Risk-taking behaviors in adolescent men who have sex with men (MSM): An association between homophobic victimization and alcohol consumption.

OBJECTIVE: The aim of this study was to determine whether homophobic victimization was associated with alcohol consumption and riding with an intoxicated driver or driving a car while under the influence of alcohol or drugs among adolescent men who have sex with men (MSM).
METHODS: Cross-sectional analysis used baseline data from a national HIV prevention trial (NCT03167606) for adolescent MSM aged 13-18 years (N = 747). Multivariable logistic regression models assessed associations between homophobic victimization (independent variable) and alcohol-related outcomes (dependent variables), controlling for age, parents' education level, sexual orientation, health literacy, race, and ethnicity.
RESULTS: Most participants (87%) reported at least one form of homophobic victimization in their lifetime, with verbal insults being the most frequently reported (82%). In the bivariate analysis, alcohol consumption and riding with an intoxicated driver or driving a car while under the influence were associated with many forms of victimization. Exposure to at least one form of victimization was associated with increased odds of alcohol consumption (OR: 2.31; 95% CI: 1.38-3.87) and riding with an intoxicated driver or driving a car while under the influence (OR: 2.25; 95% CI: 1.26-4.00), after controlling for covariates.
CONCLUSION: Increased risk of alcohol consumption and risky alcohol-related behaviors were found among adolescent MSM who experienced homophobic victimization. Interventions should address homophobic victimization and its impact on adolescent MSM, as well as disentangling motivations for underage drinking, riding with an intoxicated driver or driving a car while under the influence.

Introduction

Underage alcohol consumption remains a significant public health concern in the United States (US) [1], particularly among sexual and gender minority (SGM) youth [2]. Despite an overall decline in alcohol consumption among underage youth [3], disparities among SGM (i.e., lesbian, gay, bisexual, asexual, transgender) youth still exist [4-6] and have even widened in recent years [2, 6]. SGM youth have a disproportionately higher prevalence of alcohol consumption, binge drinking [5, 7–9], and early initiation of alcohol use compared to their heterosexual peers [9, 10]. Disparities in underage alcohol consumption warrant concern given its association with adverse health behaviors such as risky sexual activities, injuries, suicide attempts, and riding with an intoxicated driver [11]. Moreover, among SGM youth, alcohol-related disparities may persist into late adolescence or adulthood, increasing the risk of heavy drinking and alcohol-related disorders later in life [10, 12]. SGM youth also have steeper drinking trajectories into young adulthood compared to their heterosexual counterparts [13]. To address this health concern, it is imperative for researchers to improve their understanding of risk factors predicting underage drinking among SGM youth in effort to inform targeted prevention strategies and empirically based interventions [14].

Accumulating evidence on alcohol-related disparities among SGM youth suggest that one contributing factor is homophobic victimization [5, 7, 15–17], which is defined as a direct or indirect act of aggression, negative behavior, derogatory comment, verbal harassment, physical threat, or act of violence towards a person due to their actual or perceived sexual orientation [18]. Today, homophobic victimization among youth remains pervasive and occur most often among SGM youth [8, 19–21]. Approximately 69% and 26% of SGM youth report being verbally and physically harassed in school because of their sexual orientation, respectively [22]. Moreover, SGM males report more severe or direct forms of victimization (e.g., physical assault or assault with weapon) compared to SGM females [18, 20]. In response to homophobic victimization, researchers suggest that alcohol consumption among SGM youth is a coping mechanism to help alleviate negative effects or stress induced by victimization [23]. In fact, some studies have found school-based victimization to be strongly related to substance use (including alcohol use) among SGM youth [3, 15]. Future research is needed to identify specific forms of homophobic victimization experienced by SGM youth and their association with alcohol consumption to better understand the risk factors contributing to underage drinking in this population.

Even with well documented studies linking homophobic victimization and alcohol use among SGM youth, there are three major limitations that have not been addressed. First, few studies have examined the effects of different forms of homophobic victimization (i.e., verbal, physical, or sexual assaults) on underage alcohol consumption in this population [15]. By identifying the forms of homophobic victimization associated with alcohol consumption, interventions can be implemented to target specific victimization tactics aimed at SGM youth. Such information is also essential to fully capture the experiences of SGM youth and how homophobic victimization contributes to the risk of underage drinking. Second, limited research has been conducted to understand victimization as a risk factor for alcohol use specifically among adolescent men who have sex with men (MSM) [3]. We contend that adolescent MSM may be at particularly high risk of underage drinking due to their frequent exposure to severe forms of victimization [18, 20], warranting concern. Additionally, such focus on adolescent MSM alone will allow researchers to compare alcohol consumption among adolescent MSM who experienced homophobic victimization to adolescent MSM who did not, unlike previous comparisons that have been made to heterosexual youth [2, 6, 8]. Furthermore, research on underage drinking among adolescent MSM is needed to improve our understanding of alcohol-related disparities found within the SGM population. Third, to our knowledge, no previous study has assessed the association between homophobic victimization and risky alcohol-related behaviors, specifically driving while intoxicated or riding with an intoxicated driver. Previously, over 20% of SGM youth reported riding with an intoxicated driver and 8% drove while intoxicated [9]. Identifying homophobic victimization as a risk factor for alcohol-related behaviors will provide evidence that victimization may influence adverse health behaviors beyond substance abuse and significantly impacts the health of adolescent MSM. Therefore, the objectives of the present study were two-fold: 1. To measure the prevalence of various forms of homophobic victimization experienced by adolescent MSM using a national sample and 2. To determine whether significant associations exist between various forms of homophobic victimization and underage drinking and risky alcohol-related behaviors among adolescent MSM. We hypothesized that exposure to homophobic victimization increased the risk of underage drinking and risky alcohol-related behaviors in this population.

Methods

Study population

A cross-sectional analysis was conducted using baseline data from a randomized control trial (RCT), ‘Male Youth Pursuing Empowerment, Education, and Prevention around Sexuality’ (MyPEEPS). MyPEEPS is a nationwide mobile-health HIV prevention RCT that was conducted during 2018–2020 using a diverse sample of adolescent MSM (N = 761). Eligible participants were adolescent MSM aged 13–18 years, assigned male at birth, identified as male or non-binary, sexually attracted to males, HIV-negative or unknown status, had access to a smartphone or tablet, felt comfortable speaking and reading English, and resided in the US or US territories. The current analysis used data from 747 study participants, of whom homophobic victimization data were available, and excluded 1.8% (N = 14) of participants with missing data on victimization. All participants provided written informed assent or consent. The study was approved by the Institutional Review Board (IRB) of Columbia University, which served as the single IRB for the MyPEEPS RCT (NCT 03167606).

Exposure

Homophobic victimization was measured using standard questions on lifetime exposure to 10 forms of victimization based on sexual orientation or attraction (i.e. because they were gay, bisexual, or a guy who has sex with guys): verbal insult, threatened with physical violence, threatened with a weapon, object thrown at you, physical assault, attacked sexually, threatened to be outed, chased or followed, property damaged, and spat upon (Cronbach Coefficient α = 0.83). The frequency of each victimization occurrence was reported by participants as ‘never’, ‘once’, ‘twice’, or ‘three times or more’. Each response was dichotomized to create a binary independent variable for lifetime homophobic victimization (categorized as ‘no, never occurred’ or ‘yes, occurred at least once’).

Outcomes

Two dichotomous outcome variables were of interest: underage drinking and risky alcohol-related behavior. Participants self-reported underage drinking by answering whether they drank alcohol (more than a few sips but not including alcohol taken during family or religious events) in the past 12 months. Risky alcohol-related behavior was determined by asking participants: Have you ever ridden in a car driven by someone (including yourself) who was high or had been using alcohol or drugs? Of the 747 participants included in this study, all had complete data on alcohol consumption. However, we excluded one participant with missing data on whether they have ridden in a car with an intoxicated driver or have driven a car while they were under the influence of alcohol or drugs.

Covariates

Based on extensive review of the literature and an analysis of a directed acyclic graph (DAG), the following potential covariates were selected a priori: age, health literacy, mother’s education level, father’s education level, sexual orientation, race, and ethnicity. Participant’s age was treated as a continuous variable in the analysis. Health literacy was determined by asking participants their level of confidence when filling out medical forms by themselves. This was categorized as ‘not at all/ little bit’, ‘somewhat’, or ‘quite a bit/extremely’. All other variables were categorized as follows: mother’s and father’s education level (advanced graduate degree, graduated 4-year college, some college/ technical training, high school graduate/ GED/ did not finish high school), sexual orientation (bisexual, mostly gay/only gay/homosexual, mostly heterosexual/only heterosexual, or something else), race (American Indian/Alaskan Native, Asian American, Black/African American, Native Hawaiian/Asian Pacific Islander, White/Caucasian, Multiracial, or unknown/not reported), and Hispanic/Latino/Latinx ethnicity (yes or no).

Data analysis

Univariate analyses were conducted to estimate the prevalence of 10 forms of homophobic victimization. The frequency and percent of participants’ characteristics, underage drinking, and riding/driving a car while under the influence were calculated by homophobic victimization. To assess percent difference in the bivariate analysis, the Pearson’s chi-squared test or Fisher’s exact test was applied as appropriate [24]. Logistic regression models assessed the associations between 1. homophobic victimization and underage drinking and 2. homophobic victimization and riding/driving a car while under the influence. Multivariable logistic regression models adjusted for participant’s age, parents’ education level, sexual orientation, health literacy, race, and ethnicity. Participants with missing data on covariates were dropped from the multivariable regression models. Odds ratios (ORs), 95% confidence intervals (CIs), and p-values were calculated for all regression models. A p-value of <0.05 was considered statistically significant. All analyses were performed using SAS 9.4 software (SAS Institute, Cary, NC, USA).

Results

The majority of study participants were 16 years or older (72%), had parents who received some college education or more (67% of mothers and 59% of fathers), self-identified as mostly or only gay/homosexual (75%), had quite a bit of confidence or were extremely confident when filling out medical forms by themselves (54%), self-identified as belonging to a racial minority group (50%), and did not identify as Hispanic/Latino/Latinx (59%). (Table 1)

Table 1

Characteristics of study participants by exposure to homophobic victimization.

Characteristics	Total Sample	Victimization
		No	Yes	p-value
	N = 747 (%)	N = 94 (%)	N = 653 (%)
Age at baseline				0.6682*
13	22 (3.0)	3 (3.2)	19 (2.9)
14	82 (11.0)	8 (8.5)	74 (11.3)
15	107 (14.3)	12 (12.8)	95 (14.6)
16	184 (24.6)	19 (20.2)	165 (25.3)
17	206 (27.6)	30 (31.9)	176 (27.0)
18	146 (19.5)	22 (23.4)	124 (19.0)
Mother’s education level				0.0702
Advanced graduate degree	109 (15.8)	13 (14.4)	96 (16.0)
Graduated 4-year college	178 (25.8)	21 (23.3)	157 (26.2)
Some college/ technical training	174 (25.3)	16 (17.8)	158 (26.4)
High school graduate/ GED	134 (19.5)	20 (22.2)	114 (19.0)
Did not finish high school	94 (13.6)	20 (22.2)	74 (12.35)
Missing	58
Father’s education level				0.4953
Advanced graduate degree	92 (15.1)	12 (15.2)	80 (15.1)
Graduated 4-year college	128 (21.1)	12 (15.2)	116 (21.9)
Some college/ technical training	139 (22.9)	16 (20.3)	123 (23.3)
High school graduate/ GED	149 (24.5)	24 (30.4)	125 (23.6)
Did not finish high school	100 (16.5)	15 (19.0)	85 (16.1)
Missing	139
Sexual orientation				0.0007*
Bisexual	158 (21.2)	26 (27.7)	132 (20.2)
Mostly or only gay/ homosexual	563 (75.4)	63 (67.0)	500 (76.6)
Mostly or only heterosexual	6 (0.8)	2 (2.1)	4 (0.6)
Something else	20 (2.7)	3 (3.2)	17 (2.6)
Health literacy				0.7324
Not at all or a little bit	156 (20.9)	22 (23.4)	134 (20.5)
Somewhat	183 (24.5)	24 (25.5)	159 (24.4)
Quite a bit or extreme	408 (54.6)	48 (51.1)	360 (55.1)
Race				0.0217*
American Indian/ Alaskan Native	42 (5.6)	4 (4.3)	38 (5.8)
Asian American	72 (9.6)	17 (18.1)	55 (8.4)
Black/African American	151 (20.2)	22 (23.4)	129 (19.8)
Native Hawaiian/ Asian Pacific Islander	10 (1.3)	1 (1.1)	9 (1.4)
White/Caucasian	280 (37.5)	27 (28.7)	253 (38.7)
Multiracial	95 (12.7)	7 (7.5)	88 (13.5)
Unknown/not reported	97 (13.0)	16 (17.0)	81 (12.4)
Hispanic/Latino/Latinx ethnicity				0.7144
No	440 (58.9)	57 (60.6)	383 (58.7)
Yes	307 (41.1)	37 (39.4)	270 (41.4)

*Fishers exact test was used (need to check p-values) when cell number<5.

Most participants (87%) were exposed to at least one form of homophobic victimization in their lifetime, with verbal insults (yelled at or criticized) being the most frequently reported form of victimization (82%). Approximately half of participants reported that someone threatened to out them (tell someone that they are gay or bisexual) (56%) or threatened them with physical violence (46%). One-third of participants had an object thrown at them (33%) and a quarter of them were physically assaulted (punched, kicked, or beaten) (25%). About one in five participants were chased or followed (22%), attacked sexually (21%), or had their property damaged (18%). Sixteen percent of participants were spat upon and 13% were threatened with a knife, gun, or another weapon. (Table 2)

Table 2

Exposure to homophobic victimization in lifetime.

Homophobic Victimization	N (%)
Total	747 (100)
Exposure to at least one form of homophobic victimization	653 (87.4)
No exposure to homophobic victimization	94 (12.6)
10 Forms of Homophobic Victimization *
Verbally insulted (yelled at, criticized)	614 (82.2)
Someone threatened to out you	418 (56.0)
Threatened with physical violence	341 (45.7)
Had an object thrown at you	243 (32.5)
Been punched, kicked, or beaten	186 (24.9)
Someone chased or followed you	166 (22.2)
Attacked sexually	153 (20.5)
Your property was damaged	137 (18.3)
Been spat upon	119 (15.9)
Threatened with a knife, gun, or another weapon	100 (13.4)

*Categories are not mutually exclusive.

In the bivariate analysis, underage drinking was significantly associated with seven forms of homophobic victimization: verbal insults, threatened with physical violence, threatened with a weapon, attacked sexually, threatened to be outed, property damaged, and being spat upon. Being physically assaulted (punched, kicked, or beaten) was borderline associated with underage drinking. Riding with an intoxicated driver or driving a car while under the influence of alcohol or drugs was significantly associated with all forms of homophobic victimization except being threatened with a knife, gun, or another weapon. (Table 3) Unadjusted regression models, performed to account for the logistic distribution of the data, also confirmed these results.

Table 3

Exposure to specific forms of homophobic victimization by underage drinking and riding with an intoxicated driver or driving while under the influence of alcohol or drugs.

Victimization		Underage drinking			Riding/ driving under the influence
	Total Sample N (%)	No	Yes		No	Yes
		N (%)	N (%)	p-value	N (%)	N (%)	p-value
Total	747	356 (47.7)	391 (52.3)		496 (66.4)	250 (33.5)
Verbally insulted (yelled at, criticized)				0.0028			0.0060
No	133 (17.8)	79 (22.2)	54 (13.8)		102 (20.6)	31 (12.4)
Yes	614 (82.2)	277 (77.8)	337 (86.2)		394 (79.4)	219 (87.6)
Threatened with physical violence				0.0041			0.0420
No	406 (54.4)	213 (59.8)	193 (49.4)		283 (57.1)	123 (49.2)
Yes	341 (45.7)	143 (40.2)	198 (50.6)		213 (42.9)	127 (50.8)
Had an object thrown at you				0.1251			0.0213
No	504 (67.5)	250 (70.2)	254 (65.0)		349 (70.4)	155 (62.0)
Yes	243 (32.5)	106 (29.8)	137 (35.0)		147 (29.6)	95 (38.0)
Been punched, kicked, or beaten				0.0486			0.0085
No	561 (75.1)	279 (78.4)	282 (72.1)		387 (78.0)	173 (69.2)
Yes	186 (24.9)	77 (21.6)	109 (27.9)		109 (22.0)	77 (30.8)
Threatened with a knife, gun, or another weapon				0.0121			0.5711
No	647 (86.6)	320 (89.9)	327 (83.6)		432 (87.1)	214 (85.6)
Yes	100 (13.4)	36 (10.1)	64 (16.4)		64 (12.9)	36 (14.4)
Attacked sexually				0.0003			0.0026
No	593 (79.5)	303 (85.1)	290 (74.4)		409 (82.6)	183 (73.2)
Yes	153 (20.5)	53 (14.9)	100 (25.6)		86 (17.4)	67 (26.8)
issing	1
Someone threatened to out you				0.0360			0.0002
No	329 (44.0)	171 (48.0)	158 (40.4)		243 (49.0)	86 (34.4)
Yes	418 (56.0)	185 (52.0)	233 (59.6)		253 (51.0)	164 (65.6)
Someone chased or followed you				0.0502			0.0060
No	581 (77.8)	288 (80.9)	293 (74.9)		401 (80.9)	180 (72.0)
Yes	166 (22.2)	68 (19.1)	98 (25.1)		95 (19.2)	70 (28.0)
Your property was damaged				0.0200			0.0126
No	610 (81.7)	303 (85.1)	307 (78.5)		418 (84.3)	192 (76.8)
Yes	137 (18.3)	53 (14.9)	84 (21.5)		78 (15.7)	58 (23.2)
Been spat upon				0.0320			0.0185
No	628 (84.1)	310 (87.1)	318 (81.3)		428 (86.3)	199 (79.6)
Yes	119 (15.9)	46 (12.9)	73 (18.7)		68 (13.7)	51 (20.4)
Any victimization				0.0017			0.0035
No	94 (12.6)	59 (16.6)	35 (9.0)		75 (15.1)	19 (7.6)
Yes	653 (87.4)	297 (83.4)	356 (91.0)		421 (84.9)	231 (92.4)

Lifetime exposure to at least one form of homophobic victimization was significantly associated with greater odds of underage drinking, even after adjusting for age, parents’ education level, sexual orientation, health literacy, race, and ethnicity (OR: 2.31; 95% CI: 1.38–3.87). In the multivariable regression models shown in Table 4, five of the 10 forms of homophobic victimizations were associated with underage drinking: verbal insults (OR: 1.99; 95% CI: 1.27–3.10), threatened with physical violence (OR: 1.59; 95% CI: 1.12–2.25), attacked sexually (OR: 1.65; 95% CI: 1.07–2.55), property damaged (OR: 1.63; 95% CI: 1.02–2.60), and being spat upon (OR: 1.75; 95% CI: 1.08–2.85). Similarly, exposure to at least one form of homophobic victimization was significantly associated with riding with an intoxicated driver or driving a car while under the influence of alcohol or drugs, after adjusting for covariates (OR: 2.25; 95% CI: 1.26–4.00). More specifically, in the multivariable models seven of the 10 forms of homophobic victimization were individually associated with greater odds of riding with an intoxicated driver or driving a car while under the influence: verbal insults, physical assault, attacked sexually, threatened to be outed, chased, property damaged, and being spat upon. For each of the seven forms of victimization, if exposed, participants had a significantly greater odds (ORs range: 1.22–2.08) of riding with an intoxicated driver or driving a car while under the influence compared to those who were not exposed to homophobic victimization. Being threatened with a knife, gun, or another weapon was not assessed in a multivariable model for this outcome since there was no significant association found in the bivariate analysis. (Table 5)

Table 4

Bivariate and multivariable models assessing the association between exposure to homophobic victimization and underage drinking.

	Underage drinking
	Bivariate	Multivariable*	Multivariable*	Multivariable*	Multivariable*	Multivariable*
	OR (95% CI)	OR (95% CI)	OR (95% CI)	OR (95% CI)	OR (95% CI)	OR (95% CI)
Verbally insulted	1.78	1.99
	(1.22, 2.60)	(1.27, 3.10)
Threatened with physical violence	1.53		1.59
			(1.12, 2.25)
	(1.14, 2.04)
Been punched, kicked, or beaten	1.40			1.41
	(1.00, 1.96)			(0.93, 2.14)
Threatened with weapon	1.74				1.60
					(0.94, 2.73)
	(1.12, 2.69)
Attacked sexually	1.97					1.65
	(1.36, 2.85)
						(1.07, 2.55)
Someone threatened to out you	1.36	1.28
	(1.02, 1.82)	(0.91, 1.80)
Your property was damaged	1.56		1.63
	(1.07, 2.28)		(1.02, 2.60)
Been spat upon	1.55			1.75
	(1.04, 2.31)			(1.08, 2.85)
Victimization (yes vs. no)	2.02				2.31
	(1.29, 3.16)				(1.38, 3.87)

*Multivariable models adjusted for age, sexual orientation, mother’s education, father’s education, health literacy, race, and ethnicity.

Table 5

Bivariate and multivariable models assessing the association between exposure to homophobic victimization and riding with an intoxicated driver or driving while under the influence of alcohol or drugs.

	Riding with an intoxicated driver or driving while under the influence
	Bivariate	Multivariable*	Multivariable*	Multivariable*	Multivariable*	Multivariable*
	OR (95% CI)	OR (95% CI)	OR (95% CI)	OR (95% CI)	OR (95% CI)	OR (95% CI)
Verbally insulted	1.83	2.08
	(1.18, 2.82)	(1.28, 3.39)
Threatened with physical violence	1.37		1.22
	(1.01, 1.86)		(0.86, 1.73)
Had an object thrown at you	1.46			1.35
	(1.06, 2.00)			(0.93, 1.97)
Been punched, kicked, or beaten	1.58				1.60
	(1.12, 2.23)				(1.06, 2.41)
Attacked sexually	1.74					1.83
						(1.20, 2.77)
	(1.21, 2.51)
Someone threatened to out you	1.83	2.05
	(1.34, 2.51)	(1.43, 2.93)
Someone chased or followed you	1.64		1.59
	(1.15, 2.34)		(1.05, 2.41)
Your property was damaged	1.62			1.66
	(1.11, 2.37)			(1.06, 2.60)
Been spat upon	1.61				1.74
	(1.08, 2.41)				(1.09, 2.76)
Victimization (yes vs. no)	2.17					2.25
	(1.28, 3.67)
						(1.26, 4.00)

*Multivariable models adjusted for age, sexual orientation, mother’s education, father’s education, health literacy, race, and ethnicity.

Discussion

The current study contributes new knowledge to the field by providing cross-sectional evidence of various forms of homophobic victimization, alcohol use, and risky alcohol-related behaviors among adolescent MSM.

This study found that exposure to homophobic victimization was common among adolescent MSM, with 87% reporting exposure to at least one form of victimization due to their sexual orientation or attraction. It has been postulated that exposure to homophobic victimization among adolescent MSM may act as a sexual minority-specific stressor, increasing the risk of adverse health behaviors notably at earlier ages compared to heterosexual counterparts [10, 12, 15, 25]. According to the minority stress model, experiencing stressors related to sexual minority status can increase the likelihood of alcohol misuse and early alcohol initiation among SGM [14, 26–28]. Our study provides evidence that alcohol consumption is common among adolescent MSM, with half of the adolescent MSM reporting alcohol consumption, which warrants concern given that they are all under the US legal drinking age of 21. We found that among adolescent MSM underage drinking was associated with various forms of homophobic victimization, such as verbal insults or threats, physical or sexual assaults, and property damage. We compared our results to studies focused on school-based victimization and alcohol use among SGM youth due to the lack of data surrounding homophobic victimization in MSM youth in other setting. Data from one study demonstrated that alcohol-related disparities in SGM youth could be explained by exposure to school-based victimization [17]. Another large study of over 13,000 Midwestern high school students found that homophobic teasing was associated with alcohol use among all students regardless of sexual identity, however, the association was strongest among SGM [29]. Conversely, another study found that victimization did not fully explain alcohol-related disparities when comparing White, Black, and Latino SGM youth [30], while another study reported no evidence to support the association between victimization and alcohol consumption [31]. Our study expanded on previous work by examining specific forms of homophobic victimization. We found five forms of victimization associated with alcohol consumption, which were verbal insults, being spat upon, sexual attacks, property damaged, and being threatened with physical violence. Although these forms of victimization had similar effects on alcohol consumption (ORs 1.6‒2.0), there was some gradient found. For instance, verbal insults had a stronger association with alcohol consumption than other forms of victimization such as being threatened with physical violence or having property damaged. This finding may inform targeted interventions to focus on specific forms of homophobic victimization to significantly reduce underage alcohol consumption among adolescent MSM. To our knowledge, this is the first study to examine specific forms of homophobic victimization and alcohol consumption in this population, and future investigation is needed to understand the causal mechanisms linking victimization to underage drinking.

In addition, our study found that 34% of participants have ridden with an intoxicated driver or driven a car while under the influence of alcohol or drugs. This is of great public health concern given that young drivers are more likely to be involved in alcohol-related crashes when driving under the influence [32]. Our estimates, however, were higher than that previously reported by the Centers for Disease Control and Prevention (CDC) Morbidity and Mortality Weekly Report (MMWR), where 21% and 8% of SGM high school students reported riding with an intoxicated driver and driving a car while under the influence, respectively [9]. We also demonstrated that riding with an intoxicated driver or driving a car while under the influence was associated with homophobic victimization. Taken together, we contend that victimization has negative consequences on the health and behavior of adolescent MSM and is an important public health issue that should be addressed.

Feeling unsafe at school because of one’s sexual orientation has been linked to compromised academic achievement, school absenteeism, aggressive behavior, and adverse health outcomes [18, 22, 31]. For this reason, increasing recognition of victimization as a public health issue has led to the implementation of anti-bullying policies that have been shown to effectively reduce violence in schools and improve various outcomes [33, 34]. In fact, some anti-bullying policies encourage teachers to be more supportive of SGM youth, which has shown to buffer the effects of victimization on underage alcohol use [35]. However, these policies are limited to the school environment and do very little to address homophobic victimization occurring in the community or other settings [9]. Because some SGM youth continue to grabble with growing up in communities that may not approve of their sexual orientation [25], creating more supportive community environments coupled with efforts that promote the inclusion of SGM youth in the community is critical. Such efforts may reduce homophobic victimization and yield considerable benefits to alcohol-related prevention programs for SGM youth. Yet, more research is needed to identify both effective and culturally appropriate strategies.

There were several limitations to the study findings. First, homophobic victimization, alcohol use, and alcohol-related behaviors were all self-reported by participants. Consequently, the study findings linking homophobic victimization to underage drinking and alcohol-related behaviors were subject to recall and social desirability bias [36, 37]. Second, there were limitations to some of our measures. For instance, we were unable to determine where homophobic victimization occurred and could not control for school-based victimization in our analysis. Also, when assessing riding or driving while under the influence, we did not differentiate between the use of alcohol or drugs, and the frequency or intensity of alcohol consumption was not measured. Third, the cross-sectional design of the study limited our ability to assess temporality of the associations, and causal inferences could not be made. Finally, we did not estimate the prevalence of homophobic victimization over time, nor did we determine how often these events occurred throughout a person’s lifetime. Future studies should examine the cumulative effects of multiple homophobic victimization events over time to better understand the long-term impacts on the health and behavior of adolescent MSM.

This study also had some notable strengths. First, it expanded earlier work examining the association between homophobic victimization and alcohol-related outcomes with a focused analysis on adolescent MSM [3, 26, 38]. Using data from the MyPEEPS study, we had an unprecedented opportunity to investigate alcohol-related outcomes and various homophobic victimization events among a nationwide sample of adolescent MSM. For further analysis, we also included data on risky alcohol-related behaviors, such as riding with an intoxicated driver or driving a car while under the influence of alcohol or drugs. Finally, adolescent MSM may face rejection, isolation, verbal harassment, and physical violence at school, home, or other settings [25], yet most studies have focused on school-based victimization only [31]. Our study adds to the existing body of literature by examining general homophobic victimization as well as various forms of homophobic victimization experienced by adolescent MSM.

The extent to which adolescent MSM engage in underage drinking is concerning due to its immediate and long-term effects on adolescent health and behavior [11, 39]. Due to homophobic victimization experienced by adolescent MSM, they are at increased risk of alcohol misuse [23]. This study highlights the importance of reducing homophobic victimization and developing alcohol-related intervention strategies tailored to this population. By identifying potential risk factors associated with alcohol-related outcomes, we hope that the results of this study will be used to bring awareness to the high prevalence of homophobic victimization and risky alcohol-related behaviors among adolescent MSM.

Percent change in odds ratio of multivariable models to assess change in the association between homophobic victimization and underage drinking among adolescent MSM.

(DOCX)

Click here for additional data file.

Percent change in odds ratio of multivariable models to assess change in the association between homophobic victimization and riding with an intoxicated driver or driving while under the influence among adolescent MSM.

(DOCX)

Click here for additional data file.

(XLS)

Click here for additional data file.

13 May 2021

PONE-D-20-39463

Risk-taking behaviors in adolescent men who have sex with men (MSM): An association between homophobic victimization and alcohol consumption

PLOS ONE

Dear Dr. Cordoba

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Reviewer #1: Partly

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

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Reviewer #1: Yes

Reviewer #2: Yes

**********

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Reviewer #2: Yes

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Reviewer #1: The data analysis is routine and includes univariate analyses with non parametric approaches such as Fisher’s exact test when appropriate.. Logistic regression models and multivariable logistic regression were applied appropriately. The sample size appears reasonable. The conclusion appears to follow from the analysis in that adolescent men who experience homophobic victimization are at increased risk of alcohol consumption and risky-alcohol related behaviors.

The strengths and weaknesses of the manuscript are noted by the investigators. However, some concordance and sensitivity measures of these models should have been included in the analyses.

Reviewer #2: The purpose of this study was to examine if there was an association between homophobic victimization and two alcohol related outcomes – alcohol consumption and riding with an intoxicated driver/riding in a car while under the influence of alcohol or drugs. The article is methodologically sound and has the potential to contribute a more nuanced understanding of how different forms of homophobic victimization contribute to substance use related outcomes for young men who have sex with men (YMSM). As the authors point out, there have been numerous studies that find this association--the novel contributions of this study are (1) looking at different aspects of homophobic victimization, (2) focusing on YMSM, and (3) looking at a less studied outcome (riding with an intoxicated driver or driving while intoxicated). My main, critique of the study is that these novel contributions are not highly emphasized, and the front end of the paper is highly general rather than specific to the current study, which is critical given numerous other studies with similar findings.

Abstract

Given the cross-sectional nature of the data, the authors should rephrase this sentence, “Adolescent men who experience homophobic victimization are at increased risk of alcohol consumption and risky-alcohol related behaviors.” so that it sounds less directional.

Introduction

On page 5, the authors conclude by saying: “However, results have been inconsistent, including a null finding [24]. More research is needed to better understand risk factors contributing to underage drinking among SGM youth.” Its unclear which results have been inconsistent – either that homophobic victimization is linked to alcohol related behaviors, or that school-based victimization (not clear if the school-based victimization was LGB specific or not) being the strongest predictor is inconsistent—either way, one null finding does not necessarily make the findings inconsistent given how much research has been done on both topics. The authors should consider rephrasing this sentence to provide a stronger conclusion regarding previous research, perhaps linking it specifically why more research is needed for homophobic victimization as a risk factor for underage drinking.

In the last paragraph before the methods the authors clearly outline the gaps of previous research, but do not provide much specific justification for why these particular gaps matter and are too general.

For the first gap, I do not buy that there is sparse research on homophobic victimization outside of school contexts—the Katz-Wise study that the authors cite, addresses several types of non-school-based victimization for LGB people in research studies conducted up to 2012 (which was 9 years ago), and school-based victimization was not the most frequent forms of victimization measured in those studies.

For the second gap—it is true that few studies compare several forms of homophobic victimization, but the authors should explain why comparing different types of homophobic victimization matters for understanding the effect of homophobic victimization on substance use.

For the third gap, there have been plenty of studies on risk factors within SGM groups, the statement is again very general, which make it boarder on being untrue—there are lots of studies on risk factors within SGM groups (MSM in particular), but there are fewer specific to homophobic victimization. The authors should spend more time addressing why this is important for the group they study, what will understanding this association among YMSM tell us that previous studies cannot or do not?

Lastly, one novel contribution of this study is looking at a less common substance use-related outcome-- riding with an intoxicated driver or driving while intoxicated—and the authors do not provide much rationale for examining this additional outcome.

Methods

The methods are solid. One question had that was unaddressed was how the authors dealt with missing data. There doesn’t appear to be much missing on homophobic victimization, but there is some missing on some of the covariates would mean that the regressions would have different sample sizes.

I also noted here that there is a discrepancy with abstract where it says that 88% of youth reported at least one form of homophobic victimization, and in the text it is reported as 87% in text—"Most participants (87%) were exposed to at least one form of homophobic victimization in their lifetime”

Discussion

In the first full paragraph of the discussion, the authors mention several studies and prevalence rates of different types (homophobic?) victimization from other studies, but then conclude by saying, “Caution should be taken when comparing results across studies due to differences in the study populations and the measure of homophobic victimization.” Why mention the prevalence rates then? What does this add to understanding the current study? This space could be better utilized discussing why these different associations inform our understanding risk factors for substance use-related behaviors.

For example, its perhaps less surprising that someone who was attacked sexually had greater odds of risky substance use behaviors because there is a research base supporting this association, but why having one’s property damaged be related to substance use? Along the same lines, its notable that many of the odds ratios are pretty similar—actually, the largest association was for experiencing any victimization, which is not an uncommon way to use a multi-item measure homophobic victimization. So, do the different forms matter if they all have similar effects on the outcomes? Even if this is not discussed in this specific paragraph, this is not addressed at all throughout the discussion, yet it is one of the important and novel contributions of the study.

**********

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Submitted filename: Review for Risk taking YMSM Victimization and Alcohol.pdf

Click here for additional data file.

12 Jun 2021

Author’s response to reviewers' comments:

We thank the reviewers for their comments and suggestions on our manuscript, entitled “Risk-taking behaviors in adolescent men who have sex with men (MSM): An association between homophobic victimization and alcohol consumption.” We substantially revised our manuscript in response to these suggestions, and we feel that our revised manuscript is stronger because of these changes. Revisions are tracked in the revised manuscript. Detailed responses to reviewers are as follows (see bold font):

Reviewer #1:

The data analysis is routine and includes univariate analyses with non parametric approaches such as Fisher’s exact test when appropriate. Logistic regression models and multivariable logistic regression were applied appropriately. The sample size appears reasonable. The conclusion appears to follow from the analysis in that adolescent men who experience homophobic victimization are at increased risk of alcohol consumption and risky-alcohol related behaviors.

1. The strengths and weaknesses of the manuscript are noted by the investigators. However, some concordance and sensitivity measures of these models should have been included in the analyses.

Thank you for this suggestion. However, we believe that concordance measures are not appropriate to compare the models in our study because such measures are most often used to assess the discriminative ability of risk prediction models, whereas our analysis included causal models. Additionally, a sensitive analysis is used to compare models with varying modelling methods of analysis, different definitions of outcomes, or assess the effects of protocol deviations, missing data, or outliers. This was not the case in our study; all models used the same method of analysis and outcome definition but had different exposure variables (i.e., varies forms of victimization). Instead, to accurately compare these models to one another we compared the effect measures of each model with specific forms of victimization to the effect measure of the generalized victimization model (those experiencing any form of victimization). This analysis has been added as supplementary tables on page 25 of the manuscript.

Reviewer #2:

1. The purpose of this study was to examine if there was an association between homophobic victimization and two alcohol related outcomes – alcohol consumption and riding with an intoxicated driver/riding in a car while under the influence of alcohol or drugs. The article is methodologically sound and has the potential to contribute a more nuanced understanding of how different forms of homophobic victimization contribute to substance use related outcomes for young men who have sex with men (YMSM). As the authors point out, there have been numerous studies that find this association--the novel contributions of this study are (1) looking at different aspects of homophobic victimization, (2) focusing on YMSM, and (3) looking at a less studied outcome (riding with an intoxicated driver or driving while intoxicated). My main, critique of the study is that these novel contributions are not highly emphasized, and the front end of the paper is highly general rather than specific to the current study, which is critical given numerous other studies with similar findings.

Thank you for this comment. We have revised the language in third paragraph of the introduction to emphasize the novel contributions of this study to the current literature, as suggested.

2. Abstract: Given the cross-sectional nature of the data, the authors should rephrase this sentence, “Adolescent men who experience homophobic victimization are at increased risk of alcohol consumption and risky-alcohol related behaviors.” so that it sounds less directional.

This sentence has been revised to read: Increased risk of alcohol consumption and risky alcohol-related behaviors were found among adolescent men who experienced homophobic victimization.

3. Introduction: On page 5, the authors conclude by saying: “However, results have been inconsistent, including a null finding [24]. More research is needed to better understand risk factors contributing to underage drinking among SGM youth.” Its unclear which results have been inconsistent – either that homophobic victimization is linked to alcohol related behaviors, or that school-based victimization (not clear if the school-based victimization was LGB specific or not) being the strongest predictor is inconsistent—either way, one null finding does not necessarily make the findings inconsistent given how much research has been done on both topics. The authors should consider rephrasing this sentence to provide a stronger conclusion regarding previous research, perhaps linking it specifically why more research is needed for homophobic victimization as a risk factor for underage drinking.

Thank you for this suggestion. We have revised this sentence to read: Future research is needed to identify the specific forms of homophobic victimization experienced by SGM youth associated with increased risk of alcohol consumption for a comprehensive understanding of risk factors contributing to underage drinking in this population.

4. Introduction: In the last paragraph before the methods the authors clearly outline the gaps of previous research, but do not provide much specific justification for why these particular gaps matter and are too general.

Justification for studying specific homophobic victimization has been mentioned as: Such information is also essential to fully capture the homophobic victimization experiences of SGM youth and how these experiences contribute to the risk of underage drinking for the implementation of future interventions.

Justification for studying adolescent MSM only has been mentioned as: Research on underage alcohol consumption among adolescent MSM is needed to improve our understanding of alcohol-related disparities found within the SGM population.

Justification for study the association between homophobic victimization and driving while intoxicated or riding with an intoxicated driver has been added to the manuscript as: Previously, over 20% of SGM youth reported riding with an intoxicated driver and 8% drove while intoxicated [9]. Identifying homophobic victimization as a risk factor for alcohol-related behaviors may inform future studies and provide evidence that victimization can influence adverse health behaviors beyond substance abuse, and significantly impact on the health of adolescent MSM.

5. Introduction: For the first gap, I do not buy that there is sparse research on homophobic victimization outside of school contexts—the Katz-Wise study that the authors cite, addresses several types of non-school-based victimization for LGB people in research studies conducted up to 2012 (which was 9 years ago), and school-based victimization was not the most frequent forms of victimization measured in those studies.

The first gap mentioned has been removed from the introduction, as suggested.

6. Introduction: For the second gap—it is true that few studies compare several forms of homophobic victimization, but the authors should explain why comparing different types of homophobic victimization matters for understanding the effect of homophobic victimization on substance use.

As suggested, we added a sentence to emphasize the importance of studying several forms of homophobic victimization. This sentence reads: By identifying which form of homophobic victimization is associated with alcohol consumption, targeted interventions can be implemented to end specific victimization tactics aimed at SGM youth.

7. Introduction: For the third gap, there have been plenty of studies on risk factors within SGM groups, the statement is again very general, which make it boarder on being untrue—there are lots of studies on risk factors within SGM groups (MSM in particular), but there are fewer specific to homophobic victimization. The authors should spend more time addressing why this is important for the group they study, what will understanding this association among YMSM tell us that previous studies cannot or do not?

As suggested, we added a few sentences to address why it is important to study the association between homophobic victimization and alcohol consumption among YMSM. These sentences read: Second, little research has been conducted to understand victimization as a risk factor for alcohol use specifically for adolescent men who have sex with men (MSM) [3]. We contend that adolescent MSM may be at particularly high risk of underage drinking due to the severe forms of victimization more often reported by them compared to other SGM subgroups [18],[20], warranting concern and future research. Additionally, by focusing on adolescent MSM alone, researchers will be able to compare alcohol consumption among adolescent MSM who experienced homophobic victimization to adolescent MSM who did not, whereas previous comparisons have been made to heterosexual youth [2], [6], [8].

8. Introduction: Lastly, one novel contribution of this study is looking at a less common substance use-related outcome-- riding with an intoxicated driver or driving while intoxicated—and the authors do not provide much rationale for examining this additional outcome.

We have revised the language in the introduction to provide more rationale for why we examined the outcome ‘riding with an intoxicated driver or driving while intoxicated’. We added the following sentences: Third, to our knowledge, no previous study has assessed the association between homophobic victimization and risky alcohol-related behaviors, specifically driving while intoxicated or riding with an intoxicated driver. Previously, over 20% of SGM youth reported riding with an intoxicated driver and 8% drove while intoxicated [9]. Identifying homophobic victimization as a risk factor for alcohol-related behaviors may inform future studies and provide evidence that victimization can influence adverse health behaviors beyond substance abuse, and significantly impact on the health of adolescent MSM.

9. Methods: The methods are solid. One question had that was unaddressed was how the authors dealt with missing data. There doesn’t appear to be much missing on homophobic victimization, but there is some missing on some of the covariates would mean that the regressions would have different sample sizes.

Thank you for pointing out this omission. We added the sentence “Participants with missing data on covariates were dropped from the multivariable regression models” to clarify how missing data was handled in the regression models on page 9, line 199-200.

10. Methods: I also noted here that there is a discrepancy with abstract where it says that 88% of youth reported at least one form of homophobic victimization, and in the text it is reported as 87% in text—"Most participants (87%) were exposed to at least one form of homophobic victimization in their lifetime”

This sentence has been corrected in the abstract and now reads: Most participants (87%) reported at least one form of homophobic victimization in their lifetime, with verbal insults being the most frequently reported (82%). This reflects the data presented in text and in Table 2.

11. Discussion: In the first full paragraph of the discussion, the authors mention several studies and prevalence rates of different types (homophobic?) victimization from other studies, but then conclude by saying, “Caution should be taken when comparing results across studies due to differences in the study populations and the measure of homophobic victimization.” Why mention the prevalence rates then? What does this add to understanding the current study? This space could be better utilized discussing why these different associations inform our understanding risk factors for substance use-related behaviors. For example, its perhaps less surprising that someone who was attacked sexually had greater odds of risky substance use behaviors because there is a research base supporting this association, but why having one’s property damaged be related to substance use? Along the same lines, its notable that many of the odds ratios are pretty similar—actually, the largest association was for experiencing any victimization, which is not an uncommon way to use a multi-item measure homophobic victimization. So, do the different forms matter if they all have similar effects on the outcomes? Even if this is not discussed in this specific paragraph, this is not addressed at all throughout the discussion, yet it is one of the important and novel contributions of the study.

Thank you for this comment. The first full paragraph on prevalence rates has been removed from the discussion, as suggested. A discussion on the different associations and how they inform our understanding of risk factors for substance use-related behaviors has been added on page 20, line 319‒331. We also addressed the finding that the different forms of victimization have similar effect on the outcomes in order to increase clarity of its significance.

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

22 Jul 2021

PONE-D-20-39463R1

Risk-taking behaviors in adolescent men who have sex with men (MSM): An association between homophobic victimization and alcohol consumption

PLOS ONE

Dear Dr. Cordoba,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Sep 05 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

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We look forward to receiving your revised manuscript.

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Academic Editor

PLOS ONE

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Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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Reviewers' comments:

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Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: (No Response)

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: (No Response)

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: (No Response)

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: (No Response)

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: (No Response)

Reviewer #2: No

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: (No Response)

Reviewer #2: The authors have generally responded well to my comments. I have a few remaining suggestions listed below.

• I recommend that the authors update their literature review and focus it only on research specific to MSM or SGM men. Much the research on SGM populations related to alcohol use and substance use is discussed in terms of gender difference among SGM populations, so general findings about SGM don’t necessarily apply to this study focused on MSM. I have more specific suggestions below, but the discussion should also be focused more around MSM than SGM populations more generally.

• I noted some typographical errors in the literature review, so the authors should carefully edit the manuscript.

• The authors have a claim that school-based homophobic victimization is one of the strongest predictors of alcohol use on page 5 line 95 and 96. However, neither of the references cited makes this claim and I am unsure that that there has been a study testing this claim. I recommend the authors remove the statement or update to say that school-based victimization has been fond to be strongly related to substance use.

• The discussion still has track changes in it.

• In the discussion, the authors state: “We found that half of the adolescent MSM study participants reported alcohol consumption, which is noteworthy since they are all under the US legal drinking age of 21. However, this estimate was lower than that previously reported by a nationwide study, where 75% of SGM high school students drank alcohol [9]. This difference may be explained by our younger sample population, which included both middle school and high school students.” This statement should be removed—the comparison is MSM to SGM which while there is overlap are not the same populations, so there are numerous reasons that the prevalence rates could differ beyond those the author’s mention, namely that SGM women tend to have more elevated rates of alcohol use than SGM men.

• In the discussion, the authors state: “We found that among adolescent MSM underage drinking was associated with various forms of homophobic victimizations, such as verbal insults or threats, physical or sexual assaults, and property damage. This finding aligned with results from existing studies focused on school-victimization and alcohol use among SGM youth.” It is unclear why they compare their results to studies on school victimization given that their study focuses on general victimization of MSM.

**********

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Reviewer #1: No

Reviewer #2: No

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24 Aug 2021

Editor and Reviewer comments:

We thank the reviewers for their comments and suggestions on our manuscript, entitled “Risk-taking behaviors in adolescent men who have sex with men (MSM): An association between homophobic victimization and alcohol consumption.” We substantially revised our manuscript in response to these suggestions, and we feel that our revised manuscript is stronger because of these changes. Revisions are tracked in the revised manuscript. Detailed responses to reviewers are as follows (see bold text below):

Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: (No Response)

Reviewer #2: The authors have generally responded well to my comments. I have a few remaining suggestions listed below.

Reviewer #2 Comments:

1. I recommend that the authors update their literature review and focus it only on research specific to MSM or SGM men. Much of the research on SGM populations related to alcohol use and substance use is discussed in terms of gender difference among SGM populations, so general findings about SGM don’t necessarily apply to this study focused on MSM. I have more specific suggestions below, but the discussion should also be focused more around MSM than SGM populations more generally.

Thank you for this thoughtful comment. While we agree with the reviewer that much of the research on SGM populations related to alcohol use and substance use is discussed in terms of gender difference among SGM populations, our literature review was limited by the current lack of research on alcohol use among adolescent MSM. Because this study focused on underage drinking among adolescent MSM, we believe that a comparison to older MSM (i.e., 21 years or older) may not highlight the risk of this behavior. Instead, we aimed to compare our results to other youth who may be at risk of underage drinking (i.e., SGM youth).

2. I noted some typographical errors in the literature review, so the authors should carefully edit the manuscript.

We thoroughly reviewed the full manuscript for typographical errors. The appropriate edits have been made to the manuscript.

3. The authors have a claim that school-based homophobic victimization is one of the strongest predictors of alcohol use on page 5 line 95 and 96. However, neither of the references cited makes this claim and I am unsure that that there has been a study testing this claim. I recommend the authors remove the statement or update to say that school-based victimization has been found to be strongly related to substance use.

As suggested by the reviewer, we revised the sentence to read “In fact, some studies have found school-based victimization to be strongly related to substance use among SGM youth [3], [15].”

4. The discussion still has track changes in it.

We apologize for this oversight. For this submission, we submitted two versions of the manuscript: 1. Manuscript with tracked changes and 2. Manuscript with no tracked changes (clean version).

5. In the discussion, the authors state: “We found that half of the adolescent MSM study participants reported alcohol consumption, which is noteworthy since they are all under the US legal drinking age of 21. However, this estimate was lower than that previously reported by a nationwide study, where 75% of SGM high school students drank alcohol [9]. This difference may be explained by our younger sample population, which included both middle school and high school students.” This statement should be removed—the comparison is MSM to SGM which while there is overlap are not the same populations, so there are numerous reasons that the prevalence rates could differ beyond those the author’s mention, namely that SGM women tend to have more elevated rates of alcohol use than SGM men.

Thank you for your suggestion, this statement has been removed.

6. In the discussion, the authors state: “We found that among adolescent MSM underage drinking was associated with various forms of homophobic victimizations, such as verbal insults or threats, physical or sexual assaults, and property damage. This finding aligned with results from existing studies focused on school-victimization and alcohol use among SGM youth.” It is unclear why they compare their results to studies on school victimization given that their study focuses on general victimization of MSM.

This is a good point made by the reviewer. While we agree with the reviewer that our study focuses on general victimization among adolescent MSMS, the results of our study were compared to studies on school-based victimization because this is the data currently available. We revised this sentence to read, “We compared our results to studies focused on school-based victimization and alcohol use among SGM youth due to the lack of data surrounding homophobic victimization in MSM youth in other setting.”

Submitted filename: Response to Reviewers #2.docx

Click here for additional data file.

3 Nov 2021

Risk-taking behaviors in adolescent men who have sex with men (MSM): An association between homophobic victimization and alcohol consumption

PONE-D-20-39463R2

Dear Dr. Evette Cordoba-

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Additional Editor Comments (optional):

All revisions have been addressed and the manuscript has been accepted for submission.

Reviewers' comments:

17 Nov 2021

PONE-D-20-39463R2

Risk-taking behaviors in adolescent men who have sex with men (MSM): An association between homophobic victimization and alcohol consumption

Dear Dr. Cordoba:

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