‘Chemsex’ in men who have sex with men and reducing the potential risks
There is increasing evidence that chemsex incidence is growing in men who have sex with men population. It is important to support users with the appropriate risk reduction strategies and encourage engagement with specialist services.
There is increasing evidence that chemsex incidence is growing in men who have sex with men. Chemsex use can potentially place users at higher risk of physical and mental health issues. It is important to support users with the appropriate risk reduction strategies and encourage engagement with specialist services.
Gay and bisexual men in England and Wales are three times more likely to have used an illicit drug in the previous year than compared to the heterosexual population (Office for National Statistics 2014). Men who have sex with men (MSM) and inject drugs show different behaviour patterns than the rest of the drug using population (Public Health England 2014).
The majority of MSM do not engage in drug use and only some for sexual purposes, but for the group that does, it can be intertwined with multiple and wider health issues (Public Health England 2015). ‘Chemsex’ is a vernacular term that is used to describe the practice of taking substances before or during sexual activities to purposively prolong and constructively augment the physical, mental, emotional and social dimensions of the encounter.
1 in 5
HIV negative men had engaged in chemsex
A study carried out in London identified that MSM chemsex occurs more frequently in group dynamics and is more likely to take place in private residencies or commercial sex settings (Bourne et al 2015). Data from 20 UK sexual health clinics from 2013 to 2014 demonstrated that one in five HIV negative MSM had engaged in chemsex in the previous three months (Sewell et al 2017). MSM chemsex is thought to be reported in higher rates within healthcare services based in larger UK metropolitan cities.
The most common drugs associated with chemsex are crystal methamphetamine (crystal meth), gammahydroxybutrate (GHB), gammabutyrolactone (GBL) and mephedrone. Crystal meth is part of the amphetamine drug group and provides stimulant effects that can make the user hyper alert and provide a feeling of euphoria, but can have the impact of inducing paranoia, confusion and aggression.
Crystal meth can be smoked, snorted, injected or taken rectally. GHB and GBL are typically taken orally in a liquid form or, less likely can be injected. Mephedrone is part of the amphetamine drug group and it gives stimulant effects that can include hyper alertness and intense feeling of ‘wellness’. The impact of mephedrone can include paranoia, anxiety and over stimulus for the circulatory and nervous system, this increases the risk of fits being induced.
An Australian study reported gay and bisexual men were up to ten times more likely to have injected drugs than the general population (Lea et al 2013). In Australian and UK studies of MSM the most common injected type of substances were amphetamine/methamphetamine, and least common were GHB and opioids (Lea et al 2013, Hickson et al 2016).
In the UK study, HIV positive men were at least three times more likely to have injected than men who identified as being HIV negative (Hickson et al 2016). Studies have shown MSM who use drugs for sexual enhancement are more likely to engage in higher risk sexual practices and there is an association with higher rates of sexually transmitted infections (STIs) and blood borne viruses (BBV) (Hegazi et al 2016, Marongiu et al 2012).
The majority of MSM who engage in chemsex appear to have functional lives including stable employment (Public Health England 2015), but some evidence has shown this type of drug use can be intertwined with wider negative mental health and social outcomes. A London-based study found around half of the MSM sample who engaged in chemsex found it had a direct effect on reducing performance and attendance at work, and part of the sample said it had negative consequences on social support networks (Bourne et al 2015).
A study of MSM attending a sexual health clinic reported 38% had engaged in chemsex, with more than half of those engaging in chemsex reporting a history of mild to moderate mental health problems (Dearing and Flew 2015).
Chemsex users may potentially present to non-specialist services with other physical and mental health issues and may not necessarily be engaging with specialist services. It is important to be aware of the potential short and long-term effects of chemsex related drugs and the associated health impact. Due to potential multifaceted stigma related issues it is important to adopt open communication strategies when engaging in consultations.
To understand the individual’s level of risk some areas to consider are: types of substances used, patterns and frequency of use, method of administration, environment and social dynamics in drug and sexual interactions, type of sexual activity, level of protection used in sexual activity, number and gender of sexual partners, history of sexual health/BBV screening, hepatitis B/A immunisation status and any current health impact from drug usage and sexual activity.
The Novel Psychoactive Treatment UK Network (NEPTUNE) has comprehensive guidance available online about the clinical management of acute and chronic harms related to club drugs and novel psychoactive substances (NPS). The British Association for Sexual Health and HIV has produced guidance that is available online about MSM STI testing.
To reduce the associated risks it is important to encourage the individual to engage with the appropriate addiction and sexual health services and if appropriate offer the required health prevention interventions.
- NEPTUNE guidance (Abdulrahim and Bowden-Jones 2015) provides comprehensive evidence-based information on the prevalence of use, acute/chronic health impact, methods of use, effects of the substances and managing the acute and chronic harmful effects of NPS and club drugs. This resource is targeted to specific areas including primary care.
- The British Association for Sexual Health and HIV (BASSH 2014) MSM recommendations. This information is provided on the frequency of testing (minimum 12 monthly for sexually active and three monthly for high risk), samples that should be taken and what tests might be included in a sexual health screen. Comprehensive guidance is also available on sexual health history taking and safer sex advice.
Risk reduction advice
- Provide advice regarding the dangers of poly drug use (including alcohol) and advise to stay well hydrated.
- Advise people who may be snorting or injecting drugs about the risk of BBV transmission, encourage safer drug use practices and attendance to harm reduction services.
- Promote, and if appropriate, offer the recommended STI testing, BBV testing and hepatitis B and A immunisation, as per national guidance and local service policy.
- Encourage safer sex practices and access to local services for safer sex provisions. If available and appropriate, offer to provide safer sex provisions – condoms and lubricants.
- Pre-exposure prophylaxis (PrEP) is a new biomedical measure in which someone who is HIV negative and engaging in unprotected penetrative sex, takes antiretroviral medications to reduce the risk of them acquiring HIV. PrEP is not widely available on the NHS, but NHS England will be carrying out a PrEP Impact Trial at the end of 2017. This guidance is available online.
- Post exposure prophylaxis (PEP) is an emergency biomedical measure in which someone takes a course of antiretroviral medications after potentially being exposed to the HIV virus, with the aim of minimising the risk of HIV transmission. PEP can usually be accessed via assessment at sexual health services and accident and emergency.
- Abdulrahim D and Bowden-Jones O (2015) Guidance on the Clinical Management of Acute and Chronic Harms of Club Drugs and Novel Psychoactive Substances. Novel Psychoactive Treatment UK Network.
- British Association for Sexual Health and HIV (2014) Recommendations for Testing for Sexually Transmitted Infections in Men Who Have Sex With Men.
- British Association for Sexual Health and HIV (2016) BHIVA-BASHH Position Statement on PrEP in the UK.
- Bourne A, Reid D, Hickson F et al (2015) "Chemsex" and harm reduction need among gay men in South London. International Journal of Drug Policy. 26, 12, 1171-1176.
- Dearing N, Flew S et al (2015) MSM the cost of having a good time? A survey about sex, drugs and losing control. BMJ.
- Hegazia A, Lee M, Whittaker W et al (2016) Chemsex and the city: sexualised substance use in gay bisexual and other men who have sex with men attending sexual health clinics. International Journal of STD and AIDS. 28, 4, 362-366.
- Hickson F, Reid R, Hammond G et al (2016) State of Play: Findings from the England Gay Men's Sex Survey 2014. Sigma Research, London.
- Lea T, Mao L, Bath N et al (2013) Injecting drug use among gay and bisexual men in Sydney: prevalence and associations with sexual risk practices and HIV and hepatitis C infection. AIDS and Behavior. 17, 4, 1344-51.
- Marongiu A, Hope VD, Parry J et al (2012) Male IDUs who have sex with men in England, Wales and Northern Ireland: are they at greater risk of bloodborne virus infection and harm than those who only have sex with women? Sexually Transmitted Infections. 88, 6, 456-461.
- Office for National Statistics(2014) Drug Misuse: Findings From the 2013/14 Crime Survey for England and Wales. ONS, London.
- Public Health England (2014) Promoting the Health and Well-being of Gay, Bisexual and Other Men Who Have Sex With Men: Initial Findings. PHE, London.
- Public Health England (2015) Substance Misuse Services for Men Who Have Sex With Men Involved in Chemsex. PHE, London.
- Sewell J, Miltz A, Lampeth F et al (2017) Poly drug use, chemsex drug use and associations with sexual risk behaviour in negative HIV men who have sex with men attending sexual health clinics. International Journal of Drug Policy. 9, 43, 33-43.
Steven Maxwell is a tutor in mental health nursing, King’s College London