourke, K.M.; Lucas, R.L.; Zien, C.; Clayton, K.J.; Harris, K.M.; Caddell, J.M.; Cavanaugh, B.R. & Fleischman, D. 1995. Global Appraisal of Individual Needs (GAIN): Resource Manual. Research Triangle Park, NC: Research Triangle Institute.

Dodge, K. & Potocky, M. 2000. Female substance abuse: Characteristics and correlates in a sample of inpatient clients. Journal of Substance Abuse Treatment 18: 59-64.

Eiserman, J.; Diamond, S. & Schensul, J. 2005. Rollin' on E: a qualitative analysis of Ecstasy use among inner city adolescents and young adults. Journal of Ethnicity in Substance Abuse 4: 9-38.

Emshoff, J.; Avery, E.; Raduka, G.; Anderson, D.J. & Calvert, C. 1996. Findings from SUPER STARS: A health promotion program for families to enhance multiple protective factors. Journal of Adolescent Research 11: 68-96.

Farrell, M.P. & Barnes, G.M. 1993. Family systems and social support: A test of the effects of cohesion and adaptability on the functioning of parents and adolescents. Journal of Marriage and the Family 55: 119-32.

Gerrard, M.; Gibbons, F.X.; Reis-Bergan, M. & Russell, D.W. 2000. Self-esteem, self-serving cognitions, and health risk behavior. Journal of Personality 68: 1177-1201.

Gullette, D.L. & Lyons, M.A. 2006. Sensation seeking, self-esteem, and unprotected sex in college students. Journal of the Association of Nurses in AIDS Care 17: 23-31.

Hammersley, R.; Khan, F. & Ditton, J. 2002. Ecstasy and the Rise of the Chemical Generation. New York: Routledge.

Heckathorn, D.D. 1997. Respondent-driven sampling: A new approach to the study of hidden populations. Social Problems 44: 174-99.

Higgins, S.T.; Budney, A.J.; Bickel, W.K.; Badger, G.J; Foerg, F.E. & Ogden, D. 1995. Outpatient behavioral treatment for cocaine dependence: One-year outcome. Experimental and Clinical Psychopharmacology 3: 205- 12.

Hitzler, R. 2002. Pill kick: The pursuit of "Ecstasy" at techno-events. Journal of Drug Issues 32: 459-66.

Hyman, S.M.; Gold, S.N. & Cott, M.A. 2003. Forms of social support that moderate PTSD in childhood sexual abuse survivors. Journal of Family Violence 18: 295-300.

Jaccard, J. & Wan, C.K. 1995. A paradigm for studying the accuracy of self-reports of risk behavior relevant to AIDS: Empirical perspectives on stability, recall bias, and transitory influences. Journal of Applied Social Psychology 25: 1831-58.

Jackson, C.T.; Covell, N.H.; Frisman, L.K. & Essock, S.M. 2004. Validity of self-reported drug use among people with co-occurring mental health and substance use disorders. Journal of Dual Diagnosis 1: 49-63.

Jackson, P.B. & Mustillo, S. 2001. I am woman: The impact of social identities on African American women's mental health. Women and Health 32: 33-59.

Klitzman, R.L.; Greenberg, J.D.; Pollack, L.M. & Dolezal, C. 2002. MDMA ("Ecstasy") use and its association with high risk behaviors, mental health, and other factors among gay/bisexual men in New York City. Drug and Alcohol Dependence 66: 115-25.

Klitzman, R.L. & Pope, H.G. Jr. 2000. MDMA ("Ecstasy") abuse and high-risk sexual behaviors among 169 gay and bisexual men. American Journal of Psychiatry 157: 1162-64.

Kubany, E.S. 1997. Application of cognitive therapy for trauma-related guilt (CT-TRG) with a Vietnam veteran troubled by multiple sources of guilt. Cognitive and Behavioral Practice 4: 213-44.

Kubany, E.S.; Hill, E.E.; Owens, J.A.; Iannce-Spencer, C.; McCaig, M.A.; Tremayne, K.J. & Williams, P.L. 2004. Cognitive trauma therapy for battered women with PTSD (CTT-BW). Journal of Consulting and Clinical Psychology 72: 3-18.

Lee, S.J.; Galanter, M.; Dermatis, H. & McDowell, D. 2003. Circuit parties and patterns of drug use in a subset of gay men. Journal of Addictive Diseases 22: 47-60.

Lejuez, C.W.; Simmons, B.L.; Aklin, W.M.; Daughters, S.B. & Dvir, S. 2004. Risk-taking propensity and risky sexual behavior of individuals in residential substance use treatment. Addictive Behaviors 29: 1643-47.

Lewis, B.A. & O'Neill, H.K. 2000. Alcohol expectancies and social deficits relating to problem drinking among college students. Addictive Behaviors 25: 295-99.

Mann, M.; Hosman, C.M.; Schaalma, H.P. & deVries, N.K. 2004. Self esteem in a broad-spectrum approach for mental health promotion. Health Education Research 19: 357-72.

Martin, J.I. & Knox, J. 1997. Self-esteem instability and its implications for HIV prevention among gay men. Health and Social Work 22: 264-73.

Mattison, A.M.; Ross, M.W.; Wolfson, T. & Franklin, D. 2001. Circuit party attendance, club drug use, and unsafe sex in gay men. Journal of Substance Abuse 13: 119-26.

McCree, D.H.; Ewart, C.K.; Curbow, B. & Nickerson, K.J. 1999. The association between psychosocial factors and condom use self efficacy in a college population of African American females. Cancer Research Therapy and Control S: 245-60.

McCurtis-Witherspoon, K. & Williams-Richardson, A. 2006. Sisters In Support Together Against Substances (SISTAS): An alcohol abuse prevention group for black women. Journal of Ethnicity and Substance Abuse 5: 49-60.

McLellan, A.T.; Luborsky, L.; Cacciola, J.; Griffith, J. & Evans, F. 1985. New data from the Addiction Severity Index: Reliability and validity in three centers. Journal of Nervous and Mental Diseases 173: 412-23.

McNair, L.D.; Carter, J.A. & Williams, M.K. 1998. Self-esteem, gender, and alcohol use: Relationships with HIV risk perception and behaviors in college students. Journal of Sex and Marital Therapy 24: 29-36.

Murrell, S.A.; Salsman, N.L. & Meeks, S. 2003. Educational attainment, positive psychological mediators, and resources for health and vitality in older adults. Journal of Aging and Health 15: 591-615.

National Institute on Drug Abuse (NIDA). 2006. MDMA (Ecstasy) Abuse. NIH Publication # 06-4728. Rockville, MD: National Institute on Drug Abuse.

National Institute on Drug Abuse (NIDA). 200 1. Ecstasy: What We Know and Don't Know About MDMA. Rockville, MD: National Institute on Drug Abuse.

Needle, R.; Fisher, D.G.; Weatherby, N.; Chitwood, D.; Brown, B.; Cesari, H.; Booth, R.; Williams, M.L.; Watters, J.; Andersen, M. & Braunstein, M. 1995. Reliability of self-reported HIV risk behaviors of drug users. Psychology of Addictive Behaviors 9: 242-50.

Novoa, R.A.; Ompad, D.C.; Wu, Y.; Vlahov, D. & Galea, S. 2005. Ecstasy use and its association with sexual behaviors among drug users in New York City. Journal of Community Health 30: 331-43.

Nurco, D.N. 1985. A discussion of validity. In: B. Rouse; N. Kozel & L. Richards (Eds.) Self-Report Methods of Estimating Drug Use: Meeting Current Challenges to Validity. NIDA Research Monograph #57. Washington, DC: U.S. Government Printing Office.

Nyamathi, A.; Bayley, L.; Anderson, N.; Keenan, C. & Leake, B. 1999. Perceived factors influencing the initiation of drug and alcohol use among homeless women and reported consequences of use. Women and Health 29: 99-114.

Preston, D.B.; D'Augelli, A.R.; Kassab, C.D.; Cain, R.E.; Schulze, & Starks, M.T. 2004. The influence of stigma on the sexual risk behavior of rural men who have sex with men. AIDS Education and Prevention 16: 291-303.

Rosario, M.; Schrimshaw, E.W. & Hunter, J. 2006. A model of sexual risk behaviors among young gay and bisexual men: Longitudinal associations of mental health, substance abuse, sexual abuse, and the coming-out process. AIDS Education and Prevention 18: 444-60.

Rosenberg, M. 1965. Society and the Adolescent Self-Image. Princeton, NJ: Princeton University Press.

Russell, T.T.; Salazar, G. & Negrete, J.M. 2000. A Mexican American perspective: The relationship between self-esteem and family functioning. TCA Journal 28: 86-92.

Semple, S.J.; Grant, I. & Patterson, T.L. 2005. Negative self-perceptions and sexual risk behavior among heterosexual methamphetamine users. Substance Use and Misuse 40: 1797-1810.

Semple, S.J.; Zians, J.; Grant, I. & Patterson, T.L. 2006. Sexual compulsivity in a sample of HIV-positive methamphetamine-using gay and bisexual men. AIDS and Behavior 10: 587-98.

Sinclair, J.J.; Larzelere, R.E.; Paine, M.; Jones, P.; Graham, K. & Jones, M. 1995. Outcome of group treatment for sexually abused adolescent females living in a group home setting: Preliminary findings. Journal of Interpersonal Violence 10 : 533-42.

Smith, G.E.; Gerrard, M. & Gibbons, F.X. 1997. Self-esteem and the relation between risk behavior and perceptions of vulnerability to unplanned pregnancy in college women. Health Psychology 16: 137-46.

Stein, J.A.; Burden, L.M. & Nyamathi, A. 2002. Relative contributions of parent substance use and childhood maltreatment to chronic homelessness, depression, and substance abuse problems among homeless women: Mediating roles of self-esteem and abuse in adulthood. Child Abuse and Neglect 26: 1011-27.

Sterk, C. 1999. Building bridges: Community involvement in HIV and substance abuse research. Drugs and Society 14: 107-21.

Sterk, C.E.; Theall, K.P. & Elifson, K.W. 2006. Young adult Ecstasy use patterns: Quantities and combinations. Journal of Drug Issues 36: 201-28.

Sterk, C.E.; Klein, H. & Elifson, K.W. 2004. Self-esteem and "at risk" women: Determinants and relevance to sexual and HIV-related risk behaviors. Women and Health 40: 75-92.

Sterk, C.E.; Klein, H. & Elifson, K.W. 2003. Perceived condom use self-efficacy among at-risk women. AIDS and Behavior 7: 175-82.

Theall, K.; Elifson, K. & Sterk, C. 2006. Sex, touch, and HIV risk among Ecstasy users. AIDS and Behavior 10: 169-78.

Tucker, J.S.; D'Amico, E.J.; Wenzel, S.L.; Golinelli, D.; Elliott, M.N. & Williamson, S. 2005. A prospective study of risk and protective factors for substance among impoverished women living in temporary shelter settings in Los Angeles County. Drug and Alcohol Dependence 80: 35-43.

Watters, J. & Biernacki, P. 1989. Targeted sampling: Options for the study of hidden populations. Social Problems 36: 416-30.

Zemishlany, Z.; Aizenberg, D. & Weizman, A. 2001. Subjective effects of MDMA ("Ecstasy") on human sexual function. European Psychiatry 16: 127-30.

([dagger]) This research was supported by a grant from the National Institute on Drug Abuse (ROI-DAOI4232).

Hugh Klein, Senior Researcher, Kensington Research Institute; Senior Researcher, Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, Atlanta, GA.

Kirk W. Elifson, Professor Emeritus, Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, Atlanta, GA.

& Claire E. Sterk, Professor, Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, Atlanta, GA.

Please address correspondence and reprint requests to Hugh Klein, Ph.D., 401 Schuyler Road, Silver Spring, Maryland 20910. Phone/fax: 301 -588-8875, email: hughk@aol.com
TABLE 1
Self-Esteem as a Predictor of Various HIV-Related Risk Behaviors

                   #of Sex      Condom       Condom
                   Partners     Use          Efficacy
Predictor
Self-Esteem        -0.12        0.03         0.26
                   p = .0299    p = .5962    p < .0001

Race =             0.09         -0.24        -0.01
Caucasian          p =.1195     p = .0002    p = .8565

Marital Status =   -0.37        -0.27        -0.08
Involved           p < .0001    p < .0001    p = .1848

Sexual
Orientation =      0.04         0.09         -0.07
Heterosexual       p = .5148    p = .1595    p = .2124

Age                -0.01        -0.16        0.08
                   p = .8545    p = .0157    p =.2128

Gender =           -0.01        0.02         -0.08
Male               p = .8593    p = .7622    p =.2037

R-squared          .150         .159         .097

                                   Outcome
                   Frequency of    Total Amount    # of Negative
                   Sexual Risk     of Illegal      Effects from
                   Taking          Drug Use        Ecstasy Use
Predictor
Self-Esteem        -0.03           0.12            -0.23
                   p = .6451       p = .0082       p < .0001

Race =             -0.05           -0.63           0.25
Caucasian          p = .3958       p < .0001       p < .0001

Marital Status =   0.04            0.02            -0.01
Involved           p = .4864       p = .6619       p = .8714

Sexual
Orientation =      -0.36           0.15            -0.09
Heterosexual       p < .0001       p = .0013       p = .1111

Age                0.06            -0.02           0.16
                   p = .3311       p =.6100        p = .0076

Gender =           0.22            -0.13           0.03
Male               p = .0005       p = .0044       p = .6330

R-squared          .165            .439            .132

                   #of Ecstasy
                   Dependency     #of Alcohol
                   Symptoms       Problems
Predictor
Self-Esteem        -0.23          -0.17
                   p = .0001      p = .0044

Race =             -0.08          -0.02
Caucasian          p = .1699      p = .7344

Marital Status =   0.04           -0.14
Involved           p = .5473      p = .0172

Sexual
Orientation =      0.06           -0.04
Heterosexual       p = .2864      p = .5060

Age                -0.05          0.05
                   p = .4020      p = .4062

Gender =           0.10           0.00
Male               p = .0925      p = .9426

R-squared          .072           .056

TABLE 2
Predictors of Self-Esteem Among Ecstasy Users

Predictor Variable                       b       [beta]   Statistical
                                                          Significance

Educational Attainment                    0.49    0.13    p < .05
Family-of-Origin Got Along Well           1.09    0.16    p < .01
Number of Alcohol Problems Experienced   -0.13   -0.19    p < .01
Recent Positive Effects of Ecstasy Use    0.32    0.12    p < .05
Recent Negative Effects of Ecstasy Use   -0.36   -0.18    p < .01
Post-Traumatic Stress Disorder           -0.18   -0.16    p < .01
R-squared                                  .212
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