Syndemics of stigma, minority-stress, maladaptive coping, risk environments and littoral spaces among men who have sex with men using chemsex

Chemsex Among Men Having Sex with Men: A Scoping Review on Management, Support, and Harm Reduction Strategies

Chemsex defines the practice of sexual activity under the influence of psychoactive substances, mainly by Men who have Sex with Men (MSM). This activity can be associated with negative health consequences, yet there are no recommendations to guide management of individuals who engage in chemsex. The aim of this scoping review was to identify and describe the existing treatments (pharmacological or not) and risk/harm reduction strategies for MSM who engage in chemsex. This scoping review was performed using PubMed and Embase databases and according to the PRISMA Extension for Scoping Review criteria. Overall, 19 studies were included in the review. Among these studies, four main themes were identified: management and harm reduction strategies, key actors involved in managing MSM who engage in chemsex, perceived barriers to care and the role of pre-exposure prophylaxis, and medical information sought by MSM who engage in chemsex. This scoping review concludes with the need to develop multidisciplinary approaches to improve communication about chemsex, and to design interventional studies that target MSM who engage in chemsex.

How LGBTQ + adults' experiences of multiple disadvantage impact upon their health and social care service pathways in the UK & Ireland: a scoping review

BACKGROUND

Despite increased awareness of the significant health and healthcare inequalities experienced by minoritised groups, limited research considers the interaction of multiple domains of social disadvantage. This review therefore sought to explore how LGBTQ + adults' experiences of homelessness, substance use, and criminal justice involvement impact upon their access to and use of health and social care services in the UK and Ireland.

METHODS

A qualitative scoping review was conducted in accordance with the PRISMA-ScR framework. Electronic database and web searches identified 26 eligible peer-reviewed and grey literature documents published between 2010-2024. The data were charted, coded, and knowledge gaps identified.

RESULTS

Data were coded thematically, clustered around the concept of normativity. Descriptive qualitative techniques were applied to explore how this was enacted and experienced. Synthesis across the literature identified experiences of discrimination and anticipated stigma that acted as barriers to accessing and engaging with services.

CONCLUSIONS

Structural normativity and the privilege afforded to hegemonic population groups impacted upon this population's access to and use of services. The review adds depth and context to questions around the lack of visibility or engagement in services by LGBTQ + people with experience of disadvantage, and contributes to the wider literature on improving service access for marginalised, underserved, or disadvantaged communities.

Sexualized drug use factors among rural sexual minority men

PURPOSE

Although rural sexual minority men (SMM) use substances immediately before/during sex (i.e., sexualized drug use), the factors contributing to this behavior are unknown. We examined the factors associated with past year sexualized drug use among rural SMM.

METHODS

Rural SMM in the Southern region of the United States (N = 345) completed an online cross-sectional survey from February to March 23, 2024. Participants answered questions about their sexualized drug use behaviors, sexual behaviors, minority stressors, and demographics. We conducted a hierarchical logistic regression to estimate the adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for factors associated with past year sexualized drug use.

FINDINGS

Over three-quarters of participants (79.7%) used substances immediately before/during sex in the past year. Sexualized drug use was associated with exposure to sexual minority stressors, polysubstance use, sexually transmitted infection testing, having oral sex, receiving drugs from a man in exchange for sex, and older age.

CONCLUSION

Sexualized drug use is prevalent among rural SMM, and sexual minority stressors and past year sexual risk and substance misuse behaviors were contributing factors. Rural primary care clinics, human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) service organizations, and outpatient and inpatient substance use organizations should implement integrative sexual and substance use screening, counseling, and referral services for their rural clients.

Understanding the Needs and Experiences With Health Services of Gay and Bisexual Men (GBM) Who Engaged in Chemsex During the First Year of the COVID-19 Pandemic in Quebec, Canada

Gay and bisexual men (GBM) engaging in chemsex can face various health and well-being-related challenges, the extent of which remains unknown given the limited research in the context of the COVID-19 pandemic. This paper examines the pandemic impacts on the health needs of GBM who engaged in chemsex and their experiences with related services. We applied interpretive description to produce knowledge with direct implications for improving practices and policies. Data were collected between July 2020 and January 2021 using in-depth semi-structured interviews with eight key informants who held chemsex expertise and 13 GBM with chemsex lived experiences. Interviews were transcribed, anonymized, and analyzed thematically, yielding three interrelated themes. First, participants argued that the COVID-19 public health response was heteronormative and moralizing, reinforcing feelings of shame among GBM who engaged in chemsex and further isolating them. This added a layer of stigma and exposed them to increased drug-related risks by obstructing harm reduction practices. Second, participants contended how the pandemic worsened the scarcity and shortcomings of chemsex-specialized services. The mandatory shift to online services made it harder to form meaningful therapeutic relationships, especially given the unique sensitivity and stigma associated with chemsex, further heightened during the pandemic. Third, this online shift simultaneously facilitated access to personalized and culturally sensitive care, especially for those with less urgent needs. Our findings' implications emphasize the importance of adopting a comprehensive approach in chemsex care, integrating both in-person and online methods, to counteract health iniquities reinforced by the pandemic and the institutional responses to it.

"Navigating Risk and Responsibility?": A Mixed-Methods Study Addressing Stigma and Well-Being Among Men Who Have 'Sex on Chems' with Other Men in the English Midlands

BACKGROUND

Most research on 'Chemsex' has been conducted with gay, bi-sexual, and men who have sex with men (GBMSM) in large cities with well-established infrastructures. Therefore, this study aimed to explore the 'Chemsex' risks and responsibilities of GBMSM who lived outside of the queer metropolis. This study also aimed to understand how stigma and mental health present in the absence of a well-established community infrastructure.

METHODS

This study utilized mixed methods in Leicester, Leicestershire, and Rutland, a location in the East Midlands of England. The quantitative component consisted of a survey. The qualitative component comprised three case studies based on in-depth interviews, using interpretative phenomenological analysis.

RESULTS

Of the 123 survey respondents, 86% engaged in riskier sex during sessions and 35% no longer enjoyed sober sex. In the interviews, the three men balanced risk management and personal responsibility, positioning themselves as mature, considerate, and well-educated users. All were alienated by the term 'Chemsex'. The findings are considered using theoretical frameworks, or how discourses of 'moral threat' operate within the micro-politics of regulating GBMSM's pleasure and stigma.

CONCLUSIONS

The complexities of understanding this practice for researchers and practitioners are discussed and recommendations are made for reframing education and support services for GBMSM.

Acceptance and Commitment Therapy for Hypersexuality: A Pilot Study

Hypersexuality refers to the inability to control sexual desire. Despite it has shown serious consequences for physical, psychological and social health, the evidence of available psychological interventions is still insufficient. In this open-label pilot study, an Acceptance and Commitment Therapy (ACT) intervention was conducted with adults with clinically significant levels of hypersexuality aimed to examine its feasibility and usefulness. The intervention consisted of eight weekly online individual psychological intervention sessions. Outcome self-report measures were administered at baseline, after the intervention and a 3 months follow-up. Behavioral and subjective informed changes in sexual practices were weekly assessed through self-monitoring. Twelve participants (M age = 38.8 ± 11.5 years, 83.3% male, 66.7% homo or bisexual) completed the intervention. The feasibility was found to be good, with all the participants completing the training and high levels of satisfaction. Hypersexuality, psychological flexibility, cognitive fusion and mindfulness scores significantly improved after the ACT intervention, with large effect sizes. Clinically significant changes in hypersexuality were found for the vast majority of participants, besides reductions in the time dedicated to planning and practicing sex and the sexualized drug use. Results indicate that ACT-based interventions may be considered feasible and potentially effective therapeutic alternatives for hypersexuality.

Exploring the Role of Social Support and Sexual Functioning: A Study of Chemsex and Sober Sex in Men Who Have Sex with Men

Research on chemsex, the intentional use of certain drugs in sexual contexts by gay men and other men who have sex with men (MSM), has been growing in recent years although, even today, much of it focuses on drug use and its consequences, rather than on the sexual and social experiences of users. This study aimed to explore the influence of social support and sexual functioning on the frequency of chemsex and sober sex. A sample of 160 MSM WAS recruited through social media and NGOs. Through regression analysis, it was found that lower perceived social support and greater number of routes of drug administration predicted a higher frequency of chemsex practice. On the other hand, higher perceived social support, higher levels of desire and arousal, and fewer routes of drug administration predicted a higher frequency of engaging in sober sex. This study provides empirical evidence that both social support and sexual functioning are key elements in chemsex and have an impact on both the frequency of chemsex and sober sex. Given the importance of these elements, we suggest that interventions should be framed holistically. Nevertheless, not all chemsex is problematic and it is a free choice in sexuality.

Assessing the Effectiveness of an mHealth Intervention to Support Men Who Have Sex With Men Engaging in Chemsex (Budd): Single-Case and Pre-Post Experimental Design Study

BACKGROUND

This study focuses on the Budd app, a mobile health intervention designed for gay, bisexual, and other men who have sex with men who participate in chemsex. Chemsex, the use of psychoactive drugs in a sexual context, presents substantial health risks including increased HIV transmission and mental health issues. Addressing these risks requires innovative interventions tailored to the unique needs of this population.

OBJECTIVE

This study aims to evaluate the effectiveness of the Budd app in promoting drug harm reduction practices among its users, focusing on knowledge, behavioral intention, risk behavior awareness, and self-efficacy.

METHODS

The study used a mixed methods approach, combining a single-case experimental design and a pre-post study. A total of 10 participants from an outpatient clinic were recruited, and each attended the clinic 3 times. During the first visit, participants installed a restricted version of the Budd app, which allowed them to report daily mood and risk behavior after chemsex sessions. Phase A (baseline) lasted at least 2 weeks depending on chemsex participation. In the second visit, participants gained full access to the Budd app, initiating phase B (intervention). Phase B lasted at least 6 weeks, depending on chemsex participation, with identical data input as phase A. Participants completed pre- and postintervention surveys assessing behavioral determinants during the first and third visit.

RESULTS

The study observed an increased knowledge about chemsex substances postintervention, with a mean percentage improvement in knowledge scores of 20.59% (SD 13.3%) among participants. Behavioral intention and self-efficacy showed mixed results, with some participants improving while others experienced a decrease. There was also a variable impact on awareness of risk behavior, with half of the participants reporting a decrease postintervention. Despite these mixed results, the app was generally well-received, with participants engaging with the app's features an average of 50 times during the study.

CONCLUSIONS

The Budd app showed effectiveness in enhancing knowledge about chemsex substances among gay, bisexual, and other men who have sex with men. However, its impact on safe dosing behavior, behavioral intention, self-efficacy, and risk behavior awareness was inconsistent. These findings suggest that while educational interventions can increase knowledge, translating this into behavioral change is more complex and may require more participants, a longer follow-up period, and additional strategies and support mechanisms.

Compulsive Sexual Behavior Disorder and Problematic Pornography Use in Cisgender Sexual Minority Individuals: The Associations with Minority Stress, Social Support, and Sexualized Drug Use

Compulsive Sexual Behavior Disorder (CSBD), recently recognized in the ICD-11 as an independent disorder, has been shown to be more prevalent in sexual minorities. However, we still lack studies investigating which factors contribute to CSBD and related behaviors in this group. In our cross-sectional study, we investigated the relationships between characteristics potentially contributing to CSBD and problematic pornography use (PPU) in sexual minority individuals: sexual minority stress (internalized sexual stigma, discrimination experiences, and openness about one's sexual orientation), perceived social support, and sexualized drug use (also more prevalent in sexual minorities). We adjusted for gender, age, sexual orientation, and the frequency of sexual behaviors. Cisgender sexual minority participants (n = 198, 72.7% men, 27.3% women; Mage = 27.13, SD = 7.78) completed an online survey. We conducted a two-step linear regression. In the first step, we introduced sociodemographic variables and the frequency of sexual activities. In the second step, we placed the predictors of main interest: perceived social support, minority stress measures, and the frequency of sexualized drug use. Our results showed that social support was negatively related to CSBD, while experiences of discrimination due to sexual orientation and engagement in sexualized drug use were associated with higher CSBD symptom severity. Internalized sexual stigma related to greater PPU severity. The discussed relationships were weak to moderate in strength. Implications of current results for therapy and diagnosis of CSBD in sexual minorities are discussed. The role of minority stressors and other factors specific to sexual minorities requires further exploration to design well-suited therapeutic interventions.

The "Chemsex" Phenomenon and Its Relationship with Psychological Variables in Men Who Have Sex with Men

Chemsex is described as the use of psychoactive substances during sexual activity to sustain, enhance, disinhibit, or facilitate the sexual experience. It preferentially concerns men who have sex with men. The main objective of this study was to examine the relationship between participation in chemsex and the psychological variables impulsivity, sexual assertiveness, and hypersexuality. The sample was composed of 137 Spanish men. A total of 104 participants reported that they had engaged in chemsex, with ages ranging from 19 to 42 years (M = 31.41, SD = 4.83). A total of 33 participants reported that they had never participated in chemsex sessions. The participants were contacted and recruited at social centers, LGBT associations, and key informants. Results showed that men who participated in chemsex reported higher impulsivity, higher hypersexuality, and lower sexual assertiveness than those who have never participated in it. The frequency of participation in chemsex, as well as the number of substances consumed, was positively and significantly correlated with dimensions of impulsivity and hypersexuality. This frequency and this consumption were negatively and significantly correlated with sexual assertiveness. Findings showed significant differences in the psychological variables based on the number of consumed substances (polydrug use/consumption of one substance) and the time of consumption (before, during or before and during sex). In conclusion, the study demonstrates the existence of a clear relationship between the experience of chemsex and psychological factors such as being an impulsive person, presenting hypersexual behavior, and/or having low sexual assertiveness.

Chemsex and Harm Reduction Practices Among Men Who Have Sex with Men in Malaysia: Findings from a Qualitative Study

Chemsex is a form of sexualized drug use commonly practiced among MSM with psychoactive substances, such as methamphetamine. While this phenomenon has gained global attention in the past two decades, there is a dearth of empirical data to inform culturally competent interventions. The current work investigates the socio-contextual factors related to chemsex and harm reduction practices among Malaysian MSM. Between February and August 2022, we conducted six online focus group sessions with Malaysian MSM who had engaged in chemsex during the previous 6 months (N = 22). We queried participants about perceived benefits and harms, harm reduction practices, and informational needs. Most participants' first chemsex experience occurred in a casual sexual encounter, often facilitated by mobile technology. Participants reported engaging in harm reduction practices before (e.g. medication reminders), during (e.g. peer support), and after (e.g. rest) chemsex. These findings have implications for future efforts to develop and implement tailored interventions to address the specific and acute needs of Malaysian MSM engaging in chemsex.

"I Can't Get No Satisfaction"-Psychosocial Aspects and Awareness of Negative Impacts in Chemsex Users: Results from an Anonymous Online Survey

Chemsex is the interplay of substance use by men who have sex with men (MSM) in sexual contexts. The minority stress model and the identity process theory are explanatory models. In this study, we investigated whether (i) differences in certain psychosocial aspects (i.e., shame, aspects of queer identity, and sexual self-concepts) exist between chemsex users and non-users, and (ii) which factors influence an awareness of negative impacts in chemsex users. We conducted an anonymous, cross-sectional, online survey, including sociodemography, sexual history, history of substance use, validated scales for shame-proneness, aspects of queer identity, and sexual self-concepts. Our analysis comprised descriptive statistics, t-tests, Spearman's correlations, and a multiple linear regression model. We recorded a total of 3257 datasets with 107 chemsex users. Chemsex users showed higher rates for risky sexual behavior. Values for shame proneness, more negative aspects of queer identity, and sexual self-concepts were elevated in chemsex users with an awareness of negative impacts. Sexual anxiety, intravenous substance use, and having had a difficult process coming out were significant predictors of feeling negative impacts. Aspects of shame, queer identity aspects, and sexual self-concepts play an important role in the field of chemsex. Different explanatory models seem to be relevant for different subgroups of chemsex users. Chemsex users with an awareness of a problem were particularly vulnerable and distressed but had the highest motivation for change. Prevention, counseling, and care might profit from the inclusion of these aspects. Further anti-stigma campaigns and a specialization of the healthcare system are needed. Registration: DRKS00022336, date: 29th of October, 2020.

Community experiences and strategies of risk management within chemsex practices: a qualitative study

The rise in the study of sexualised drug use among gay, bisexual and other men who have sex with men (MSM), known as chemsex, has generated a multiplicity of data that contribute to its problematisation as a public health issue through the link with HIV and addictions. The study of these practices, from a biomedical paradigm, has focused on risk and has contributed to its reduction as a unique and quantifiable phenomenon. This study aims to explore the experience of risk in the course of the practices, to find out what management strategies they employ in the face of risk and how they are generated. Semi-structured interviews were conducted with five chemsex practitioners in the Metropolitan Area of Barcelona and, subsequently, a thematic analysis was applied. The findings show how these men detect, assume and confront the risks present in these practices, where the type of relationships that take place and the social circle available to them are relevant. This study also highlights the creation of strategies based on experience and how the transmission of this knowledge among participants facilitates decision-making and risk management.

Homoprejudiced Violence Experiences and High-Risk Sexual Behaviors among Chinese Men Who Have Sex with Men: Depression Severity and Recreational Drug Usage as Potential Mediators

Homoprejudiced violence is a type of aggression against an individual or a community based on their actual or perceived sexual orientation. It may be linked to risks of acquiring HIV/STI via psychosocial variables. This study explored the association between homoprejudiced violence experiences and high-risk sexual behaviors, and potential psychosocial mediators. Using cross-sectional survey data collected in China through Blued among men who have sex with men (MSM) in January 2021, this study conducted multiple mediation analyses. Standard instruments were used to collect data on depressive symptoms in the last two weeks (PHQ-9), recreational drug usage in the last three months, and ever experiencing homoprejudiced violence (12-item survey instrument). Dependent variables were having condomless anal sex and having three or more sexual partners in the last three months. Among 1828 MSM, nearly half (847, 46%) had experienced homoprejudiced violence. Twenty-three percent (427) reached a score that suggested moderate or severe depression and 35% (644) had used recreational drugs. In the last three months, 40% (731) had condomless anal sex and 34% (626) had three or more sexual partners. The indirect mediational coefficients through depression on condomless anal sex and multiple sexual partners were 0.04 (95% CI: [0.02, 0.07]) and 0.02 (95% CI: [0.001, 0.05]), respectively. The indirect mediational coefficient of homoprejudiced violence experience on multiple sexual partners through recreational drug use was 0.05 (95% CI: [0.03, 0.08]). These findings suggest that more comprehensive interventions are needed to address the syndemic of homoprejudiced violence, mental health issues, and HIV/STI-related risks.

An object-oriented analysis of social apps, syringes and ARTs within gay Taiwanese men's chemsex practices

Critical drug studies explore the discursive and material dimensions of sexualised drug use to overcome individualised and often pathologising notions such as risk, safety, responsibility and pleasure. This article uses an object-oriented approach-following the use and flow of social apps, syringes and antiretroviral therapy (ART)-to analyse gay and bisexual Taiwanese men's drug practices. Interview data from fourteen men are used to articulate how objects were brought into gay and bisexual men's chemsex repertoire in ways that shaped individuals' safe-sex communication, intimacy maintenance and stigma negotiation. An object-oriented approach scrutinises risk, pleasure and identities in assemblages of the human and nonhuman, and can help identify new opportunities for implementing health promotion interventions and policies.

Sexualized substance use among gbMSM: Their perspectives on their intervention needs and counsellor competencies

INTRODUCTION

Treatments for problematic substance use by gay, bisexual and other men who have sex with men (gbMSM) in sexualized contexts must be adapted to take sociocultural aspects of these sexual practices into account. When treatment programs factor in sexuality, they most commonly address it from a biological perspective (STTBIs, HIV). This article sets out to identify intervention needs related to sexualized substance use (SSU) from the perspective of gbMSM, taking into consideration different dimensions of sexuality to offer more effective support.

METHODS

Twenty adult gbMSM, each of whom had previously participated in addiction-related treatment programs, took part in this study. We recruited through medical clinics, community organizations, social media advertising and word of mouth. Through one-on-one semi-structured interviews, participants shared their perspectives on the treatment they had received, how their sexuality had been addressed during treatment, and their perceptions of their treatment-related needs and requirements. The study analyzed and interpreted the data gathered during these interviews using a conceptual framework of sexual health combined with The Competencies, a model for addiction counselling training.

RESULTS

When the study asked participants what they would consider beneficial in terms of SSU-related treatment, they identified certain key competencies. These can be broken down into three categories - knowledge, skills and attitudes - that, together, participants perceived as critical to the development of adequate programs and services. While participants reported addiction-related knowledge was important, so too was an understanding of sexuality (e.g., sexual practices, gbMSM communities, sociocultural norms). With regard to attitudes, the study identified respect, non-judgment, acceptance and empathy as themes for most participants. Lastly, the desired skills were those permitting counsellors and other treatment providers to better align programs and services with each individual's singular reality within the context of their substance use.

CONCLUSIONS

The results of this study suggest that, to provide treatment programs adapted to the needs of gbMSM in a context of SSU, knowledge must be consolidated and new skills developed. Furthermore, both knowledge and skills need to be placed within an overarching perspective of cultural humility. Overall, improving these various competencies should improve the continuum of care in addiction treatment.

A Mixed-Methods Evaluation of "The Quest," A Health and Well-Being Intervention for British-Based Black, Asian and Minority Ethnic Gay and Bisexual Men

This article provides an evaluation of a health and well-being workshop-based intervention, "The Quest" for gay and bisexual men from British Black Asian and Minority Ethnic (BAME) communities. A quantitative component assessed reported and intended sexual risk, drugs and alcohol use alongside measures of psychological well-being with pre and post-program data collected from 26 men. Fourteen men participated in focus groups that discussed experiences of the intervention. Significant improvements were found on measures of internalized homophobia, self-esteem and self-efficacy but not for health behaviors including safer sex or substance use. Qualitative feedback was generally positive especially around enhanced psychological well-being, identity integration, and enhanced self-awareness. There were some concerns over group size and whether non-BAME gay men were appropriate as facilitators. Theoretically informed, culturally competent interventions can demonstrate significant potential in enhancing the well-being of BAME gay and bisexual men but follow-up data are needed to show longer-term benefits.

Getting Inside the Mind of Gay and Bisexual Men Who Have Sex with Men with Sexualized Drug Use - A Systematic Review

Objectives

Sexualized Drug Use (SDU) consists of using any drug purposely before or during sex with the intent of modifying sex experiences. SDU is especially practiced among Gay and Bisexual Men who have Sex with Men (GBMSM). This study aims to review the relevant literature to identify and summarize the reasons reported by GBMSM to engage in SDU.

Methods

A systematic review of the literature using PubMed/Medline, Scopus, Google Scholar, and PsycINFO, comprising qualitative and quantitative papers published between 2010 and 2022, was conducted with a narrative synthesis of the findings. PRISMA guidelines were followed.

Results

Our search identified 1400 publications, of which 23 were included. Reasons to engage in SDU were aggregated as follows: (1) Enhancing sexual sensations and performance, (2) Achieving hedonic mental and emotional states, (3) Tackling negative thoughts and feelings, and (4) Social motivations. Different sample methods and ways of asking for motivations may limit the internal validity of these conclusions.

Conclusion

Both individual and social factors are involved in the decision to engage in SDU. SDU practices should not be medicalized, however therapeutic support if needed should provide multidisciplinary, pleasure-centered, harm-reducing care interventions, specifically designed for these minorities of GBMSM.

Links Between Childhood Abuse, Insidious Trauma, and Methamphetamine Use Across the Lifespan Among Gay, Bisexual, and Other Men Who Have Sex with Men: A Qualitative Analysis

Developmental and lifespan examinations of methamphetamine use among gay, bisexual, and other men who have sex with men (GBM) remain limited. We used a feminist trauma framework to examine potential links between childhood trauma, trauma-related stressors, and methamphetamine use among GBM. From June 2018 to October 2018, semi-structured interviews (N = 33) were conducted with GBM across British Columbia. Interviews focused on sexual experiences, support services, and methamphetamine use. Using thematic analysis, two overarching trauma-related themes were identified: developmental and insidious trauma and coping with trauma-related stressors. GBM's methamphetamine use co-occurred with childhood experiences of family- and peer-perpetrated heterosexism, childhood sexual abuse, and intersecting forms of oppression/marginalization. These experiences manifested as internalized shame, interpersonal anxiety, and low self-esteem. In adulthood, participants reported difficulty managing emotions, low self-confidence, and loneliness. GBM reported using methamphetamine to manage negative emotions, life stressors, and overcome barriers to interpersonal connection. Findings indicate a need for trauma-informed interventions that address underlying issues and help GBM cultivate supportive relationships.

Predictors of starting and stopping chemsex in men who have sex with men in England: findings from the AURAH2 prospective study

BACKGROUND

Chemsex (the use of psychoactive drugs in sexual contexts) has been associated with HIV acquisition and other STIs, so there is benefit in identifying those most likely to start chemsex to offer risk reduction interventions such as pre-exposure prophylaxis (PrEP). To date, there have been no data from a longitudinal study analysing factors most associated with starting and stopping chemsex.

METHODS

The prospective cohort study, Attitudes to and Understanding Risk of Acquisition of HIV over Time (AURAH2), collected 4 monthly and annual online questionnaire data from men who have sex with men (MSM) from 2015 to 2018. We investigate the association of sociodemographic factors, sexual behaviours and drug use with starting and stopping chemsex among 622 men who completed at least one follow-up questionnaire. Poisson models with generalised estimating equations were used to produce risk ratios (RRs) accounting for multiple starting or stopping episodes from the same individual. Multivariable analysis was adjusted for age group, ethnicity, sexual identity and university education.

FINDINGS

In the multivariable analysis, the under 40 age group was significantly more likely to start chemsex by the next assessment (RR 1.79, 95% CI 1.12 to 2.86). Other factors which showed significant association with starting chemsex were unemployment (RR 2.10, 95% CI 1.02 to 4.35), smoking (RR 2.49, 95% CI 1.63 to 3.79), recent condomless sex (CLS), recent STI and postexposure prophylaxis (PEP) use in the past year (RR 2.10, 95% CI 1.33 to 3.30). Age over 40 (RR 0.71, 95% CI 0.51 to 0.99), CLS, and use of PEP (RR 0.64, 95% CI 0.47 to 0.86) and PrEP (RR 0.47, 95% CI 0.29 to 0.78) were associated with lower likelihood of stopping chemsex by the next assessment.

INTERPRETATION

Knowledge of these results allows us to identify men most likely to start chemsex, thus providing an opportunity for sexual health services to intervene with a package of risk mitigation measures, especially PrEP use.

Disciplined appetites: Reimagining food and nutrition programs for people living with HIV and AIDS

AIMS

Medical nutrition therapy is recommended for people living with HIV/AIDS to improve health and wellness; however, there is a lack of food and nutrition programs for people living with HIV/AIDS in Nova Scotia, Canada. The aim of this study was to explore the beliefs, values, and experiences of people living with HIV/AIDS in relation to food and nutrition programs.

METHODS

A critical social theory lens with two disciplinary contexts: critical health geography and critical dietetics guided this research. Semi-structured interviews were conducted with 12 people living with HIV/AIDS and analysed for themes.

RESULTS

The three main themes were identified: (1) intersections of social determinants of health, wellness, and food security; (2) discursive shaping of food and nutrition in relation to HIV; and (3) the dynamic nature of HIV care.

CONCLUSIONS

Participants offered recommendations on how food and nutrition programs might be reimagined to be more accessible, inclusive, and effective for people living with HIV/AIDS.

Strong Ethnic Identity Buffers the Association of Heterosexism with Substance Use Among Black Sexual Minority Men

INTRODUCTION

Heterosexist stigma, including microaggressions experienced in their own racial/ethnic communities, may partially explain disproportionate levels of substance use involvement among Black sexual minority men (BSMM). A strong sense of ethnic identity may provide BSMM with a protective resource. The purpose of this study was to explore associations between ethnic identity and substance use in BSMM.

METHODS

Data were from Black sexual minority men (n = 390 Mage = 25.28; SD = 2.81) in the PrEP and Substance Use National Survey collected from March 2020 to August 2020 that included self-reported cannabis, cocaine, methamphetamines, inhalants, hallucinogens, prescription drugs misuse, and overall substance use involvement. Using zero-inflated negative binomial regression, we assessed the association between heterosexist microaggressions within BSMM's racial/ethnic communities and substance use involvement, moderated by subjective sense of ethnic identity.

RESULTS

More than half of participants reported past 3-month substance use. Heterosexist microaggressions were associated with higher relative risk of cannabis use involvement (RR = 1.76; 95% CI 1.13-2.73) and overall substance use involvement (RR = 2.23; 95% CI 1.39-3.56). Stronger ethnic identity buffered the association of heterosexism on substance use involvement (cannabis: RR = 0.82; 95% CI 0.72-0.95; overall: RR = 0.77; 95% CI 0.66-0.89).

CONCLUSION

Nurturing ethnic identity development and reducing heterosexist stigma in Black communities may be a culturally responsive, two-pronged approach to reducing substance use involvement among BSMM. BSMM with strong ethnic identity demonstrated resilience to heterosexist stigma. Future research should examine the extent to which ethnic identity may be cultivated as a protective resource against substance use involvement.

Causal Influences of Same-Sex Attraction on Psychological Distress and Risky Sexual Behaviors: Evidence for Bidirectional Effects

Although health disparities among same-sex attracted compared to heterosexual individuals are typically explained by minority stress, there is limited evidence for a causal effect. This study investigated whether same-sex attraction was causally associated with psychological distress and risky sexual behavior using sociosexual behavior as a proxy. The sample comprised monozygotic and dizygotic twins and their non-twin siblings (n = 2036, 3780 and 2356, respectively) genotyped and assessed for same-sex attraction, psychological distress (anxiety and depressive symptoms), and risky sexual behavior. Causal influences were investigated with same-sex attraction as the predictor and psychological distress and risky sexual behavior as the outcomes in two separate Mendelian Randomization-Direction of Causation (MRDoC) models using OpenMx in R. The MRDoC model improves on the Mendelian Randomization and Direction of Causation twin models by allowing analyses of variables with similar genetic architectures, incorporating polygenic scores as instrumental variables and specifying pleiotropy and residual covariance. There were significant causal influences flowing from same-sex attraction to psychological distress and risky sexual behavior (standardized coefficients = 0.13 and 0.16; 95% CIs 0.03-0.23 and 0.08-0.25, respectively). Further analyses also demonstrated causal influences flowing from psychological distress and risky sexual behavior toward same-sex attraction. Causal influences from same-sex attraction to psychological distress and risky sexual behavior may reflect minority stress, which reinforces ongoing measures to minimize social disparities. Causal influences flowing in the opposite direction may reflect rejection sensitivity, stigma-inducing outcomes of risky sexual behavior, and recall bias; however, further research is required to specifically investigate these processes.

Patterns of Event-Level Concurrent Substance Use During Sex Among Gay, Bisexual, and Other Men Who Have Sex with Men in Metro Vancouver

This study identified patterns of sexualized substance use among gay, bisexual, and other men who have sex with men (gbMSM) and examined associated risk factors for sexually transmitted and blood borne infections (STBBI). Data were from a longitudinal cohort recruited using respondent-driven sampling between Feb-2017 and Feb-2019. Participants reported on events with up to five of their most recent sexual partners. Latent class analysis examined patterns of concurrent substance use 2 h prior to or during sex. Multinomial regression identified demographic, partner-level, and event-level factors associated across 11,877 sexual events reported by 757 participants. Most combinations of substance use were rare, but most drugs were frequently combined with other drugs when they were used prior to or during a sexual event. Six latent classes of concurrent event-level substance use were identified. The referent class (58.8% of events) was characterized by limited use of any drugs. The Common Drug Use class (12.1%) was characterized by use of alcohol, cannabis, and poppers and the Licit Drug Use class (21.6%) was characterized by use of alcohol alone. The Party 'N' Play (PnP) class (2.3%) was characterized by use of crystal methamphetamine GHB, Poppers, and Erectile Drugs; The Multi-use (3.5%) class was characterized by the PnP substances plus alcohol and ecstasy; and the Cannabis + class was characterized by use of Cannabis, Erectile Drugs, and Ecstasy. Relative to the referent class, all other classes were associated with events with more behavioural and network risk factors for STBBIs-highlighting the need for harm reduction interventions for gbMSM who use these drugs.

L’approche syndémique appliquée à la santé des minorités sexuelles et de genre : étude de la portée

INTRODUCTION

Sexual and gender minorities (SGM) represent a vulnerable population, disproportionately affected by mental health issues, a higher exposure to violence and a higher prevalence of sexually transmitted infections, including HIV, for some subgroups. Derived from medical anthropology, the concept of a syndemic consists in the clustering and interaction between multiple health conditions through adverse social conditions such as discrimination or precarity. Confronted to the multitude of adverse conditions affecting SGM, this framework is pertinent to study their health and to propose interventions.

PURPOSE OF RESEARCH

The purpose of this scoping review is to synthetize the knowledge regarding syndemic theory applied to sexual and gender minorities in order to propose concrete suggestions for scholarly research and field intervention.

RESULTS

126 papers were included. European data as well as data concerning sexual minority women and transgender men are scarce. A co-occurrence of psychosocial conditions fostered by stigmatization is well-established. Furthermore, the presence of a syndemic was associated to sexual higher odds of acquiring HIV, suicidal behavior and healthcare utilization.

CONCLUSIONS

The syndemic framework is important to the health of SGM, both for academic and interventional purposes. Current priorities should be to act against structural disadvantages leading to a syndemic, to improve our knowledge on SGM health in European context and to develop local programs based on peer-support.

Health characteristics associated with chemsex among men who have sex with men: Results from a cross-sectional clinic survey in Norway

BACKGROUND

Chemsex typically involves drugs such as GHB/GBL, crystal meth and mephedrone, and is increasingly common among MSM. The behaviour has been found to be associated with sexually transmitted infections (STIs) and mental health problems. We aimed to assess the extent of chemsex engagement and associations with different aspects of health, among MSM attending a free specialist walk-in clinic for STIs in Oslo, Norway.

METHODS

Anonymous cross-sectional survey data was collected from June to October 2016. Differences in STI health (chlamydia, gonorrhoea, syphilis, HIV diagnoses), mental health (depression/anxiety) and internalised homonegativity between MSM using and not using GHB/GBL, crystal meth, mephedrone, cocaine or ketamine with sex in the last year were assessed descriptively and in a multivariate logistic regression model. The predictors were number of self-reported chlamydia, gonorrhoea or syphilis diagnoses, HIV diagnosis, depression/anxiety, and degree of internalised homonegativity. We adjusted for age, education level and having lived abroad.

RESULTS

Of the 518 MSM respondents, 17% reported sexualised use of either GHB/GBL, crystal meth, mephedrone, cocaine or ketamine in the last year (chemsex). We found significant positive associations between chemsex and self-reported HIV diagnoses (adjusted odds ratio [aOR] = 3.26, 95%CI = 1.37-7.76), number of reported chlamydia, gonorrhoea or syphilis diagnoses in the last year (aOR = 1.63, 95%CI = 1.18-2.12), having lived more than one year abroad (aOR = 2.10, 95%CI = 1.20-3.65), but no significant association with depression/anxiety (aOR = 1.02, 95%CI = 0.53-1.93), nor internalised homonegativity (aOR = 0.62, 95%CI = 0.33-1.19).

CONCLUSION

Chemsex engagement in Norway is relatively low compared to findings from STI clinics in other European countries, and GHB/GBL and cocaine the two most commonly used drugs with sex. Chemsex was more common among MSM having lived more than one year abroad, reporting HIV diagnoses and a higher number of either chlamydia, gonorrhoea or syphilis diagnoses in the last year. Health care providers need to be made aware of chemsex as a behavioural phenomenon among MSM, and special care should be afforded to MSM living with HIV and being diagnosed with STIs.

Chemsex, Identity and Sexual Health among Gay and Bisexual Men

This article focuses on some of the social, cultural and psychological aspects of drug use in sexualized settings in gay and bisexual men (referred to as "chemsex"). Using a narrative review approach, the article examines previous empirical research in this area and presents a novel theoretical approach for understanding and predicting chemsex behavior. Tenets of identity process theory from social psychology are drawn upon to offer an integrative theoretical framework within which the social, cultural and psychological underpinnings of chemsex can be collectively examined. Existing empirical research suggests that gay and bisexual men may experience sexuality-related stressors that can undermine feelings of self-esteem, self-efficacy, continuity and positive distinctiveness. Identity process theory examines how individuals react to threats to identity brought about by these stressors. In response to identity threat, gay and bisexual men may engage in chemsex as a coping response that encompasses and facilitates various, largely maladaptive, coping strategies and tactics. The more chemsex is perceived as enhancing identity processes and as averting identity threat, the more central it is likely to be to the identities of participants. The centrality of chemsex to one's identity may preclude self-withdrawal from the practice. Several directions for future research are presented based on existing work on chemsex viewed through the lens of identity process theory. These should form the basis of future empirical research in the sphere of sexual health among gay and bisexual men and the outcomes of this research should inform policy and practice in this area.

Mapping the current knowledge in syndemic research applied to men who have sex with men: A scoping review

Men who have sex with Men (MSM) represent a population affected by numerous health conditions. Syndemic theory has been used as a framework to study the health of MSM for nearly 20 years. However, the literature is plagued by a lack of consensus regarding what constitutes a synergy in a syndemic and recent reviews have shown that most of the papers published thus far have failed to demonstrate a synergy nor describe the bio-social interaction needed to account for a true syndemic. Moreover, to our knowledge, none of the existing reviews have focused specifically on MSM. This scoping review aims to fill this gap by mapping in detail how syndemic research on MSM has been conducted. A systematic database search was conducted between 2020 and 2021 and 115 studies were included. Our findings showed a lack of diversity regarding the location, design, subpopulation, and outcomes studied. In addition, the syndemic conditions, as well as their measurement, were not focused enough to ensure the robustness and reproducibility of the findings. Furthermore, our results support previous reviews showing a lack of empirical data to support disease interaction in syndemic research applied to MSM. Our review offers some important recommendations to help move the field forward in future work and describes some promising methodological advances.

Chemsex users in Czechia: EMIS survey

OBJECTIVES

Chemsex is a phenomenon highly relevant to public health concerns. Our primary aim is to describe the Czech chemsex scene regarding substances used, sexual behaviour, mental health, sexual life satisfaction, internalization of homonegative attitudes, and prevalent chemsex patterns.

METHODS

The data from the European Men Who Have Sex With Men Internet Survey (EMIS) 2017 were used. The mental health of chemsex users was assessed by the Patient Health Questionnaire 4 (PHQ4), internalized homonegativity was measured using the Short Internalized Homonegativity Scale. A sample of 87 men who have sex with men (MSM) chemsex users and a comparison group of 261 MSM were selected from the total sample of 1,688 respondents. Mann-Whitney and χ² tests were used to compare groups.

RESULTS

Active chemsex users made up 5% of the sample (87 of 1,688), with an average age of 37 years. Chemsex users were more likely to engage in condomless sex with non-steady partners (χ² = 46.8, p < 0.001), and had dramatically more STIs, such as HIV (χ² = 52.9, p < 0.001), HCV (χ² = 25.9, p < 0.001), and syphilis (χ² = 41.5, p < 0.001). Chemsex users frequently injected drugs (n = 19, 20%). More than half (n = 48; 55%) of chemsex users had sober sex in the last 4 weeks. Chemsex culture was associated with riskier substance use, both in terms of mode and frequency. The mental health of chemsex users in our sample did not differ significantly from the comparison group (χ² = 0.2, p < 0.7). Chemsex users did not conceal their sexual identity more often than the comparison group, on the contrary, 69% (n = 59) of them were out to most significant others, compared to 53% (n = 134) in the comparison group (χ² = 8.8, p < 0.05). In addition, we did not find differences in the degree of internalized homonegativity (χ² = 0.9, p < 0.4). Chemsex users were clearly and significantly more satisfied with their sex life than the comparison group (Mann-Whitney U test, p < 0.001).

CONCLUSIONS

In our sample, chemsex use was not associated with a negative impact on health or wellbeing. Our results suggest that chemsex is not a homogeneous phenomenon. Many different patterns and subcultures exist, some of them are riskier, some safer than others.

Information-seeking behaviours in Australian sexual minority men engaged in chemsex

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Participants engaged in chemsex over long periods of time and on a regular basis.

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Most know where to seek professional help and access harm reduction information.

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Many worry about being judged by health professionals and few seek out assistance.

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Participants feel uncomfortable discussing chemsex with most health professionals.

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Information from sexual health professionals is trusted the most.

Introduction

Chemsex refers to using illicit substances to facilitate sexual experiences in men who have sex with men. Chemsex has been linked to significant negative impacts on psychological, social, and physical wellbeing. Little is known about information-seeking behaviours in this population. This study aims to provide an in-depth understanding of seeking and engaging with health information.

Methods

Self-identified Australian sexual minority men who engage in chemsex (N = 184) participated in an anonymous cross-sectional survey. Variables included chemsex engagement, knowledge, perception and use of harm-reduction information, and associated health and support services. Pearson correlation and ANOVAs were conducted. Wilcoxon-Signed-Rank and Friedman tests were applied to analyse the perceived trustworthiness of information sources.

Results

Chemsex represented a meaningful part of sexual events. Most participants knew where to access professional help and harm-reduction information but worried about being judged. Most did not feel comfortable discussing chemsex with health professionals except with sexual health doctors/counsellors. Few users discussed health risks with a professional. Information on chemsex was received through multiple sources with significant differences in perceived relevance and trustworthiness, with sexual health doctors/nurses ranked the most trustworthy information. Interest in non-traditional sources of information was low except for formal peer networks and anonymous personal expert advice.

Conclusion

Engagement with health professionals and harm-reduction information is limited in this population, despite high risk and potentially significant adverse health outcomes. Results suggest that new and combined approaches are necessary to reach this population, including peer support networks, anonymous personal advice and changing community attitudes towards chemsex.

Substance Use and Chemsex in MSM - A Latent Class Analysis

Engagement in “chemsex” among men who have sex with men is associated with higher rates of STIs and HIV seroconversion as well as an increased mental health burden. MSM were recruited for an anonymous online survey. The survey included questions of substance use, consumption motives, sexual risk behavior, HIV serostatus, and psychological characteristics. A latent class analysis was used to identify subgroups based on the consumed substances. 597 MSM answered the questionnaire. The latent class analysis revealed four different clusters. Most men described the use of amyl nitrite and cannabis ( n = 370). One cluster consumed mainly MDMA, cocaine, and amphetamine ( n = 106) and another cluster used mainly chemsex-related drugs ( n = 43). A fourth cluster reported a range of consumed substances ( n = 78). This cluster reported higher rates of suicide attempts, STIs, and risk behaviors. Substances typically related to chemsex were consumed in a sexualized context to a relevant extent.

Sexual Exposure to HIV Infection during the COVID-19 Pandemic in Men Who Have Sex with Men (MSM): A Multicentric Study

The practice of sex with casual partners without the use of adequate prevention in the period of social distancing due to the COVID-19 pandemic among men who have sex with men (MSM) can expose them to the risk of infection by the HIV virus. To assess this, we conducted an online survey in April and May 2020 in the entire national territory of Brazil and Portugal. We used the snowball technique for sampling, associated with circulation in social networks, totaling 2934 participants. Bivariate and multivariate logistic regression was used to produce the adjusted Odds Ratio (aOR). Eight-hundred-and-forty-two (28.7%) MSM presented at-risk sexual exposure in this period. In general, the types of sexual practices that most increased the chances of sexual exposure were having multiple partners (aOR:14.045); having practiced chemsex (aOR:2.246) and group sex (aOR:2.431), as well as presenting a history of at-risk sexual exposure (aOR:5.136). When we consider each country separately, the chances are increased in Brazil since the probability of the outcome was increased in those who practiced group sex (aOR:5.928), had multiple partners (aOR:19.132), and reported a sexual history of at-risk exposure (aOR:8.861). Our findings indicate that practices that are classically associated with greater chances of engaging in risky sexual exposure to HIV infection were the factors that most increased the chances of acquiring the virus in the pandemic context.

The sexualised use of cannabis among young sexual minority men: "I'm actually enjoying this for the first time"

The objective of this study was to identify how cannabis use features within the sexual lives of young sexual minority men who use substances, and how this might intersect with features of their contemporary socio-cultural contexts in a setting where non-medical cannabis was recently legalised: Vancouver, Canada. Forty-one sexual minority men ages 15 to 30 years were recruited between January and December 2018 to participate in in-depth, semi-structured 1-2 h interviews about their experiences of using substances (e.g. cannabis) for sex. Drawing on constant comparative analytic techniques, two themes emerged with regards to participants' perceptions of, and experiences with, the sexualised use of cannabis. First, participants described how they used cannabis for sex to increase sexual pleasure and lower inhibitions. Second, participants described using cannabis for sex to reduce feelings of anxiety and shame, and foster intimacy and connection with sexual partners. These findings identify how the sexualised use of cannabis functions as a 'strategic resource' for sexual minority men to deliberately achieve both physiological and psychoactive effects, while concurrently underscoring the extent to which the contexts, patterns and motivations associated with cannabis use for sex parallel those associated with this form of Chemsex.

Ecological and Syndemic Predictors of Drug Use During Sex and Transactional Sex among U.S. Black Men Who Have Sex with Men: A Secondary Data Analysis from the HPTN 061 Study

Threats to sexual health among U.S. Black men who have sex with men (MSM) may manifest in a context of social adverse experiences. Situational sex is one such context, which we characterize as sexual behaviors driven either by a desire to cultivate a specific sexual experience or attributable to social vulnerability. Two characterizations of situational sex explored in this study were drug use during sex and transactional sex. Guided by ecological and syndemic frameworks, we conducted a secondary data analysis of social conditions and sexual behaviors among a prospective cohort of Black MSM from the HIV Prevention Trial Network (HPTN) 061 study. Using structural equation modeling, this analysis examined the indirect effect of syndemic factors (substance use, depression, violence exposure) in the relationship between ecological constructs (anti-Black/homophobic stigma, childhood violence, and economic vulnerability) and situational sex (drug use during sex, transactional sex). Model fit indices, CFI (.870) and SRMR (.091), demonstrated reasonable fit. Significant indirect effects emerged via substance use for economic vulnerability (indirect effect = .181, 95% CI [.078, .294]) and anti-Black/homophobic violence and stigma (indirect effect = .061, 95% CI [.008, .121]) on drug use during sex; as well as on transactional sex (economic vulnerability indirect effect = .059, 95% CI [.018, .121] and anti-Black/homophobic stigma and violence indirect effect = .020, 95% CI [.003, .051]). Findings implicate the need for social and fiscal intervention to address upstream, ecological, and syndemic factors that influence inherent vulnerability of situational sex and overall threats to sexual health among Black MSM.

Sex, drugs and techno - a qualitative study on finding the balance between risk, safety and pleasure among men who have sex with men engaging in recreational and sexualised drug use

BACKGROUND

Recreational and sexual drug use among men who have sex with men may result in increased risk of poor health. The aim of this study was to better understand drug use and harm reduction techniques among Swedish men who have sex with men traveling to Berlin in order to improve the health of this population and inform public health strategies.

METHODS

A qualitative study based on semi-structured interviews with 15 Swedish men aged 23-44 with experience of drug use were recruited through network sampling. Interviews were conducted in Stockholm and Berlin and analysed using content analysis. The interview guide included questions on drug use, context, health and safety.

RESULTS

The participants engaged in drug use in both settings and in various contexts. Participants saw themselves as capable of finding a balance between pleasure, safety and risk with the aim to maximize positive effects while minimizing negative ones. The different risks of drug use were known, and participants relied on knowledge, harm reduction strategies and self-defined rules of intake to stay safe and healthy in a broad sense, both short term (i.e. during each session) and long term. Choice of drug and, frequency of intake, multi-use, risk of overdose, risk of HIV, purpose and context of use, how often, etc. were all part of the overall strategy. Knowledge of these methods was spread within the community and on-line rather than from counsellors or other health care providers. However, it did not always translate perfectly into practice and some had experienced overdoses and problematic use.

CONCLUSIONS

The findings of this study point to the need for increased adoption of harm reduction techniques in this population focusing on mitigating harm and prevention of risk of problematic use or starting injection drugs. Existing traditional services require adaptations to become more accessible and acceptable to sub-groups of drug users, including low-threshold services providing non-judgemental, evidence-based information. This will require funding of alternative providers such as STI/HIV clinics, among others, and health care providers to increase adoption of prevention strategies, specifically pre-exposure prophylaxis for HIV.

Chemsex Practices and Health-Related Quality of Life in Spanish Men with HIV Who Have Sex with Men

Chemsex, a new risky sexual behavior involving participation in sexual relations under the influence of drugs, has shown a significantly increased prevalence in recent years. This fact entails a serious public health issue, especially when Chemsex is practiced by individuals with an HIV (Human Immunodeficiency Virus) diagnosis. Hence, analyzing the characteristics of Chemsex practices, associated sexual practices and the health outcomes of individuals who participate in Chemsex, is extremely important. The main aim of the present study is to analyze the prevalence and characteristics of the practice of Chemsex in a sample of 101 men with HIV who have sex with men who attended the Department of Infectious Diseases of the General University Hospital of Alicante (Spain). Furthermore, the association between Chemsex and Health-Related Quality of Life (HRQoL) was also assessed. Chemsex and sexual practices were evaluated by employing a questionnaire applied on an ad hoc basis. HRQoL was assessed by employing the Medical Outcomes Study HIV Health Survey (MOS-HIV). In total, 40.6% of the participants had practiced Chemsex during the last year. When sexual practices were compared between those individuals who practiced Chemsex and those who did not, the former presented a higher level of risky sexual behaviors, especially with occasional and multiple sexual partners. Regarding HRQoL, those individuals who practiced Chemsex exhibited a poorer HRQoL in the majority of domains, especially those participants who practiced it with a higher intensity. The present study points out the high prevalence of Chemsex practice between men with HIV who have sex with men in Spain. Moreover, this study highlights the negative effects of Chemsex on HRQoL, probably due to the mixed effects of higher levels of risky sexual practices and the consequences of drug consumption.

Chemsex, identity processes and coping among gay and bisexual men

Purpose

Chemsex constitutes a significant public health concern among gay and bisexual men (GBM). Using the identity process theory, this study focuses on GBM’s motivations for engaging in chemsex and the functions that the practice performs for constructing a positive sense of self and for coping with psychological stress.

Design/methodology/approach

Sixteen GBM were interviewed, and the qualitative data were analyzed using thematic analysis.

Findings

Individuals reported facing various stressors, such as homonegativity, rejection and HIV stigma, which were threatening for self-esteem and distinctiveness. There was habitual use of deflection (e.g. denial and self-concealment) for coping with these stressors. Chemsex enabled some interviewees to engage in more elaborate forms of deflection, such as transient depersonalization, compartmentalization and fantasy.

Originality/value

In contrast to the risk-focused analyses of chemsex, this study provides a novel identity-based approach to understanding GBM’s motivations for engaging in chemsex and focuses on the functions that chemsex may perform for identity processes.

Priorities and practices of risk reduction among gay and bisexual men in Australia who use crystal methamphetamine for sex

Crystal methamphetamine (hereafter crystal) is associated with deleterious health outcomes, such as drug dependence and physical and mental health disorders. While some harms from crystal use can affect all users, there may be additional risks for people who combine the use of drug with sex. Compared with the broader population, gay and bisexual men in Australia report a higher prevalence of methamphetamine use, and crystal is the most commonly injected illicit drug among this population. The Crystal, Pleasures and Sex between Men research project was conducted between 2017 and 2019 and examined gay and bisexual men's crystal use in four capital cities in Australia, with the aim of identifying how to best support men who use crystal for sex. In this article, we examine how risk is understood and prioritised by gay and bisexual men who combine crystal use and sex and identify the range of risk reduction practices that they used. We classified these risks as those associated with the transmission of HIV, HCV and STIs, and those associated with dependence on either crystal or the sex it facilitated. Gay and bisexual men overwhelmingly prioritised the risk of dependence over any other risks associated with crystal-enhanced sex, and this prioritization was reflected in the risk reduction practices they employed. While some of the strategies that gay and bisexual men have adopted may contradict anticipated public health principles, they derive from a carefully considered and shared approaches to the generation of pleasure, the maintenance of a controlled form of feeling "out of control", and the negotiated reduction of risk. The consolidation of these strategies effectively constitutes a "counterpublic health" underpinned by forms of "sex-based sociality", which gives primacy to the priorities and practices of gay and bisexual men in Australia who combine crystal and sex.

Psychological and Interpersonal Factors Associated with Sexualized Drug Use Among Men Who Have Sex with Men: A Mixed-Methods Systematic Review

Chemsex-the use of specific drugs during planned sexual activity to sustain or enhance sexual functioning (Bourne et al., 2015)-is widely reported as a major public health issue among gay, bisexual, and other men who have sex with men (GBM) in Western countries. Considering current evidence surrounding Chemsex, we conducted a mixed-methods systematic review regarding psychological and interpersonal factors associated with Chemsex behaviors among GBM. Publications covering Chemsex and psychological or social variables were eligible. Theoretical papers and studies solely presenting physical health outcomes were excluded. 35 English papers published between January 2008 and June 2019 were identified through PubMed, Scopus, and PsycINFO. We performed a parallel-results convergent synthesis (Hong, Pluye, Bujold, & Wassef, 2017) on results extracted from qualitative and quantitative studies comprising the final corpus. Qualitative data suggest that six mechanisms promote Chemsex-related behaviors: dealing with painful emotions or stressful events; normalization and risk minimization of sexualized drug use; giving into interpersonal pressure or fulfilling desire for community belonging; increasing intimacy or connectedness; enhancing sexual performance and functioning; lessening interpersonal and sexual inhibitions. In quantitative reports, six variable categories emerged: sexual control and self-efficacy; sexual functioning; mental health; attitudes toward substance use; life stressors and internalized stressors; and identification with sexual identities or scenes. This review summarizes key psychological and interpersonal correlates of Chemsex among GBM. Further research is needed to replicate current findings and explore new hypotheses across multiple GBM sociodemographic groups and cultural contexts, following best practices in sampling for hard-to-reach populations.

The Effects of Methamphetamine Use on the Sexual Lives of Gender and Sexually Diverse People in Dhaka, Bangladesh: A Qualitative Study

Methamphetamine use has increased among gender and sexually diverse people in several countries, including Bangladesh. This study aimed to explore the effects of methamphetamine on the sexual lives of these people in Dhaka, Bangladesh. An exploratory qualitative study was conducted, comprising 30 in-depth interviews with gender and sexually diverse people including males having sex with males, male sex workers, and transgender women (hijra) under HIV intervention coverage. Ten key informant interviews were also conducted with individuals who have expertise in relevant disciplines such as drug use, harm reduction, and HIV and AIDS. Digitally recorded data were manually analyzed under the thematic analysis framework. Findings indicated that many participants reported that methamphetamine brought changes in their sexual lives such as increased sexual drive, engagement in group sex, the increased ability to perform serial sex, transactional sex, impulsive and coercive sex, initiation and switching of male-to-male sexual practices, and limited condom use. Key informants noted that there is a dearth of methamphetamine-related services in Bangladesh. Methamphetamine use was found to lead to diverse effects on the sexual lives of gender and sexually diverse people, thus making it a driving force for shaping sexual practices and, hence, sexual risks. Therefore, it is essential for policy-level stakeholders and program managers to consider the risks of methamphetamine use due to their negative ramifications on sexual health, including HIV risks.

Service provision and barriers to care for men who have sex with men engaging in chemsex and sexualised drug use in England

BACKGROUND

Chemsex and sexualised drug use (SDU) among men who have sex with men (MSM) has become a public health issue because of its associated sexual risks. Some MSM engaging in SDU require further help and support, but it is not clear if this need is being met. This research seeks to understand MSM and service provider (SP) perspectives of the current standard of service provision for MSM engaging in SDU.

METHOD

Semi-structured interviews were conducted with 13 MSM and 16 SPs in England (January-December 2019). MSM who reported taking one of ten substances for sex in the past 12 months were recruited from a mailing list or a community organisation providing chemsex support. Potential SP participants were recruited via an email sent from their local healthcare NHS Trust. Data for MSM and SPs were analysed separately using thematic analysis.

RESULTS

MSM participants had a median age of 34 years (range 23-66).The majority of SPs recruited were genitourinary medicine (GUM) consultants. We found that the main reason for engagement in SDU was because of the enhanced sexual experience. Most MSM recruited were satisfied with their sexual health service provision, but barriers to care were highlighted by both MSM and SPs. Four themes relating to barriers to care were identified: accessibility of sexual health services, funding of services, SP's attitudes towards MSM who engage in SDU, and services outside sexual healthcare.

CONCLUSION

SPs appeared to have adopted a harm reduction approach to MSM engaging in SDU, but for MSM wanting further help and assistance in relation to their SDU additional barriers to care existed. Training healthcare providers outside of sexual health services regarding chemsex and SDU may reduce some of these barriers, but funding for sexual health services needs to be improved to maintain and further develop services.

Conceptualizing LGBT Stigma and Associated HIV Vulnerabilities Among LGBT Persons in Lesotho

Social marginalization harms lesbian, gay, bisexual, and transgender (LGBT) persons’ wellbeing in Lesotho. Socio-cultural mechanisms linking LGBT stigma, depression, substance use, and HIV among LGBT persons in Lesotho are understudied. We explore associations between LGBT stigma, mental health stressors, and HIV vulnerabilities among LGBT persons in Lesotho. We conducted in-depth, semi-structured interviews with 46 LGBT persons and six key informants (e.g. healthcare providers). Participants described depression, substance use, and HIV as mutually reinforcing and situated in larger social contexts of stigma. Alcohol use was a stigma coping strategy and a way to build LGBT connections. At the same time, alcohol use elevated HIV vulnerabilities by lowering condom use uptake. Pervasive stigma reinforced barriers to healthcare engagement. Community-led support and services were leveraged to navigate stigma, reduce HIV vulnerabilities, and ultimately improve health. Findings emphasize the key role contexts play in shaping sexual and mental health among LGBT persons in Lesotho.

Links between chemsex and reduced mental health among Norwegian MSM and other men: results from a cross-sectional clinic survey

BACKGROUND

The use of specific drugs to facilitate, enhance or prolong sexual sessions is referred to as 'chemsex'. The popularity of the behavior seems to be growing, but there is a paucity of information on the mental health aspects associated with chemsex and no data on chemsex from Nordic countries. We investigated the link between chemsex and mental health among men who have sex with men (MSM) and other men in Norway.

METHODS

We recruited participants from a walk-in sexually transmitted infections (STI) clinic. Participants completed a piloted, anonymous self-administered survey. It consisted of questions about men's sociodemographic characteristics, mental health, sexual behaviors, substance use, and chemsex. The outcome we investigated was reduced mental health, measured with the validated Hopkins Symptom Check List. We obtained descriptive statistics and performed univariate and multivariate logistic regression analyses.

RESULTS

1013 (96%) of the surveys were complete and could be analysed. The mean age of the sample was 33, 51% were MSM, and 21.7% had reduced mental health. More MSM than other men engaged in chemsex in the past year (17% vs 12%). The most frequently reported chemsex drugs were cocaine and gamma hydroxybutyrate/gamma butyrolactone (GHB/GBL). Men engaged in chemsex primarily to enhance sexual pleasure and excitement, and about half reported almost never or never using condoms for chemsex. In univariate analyses, significant predictors of reduced mental health was chemsex (Odds Ratio [OR] = 1.82), being unemployed (OR = 3.54), and having sex with only women (OR = 0.58). In multivariate analyses, two variables remained significantly associated with reduced mental health: chemsex (adjusted OR = 2.18, 95%CI = 1.25-3.78) and being unemployed (adjusted OR = 4.10, 95%CI = 2.13-7.87).

CONCLUSIONS

In our sample of men from an STI clinic in Norway, about 14% self-reported engaging in chemsex in the past year and about a fifth of the men had reduced mental health. Men who engaged in chemsex, which more MSM engaged in than other men, had two times greater odds of reduced mental health. These findings suggest that mental health assistance should be among the interventions offered to men engaging in chemsex.

Cannabis use and mental health among young sexual and gender minority men: A qualitative study

Despite a growing body of evidence demonstrating that cannabis use is associated with mental illness among sexual and gender minority (SGM) men, little is known about the motivations, patterns and contexts that influence this relationship. Our study aimed to characterize how cannabis use features within the mental health-related experiences of young SGM men in Vancouver, Canada. From January to December 2018, semi-structured interviews were conducted with 50 SGM men ages 15 to 30 years to explore their experiences using cannabis. We draw on thematic analysis to reveal three themes regarding participants' experiences with cannabis use and mental health. First, participants experiences emphasized the interconnectedness of cannabis use, sexual, and mental health, including using cannabis to: (i) cope with mental health symptoms during sexual encounters (e.g., anxiety, sexual trauma-related stress); and (ii) substitute or replace other substances (e.g., crystal methamphetamine, MDMA) to reduce drug-related harms in Chemsex practices (e.g., decreased ability to consent, drug-induced psychosis). Second, participants discussed the instrumental use of cannabis to alleviate and address symptoms of mental health (e.g., depression, post-traumatic experiences). Third, participants described adverse effects of cannabis use on their mental health, including feelings of paranoia that they associated with cannabis use, as well as concerns around developing cannabis dependence. Our findings reveal important implications for public health policy on how cannabis can be used to manage experiences of mental health among young SGM men, while also highlighting the need to develop harm reduction services for those who may experience mental health-related harms.

Syndemic latent transition analysis in the HPTN 061 cohort: Prospective interactions between trauma, mental health, social support, and substance use

BACKGROUND

Substance use among Black sexual minority men (BSMM) is a significant public health focus of prevention interventions due to its association with sexual risk behaviors and transmission of HIV. Traumatic experiences and mental health challenges may interact to create a syndemic associated with substance use in this population; this may be moderated by social support however.

METHODS

Using a multicenter prospective cohort of 1068 BSMM, we conducted a longitudinal syndemic latent transition analysis testing whether baseline and 6-month race and sexuality-targeted violence, intimate partner violence, other traumatic experiences, depression, and internalized homophobia was associated with 12-month substance use. We also tested if social support modified this and was associated with transitions between statuses.

RESULTS

Our analysis identified four statuses: A "low-risk" status characterized by the lowest proportions of syndemic factors, and 3 "high-risk" statuses, characterized by higher proportions of syndemic factors. All three high-risk statuses were associated with higher substance use than the low-risk status, with the greatest association observed with "high-risk status C" (aRR = 4.54, 95 % CI 1.98, 10.40). Social support attenuated this association (Interaction aRR = 0.21, 95 % CI 0.05, 0.85) and was associated with lower transition rates from low to high-risk status 6 months later (Transition ratio = 0.45, 95 % CI 0.29, 0.69).

CONCLUSIONS

Our findings identified a syndemic of trauma, depression, and homophobia among BSMM associated with substance use, but attenuated by social support. Future research into the role of social support and resiliency in substance use prevention and recovery is recommended.

Attitude and beliefs about the social environment associated with chemsex among MSM visiting STI clinics in the Netherlands: An observational study

BACKGROUND

Drug use during sex, 'chemsex', is common among men who have sex with men (MSM) and related to sexual and mental health harms. This study assessed associations between chemsex and a wide range of determinants among MSM visiting STI clinics to increase understanding of characteristics and beliefs of MSM practicing chemsex.

METHODS

In 2018, 785 MSM were recruited at nine Dutch STI clinics; 368 (47%) fully completed the online questionnaire. All participants reported to have had sex in the past six months. Chemsex was defined as using cocaine, crystal meth, designer drugs, GHB/GBL, ketamine, speed or XTC/MDMA during sex in the past six months. Associations between chemsex and psychosocial determinants, socio-demographics, sexual behaviour and using tobacco or alcohol were assessed by multivariable logistic regression analyses.

RESULTS

Chemsex was reported by 44% of MSM (161/368) and was not associated with socio-demographics. Independent determinants were 'believing that the majority of friends/sex partners use drugs during sex' (descriptive norm) (aOR: 1.95, 95%CI: 1.43-2.65), 'believing that sex is more fun when using drugs' (attitude) (aOR: 2.06, 95%CI: 1.50-2.84), using tobacco (aOR: 2.65, 95%CI: 1.32-5.32), multiple sex partners (aOR: 2.69, 95%CI: 1.21-6.00), group sex (aOR: 4.65, 95%CI: 1.54-14.05) and using online dating platforms (aOR: 2.73, 95%CI: 1.13-6.62).

CONCLUSION

MSM are likely to find themselves in distinct social networks where it is the norm to use drugs when having sex and pleasure is linked to chemsex. Health services should acknowledge the social influence and pleasurable experiences to increase acceptability of strategies aimed at minimizing the possible harms of chemsex.

Using syndemic theory to understand food insecurity and diet-related chronic diseases

Syndemic Theory (ST) provides a framework to examine mutually enhancing diseases/health issues under conditions of social inequality and inequity. ST has been used in multiple disciplines to address interacting infectious diseases, noncommunicable diseases, and mental health conditions. The theory has been critiqued for its inability to measure disease interactions and their individual and combined health outcomes. This article reviews literature that strongly suggests a syndemic between food insecurity (FI) and diet-related chronic diseases (DRCDs), and proposes a model to measure the extent of such interaction. The article seeks to: (1) examine the potential syndemic between FI and DRCDs; (2) illustrate how the incorporation of Life History Theory (LHT), into a syndemic framework can help to highlight critical lifeperiods when FI-DRCD interactions result in adverse health outcomes; (3) discuss the use of mixed methods to identify and measure syndemics to enhance the precision and predictive power of ST; and (4) propose an analytical model for the examination of the FI-DRCD syndemic through the life course. The proposed model is more relevant now given the significant increase in FI globally as a result of the ongoing COVID-19 pandemic. The differential impact that the pandemic appears to have among various age groups and by other demographic factors (e.g., race, gender, income) offers an opportunity to examine the potential FI-DRCD syndemic under the lens of LHT.

Bridging the Digital Divide Among Racial and Ethnic Minority Men Who Have Sex With Men to Reduce Substance Use and HIV Risk: Mixed Methods Feasibility Study

BACKGROUND

Ecological momentary assessment (EMA) is a promising data collection tool for mobile health interventions targeting episodic health behaviors. For substance-using men who have sex with men (SUMSM), EMA is becoming more widely utilized in efforts to characterize substance use and sexual risk factors for HIV transmission. However, recent literature demonstrates emerging concerns over compliance and lower EMA engagement and data concordance among racial and ethnic minority SUMSM.

OBJECTIVE

This study aimed to provide a qualitative evaluation of the barriers and facilitators of EMA as a data collection tool among racial and ethnic minority SUMSM.

METHODS

Between October and November 2017, 45 racial and ethnic minority SUMSM were recruited from a list of prior research participants at the San Francisco Department of Public Health to participate in daily EMA surveys on their substance use and sexual health behaviors for 1 week, followed by in-person focus groups (FGs). A total of 4 FGs explored the participants' experiences with the surveys, issues regarding privacy and confidentiality, and suggestions for improvement. Qualitative analysis was performed using content analysis. Descriptive statistics and Fisher exact tests were used to assess the associations between demographics or substance use behaviors and EMA completion.

RESULTS

Overall, 93.9% (295/314) of all delivered surveys were initiated, and of those, 98.0% (289/295) were completed. Neither participant demographics, including race (P=.65) or age (P=.43), nor substance use behaviors, including the frequency of alcohol (P=.40) or methamphetamine (P=.91) use or any cocaine (P=.28), crack (P=.99), or polysubstance use (P=.24), were found to be associated with survey completion. Overall, participants were receptive to the text message-based EMA surveys. Facilitators included survey timing, user-friendly survey design, survey-stimulated self-reflection, coding of sensitive phrases, and other privacy benefits of a mobile survey. Barriers included an inability to correct texting errors and participants' perception of judgment or stigmatization related to questions about condomless sex. To improve EMA compliance and uptake, participants suggested adding response confirmations, clarifying survey language, and continuing to diversify the study audience.

CONCLUSIONS

EMA appears to be feasible and acceptable among this sample of racial and ethnic minority SUMSM. Close attention to EMA study design and the development of nonjudgmental, contextualized questions regarding stigmatized health behaviors may be critical to further improve EMA compliance.

Sexual, addiction and mental health care needs among men who have sex with men practicing chemsex - a cross-sectional study in the Netherlands

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Almost one in four chemsex-MSM might want to be counselled by a professional.

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Sexual health experts were the preferred professionals to discuss chemsex.

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Increasing self-control was the most reported issue to discuss with professionals.

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Frequent chemsex was one of the indicative characteristics for needing counselling.

Drug use during sex (‘chemsex’) has been associated with sexually transmitted infections (STIs) and mental health harms. Little quantitative evidence exists on the health care needs of MSM practicing chemsex from a patient perspective. This study assessed self-perceived benefits and harms and the needs for professional counselling among MSM practicing chemsex. In 2018, 785 MSM were recruited at nine Dutch STI clinics and 511 (65%) completed the online questionnaire. Chemsex was defined as using cocaine, crystal meth, designer drugs, GHB/GBL, ketamine, speed and/or XTC/MDMA during sex <6 months. Chemsex was reported by 41% (209/511), of whom 23% (48/209) reported a need for professional counselling. The most reported topic to discuss was increasing self-control (52%, 25/48). Most MSM preferred to be counselled by sexual health experts (56%, 27/48). The need for professional counselling was higher among MSM who engaged in chemsex ≥2 times per month (30% vs. 17%, p = 0.03), did not have sex without drugs (sober sex) in the past three months (41% vs. 20%, p = 0.04), experienced disadvantages of chemsex (28% vs. 15%, p = 0.03), had a negative change in their lives due to chemsex (53% vs. 21%, p = 0.002), and/or had an intention to change chemsex behaviours (45% vs. 18%, p < 0.001). Our study shows that almost one in four MSM practicing chemsex expressed a need for professional counselling on chemsex-related issues. STI healthcare providers should assess the need for professional counselling in MSM practicing chemsex, especially in MSM with above mentioned characteristics, such as frequent users.