Curricular advances to develop medical students' knowledge, skills, and attitudes in health advocacy.

Substance use in general, and stimulant use in particular, among men who have sex with men (MSM) remains an important issue within the field of public health because of its rates of use, its relation to sexual behavior, and its negative psychosocial consequences. For decades, stimulants such as cocaine and methamphetamine have been discussed, distributed, and used in MSM social venues (; ; ). This presence has extended into both general recreational and sexual contexts, with research documenting sustained and, in some settings, increased cocaine use among MSM, including use during sexual encounters, across multiple decades (; ; ). Consequently, MSM are more likely to misuse illicit and licit substances, and experience substance use disorders than their heterosexual male peers (; ). This elevated risk is reflected in the consistently high prevalence of stimulant use (e.g., cocaine, methamphetamine, crack, amphetamine) documented across studies of MSM (), with evidence further indicating that MSM are more likely to meet diagnostic criteria for stimulant use disorders compared to other groups (; ; ). Within this broader context, stimulant use has been repeatedly identified as a key driver and reinforcer of psychological and sexual health disparities in MSM communities. MSM’s stimulant use frequently occurs within sexual settings (; ; ) at often higher rates than any other class of drug (). Stimulant use in the context of sex among MSM has been associated with higher odds of engaging in condomless anal intercourse and inconsistent condom use compared to MSM who do not use stimulants during sex (; ). Further, MSM who use stimulants are more likely to demonstrate suboptimal adherence to daily oral pre-exposure prophylaxis (PrEP), which, in turn, may be associated with higher rates of HIV seroconversion (; ). Variations in the prevalence of stimulant use in the context of sex have also been documented by HIV status (; ), highlighting the co-occurrence of sexualized stimulant use with HIV prevention challenges, particularly suboptimal PrEP uptake and adherence. Additionally, stimulant use in the context of sex is often stigmatized within general health care, which can create structural barriers to accessing adequate sexual health services and further exacerbate poor mental health outcomes. Motivations for substance use among MSM can vary depending on the type of substance and the setting in which the substance use occurs; therefore, understanding why MSM use substances may help contextualize these patterns and identify effective psychological intervention targets. Unlike alcohol which acts as a nervous system depressant often used as a social lubricant in social settings (), stimulants function through a different set of distinct physiological mechanisms that have been shown to induce heightened alertness, energy, and tactile sensitivity among MSM () and has been more closely linked to intense physiological arousal and enhanced experiences within intimate settings ().