Exploring practices to enhance benefits and reduce risks of chemsex among gay, bisexual, and other men who have sex with men: A meta-ethnography

BACKGROUND

Chemsex is the intentional combining of specific drugs with sex, primarily by gay, bisexual, and other men who have sex with men (GBMSM), to enhance intimacy, pleasure, and prolong sexual sessions. Practices vary across geographic and social settings. Participants report benefits and risks of chemsex. Studies have previously reviewed chemsex practices and harm reduction interventions separately. This review aims to examine both together by describing and understanding practices that men employ to navigate the perceived benefits and risks of chemsex.

METHODS

We conducted a systematic meta-ethnographic review of published qualitative literature, screening titles, abstracts, and full texts on defined inclusion and exclusion criteria. Using reciprocal and refutational translation techniques, we analysed study participants' (first-order) and researchers' (second-order) accounts of benefit-enhancing and risk-reducing chemsex practices. Finally, we employed line-of-argument synthesis techniques to develop our own higher-level interpretations (third-order constructs) of these chemsex practices.

RESULTS

Our search yielded 6356 records, from which, we included 23 articles in our review. Most studies were conducted in high-income Western countries. Across studies, participants acted at the individual, interpersonal, and community levels to enhance benefits and reduce risks, which made up our third-order constructs. Eight themes emerged from first- and second-order constructs to describe these practices, which included personal preparation, personal boundaries, biomedical measures, structured use of drugs, leaning on partners, injecting practices, group organising, watching out for others, and teaching and learning. Contextual factors like trust, agency, access, stigma, and setting moderated whether and how participants engaged in these practices, and if practices enhanced benefits or reduced risks.

CONCLUSION

Health promotion programmes and research focused on chemsex must account for the benefits and the risks that GBMSM associate with this type of sexualised drug use and target the moderating factors that shape the practices they employ to navigate these benefits and risks.

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.

Does sexuality matter? A cross-sectional study of drug use, social injecting, and access to injection-specific care among men who inject drugs in Melbourne, Australia

BACKGROUND

Gay, bisexual and other men who have sex with men (GBMSM) are overrepresented in cohorts of people who inject drugs. GBMSM's substance use is usually explored in the context of its contribution to sexual risk. We examined drug use practices, connectedness to other people who inject drugs, peer-to-peer injecting, and access to care among men who inject drugs in Melbourne, Australia. We aim to describe similarities and differences in these parameters for GBMSM and other men.

METHODS

Data were drawn from a prospective cohort study of people who inject drugs conducted in Melbourne, Australia, since 2009. This cross-sectional study used data collected between 2016 and 2021. Descriptive statistics were used to assess differences between GBMSM and other men.

RESULTS

Of 525 men who injected drugs over the study period, 48 (9%) identified as gay or bisexual, or reported sex with other men in the past 12 months. GBMSM and other men reported similar socio-demographics, drug practices (age of injecting initiation, most injected drug, peer-to-peer injecting, receptive syringe sharing) and access to injecting-specific care (drug treatment, source of needle-syringes). A significantly greater percentage of GBMSM reported past 12-month hepatitis C testing (69% vs. 52%, p = 0.028) and preferring methamphetamine (31% vs. 16%, p = 0.022). A higher percentage of GBMSM reported knowing > 50 other people who inject drugs (46% vs. 37%), but this difference was not statistically significant. Both groups primarily obtained injecting equipment from needle-syringe programs; a minority had accessed injecting-specific primary care.

CONCLUSION

Men who injected drugs in this cohort and those who identified as GBMSM reported similar drug and health-seeking practices. The higher prevalence of methamphetamine injecting among GBMSM may warrant different harm reduction support for this group. Health promotion should utilise opportunities to connect men who inject drugs in Melbourne to injecting-specific primary health care.

Sexualized Drug Use and Chemsex: Their Association with Sexual Health Among Men who have Sex with Men Living in Greece

Objectives: The study aims to investigate rates of sexualized drug use (SDU) and chemsex, a type of SDU involving specifically the use of crystal methamphetamine, mephedrone, or GHB/GBL and their association with the rates of negative sexual health outcomes among men who have sex with men (MSM) in Greece. Methods: Survey of 485 MSM in internal disease departments and community testing centers. Results: Twenty-eight percent of participants were involved in SDU and 20.4% in chemsex. HIV positive status and recent STI diagnoses were associated with SDU involvement. Conclusion: SDU and chemsex rates and their impact on health reveal the need for informed community-based services.

"Slam Sex" - Sexualized Injecting Drug Use ("SIDU") Amongst Men Who Have Sex with Men (MSM)-A Scoping Review

Sexualized injecting drug use ("SIDU") is a phenomenon associated with a wide array of high-risk injecting and sex-related practices. This scoping review establishes what is known about MSM and SIDU to assess implications for health care and policy.  Characteristics of MSM for "SIDU" may include being on anti-retroviral treatment and urban residency with drivers being challenging social taboos; a search for intimacy; convenience of administration; relationship breakdown and increased restrictions in clubs and saunas. Attraction for use appears to be enhancement or prolongation of sexual experiences/pleasure; intimacy and the facilitation of a range of potentially "unsafe" sexual activity. Traditional services are ill-equipped to address "SIDU" because of a lack of knowledge of practices, lack of associated vocabulary, and a failure to integrate sexual health with drug services. For effective responses, these issues need to be addressed.

Assemblages of excess and pleasures: The sociosexual uses of online and chemical technologies among men who have sex with men

Chemicals have penetrated everyday lives of men who have sex with men as never before, along with new online and mobile technologies used to seek pleasures and connections. Poststructuralist (including queer) explorations of these new intensities show how bodies exist in the form of (political) surfaces able to connect with other bodies and with other objects where they may find/create a function (e.g., reproduce or disrupt hegemonies). This federally funded netnographic study explored how a variety of chemicals such as recreational drugs, pharmaceuticals and steroids are contributing to the construction of gay, bisexual and other men having sex with men (GBMSM) communities and their interactions with idealized masculinities in the age of increasing technology. Five major thematic categories emerged from our analysis: (1) assembling bodies and technologies, (2) becoming orgiastic, (3) experiencing stigma, (4) becoming machinic and (5) negotiating practices. Our analysis explores how and why GBMSM pursue excesses of pleasure and connection through the assemblages they make with sexualized drug use, online platforms and other men.

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.

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.

Introduction

The everyday lives of contemporary youth are awash with chemicals to boost pleasure, energy, sexual performance, appearance, and health. What do pills, drinks, sprays, powders, and lotions do for youth? What effects are youth seeking? The ChemicalYouth ethnographies presented here, based on more than five years of fieldwork conducted in Amsterdam, Brooklyn, Cayagan de Oro, Paris, Makassar, Puerto Princesa, and Yogyakarta, show that young people try out chemicals together, compare experiences, and engage in collaborative experiments. ChemicalYouth: Navigating Uncertainty: In Search of the Good Life makes a case for examining a broader range of chemicals that young people use in their everyday lives. It focuses not just on psychoactive substances—the use of which is viewed with concern by parents, educators, and policymakers—but all the other chemicals that young people use to boost pleasure, moods, vitality, appearance, and health, purposes for using chemicals that have received far less scholarly attention. It takes the use of chemicals as situated practices that are embedded in social relations and that generate shared understandings of efficacy. More specifically, it seeks to answer the question: how do young people balance the benefits and harms of chemicals in their quest for a good life?

Knowledge, attitudes and practices related to hepatitis C among gay and bisexual men in the era of direct-acting antivirals: implications for treatment and prevention

Increases in hepatitis C (HCV) infections among gay and bisexual men have recently been reported in a number of countries, with sexual transmission being the primary route of infection. Given that in countries such as Australia most gay and bisexual men living with HIV are already engaged in clinical care - as are an increasing number of HIV-negative men - there is potential for reducing onward HCV transmission through proactive testing and treatment. This study explored knowledge, attitudes and practices related to HCV among 194 gay and bisexual men collected through an online survey in Australia. Overall, respondents had high levels of HCV knowledge; however, only 76% knew about the availability of new treatments for HCV. Men's knowledge of their own HCV testing history was uncertain, with one in six unaware if they had ever been tested. Among men who reported recent drug injecting, one-third had been injected by someone else, and two-thirds had injected someone else, indicating a subculture of cross-administering within sexualised drug-use networks. We argue that the robust sexual, socio-cultural and clinical infrastructure that has been developed by - and for - gay and bisexual men around HIV care and prevention creates the potential for reducing HCV in this group.

Injecting drug use during sex (known as "slamming") among men who have sex with men: Results from a time-location sampling survey conducted in five cities, France

BACKGROUND

In the last decade, European cities saw the development of "slamming," a practice related to chemsex that combines three elements: a sexual context, psychostimulant drug use, and injection practices. Epidemiological data on this practice is still sparse and media attention might have unintentionally distorted the size of this phenomenon. Therefore, we aimed to estimate the prevalence of men practicing slam and to identify factors associated with this practice.

METHODS

We used data from the Prevagay 2015 bio-behavioral survey to estimate the prevalence of slamming practices. A time-location sampling was performed among gay-labeled venues in five French cites. Behavioral information was recorded using a self-administered questionnaire. The HIV and HCV serostatus were investigated using ELISA tests on dried blood spots. The factors associated with slamming were assessed using a multiple logistic regression. We applied a weighting mechanism to enhance the generalizability of the estimates.

RESULTS

Among the 2646 men who have sex with men (MSM) included in our study, 3.1% reported slamming at least once during their lifetime (95% confidence interval (CI) = 2.2-4.3) and 1.6% (95% CI = 1-2.3) said they participated in a slamming session in the last 12 months. In the multivariate analysis, both HCV and HIV biological status were strongly associated with practicing "slam" in the last 12 months (OR = 13.37 (95% CI = 3.26-54.81) and 4.73 (95% CI = 1.58-14.44), respectively). Furthermore, a ten-point decrease in mental health scores was linked with the practice with an OR of 1.37 (95% CI = 1.08-1.73), indicating poorer mental health.

CONCLUSION

Even though slamming seems to involve a relatively small proportion of MSM, the vulnerability of this sub-group is high enough to justify setting up harm reduction measures and specific care. Training health professionals and creating services combining sexual health and drug dependence could be an effective response.

Sex, drugs and social connectedness: wellbeing among HIV-positive gay and bisexual men who use party-and-play drugs

Background This paper explores associations between use of party-and-play drugs, including crystal methamphetamine, and wellbeing among HIV positive gay and bisexual men (GBM) in Australia. This study considers whether use of drugs in a social or sex-based setting facilitates access to social and support networks, which may in turn support wellbeing.

METHODS

A cross-sectional survey of Australian people living with HIV (PLHIV) was conducted. There were 714 participants (79.7%) who identified as GBM. Differences between party-and-play drug users and non-users were examined using bivariate and multinomial logistic regressions. Mediation analysis examined the indirect effect of drug use on wellbeing via social connectedness and support.

RESULTS

One in three participants (29.7%) reported party-and-play drug use within the past 12 months. Only 5% reported regular use. There were no differences between users and non-users on self-reported measures of general health, wellbeing or general social support. Compared with non-users, party-and-play drug users reported higher levels of resilience and lower levels of perceived HIV-related stigma. This was associated with spending more time with other people living with HIV and friends in the gay and lesbian community.

CONCLUSIONS

While party-and-play drug use poses risks to the health of GBM, the social contexts in which these drugs are used may provide wellbeing benefits, particularly for HIV-positive GBM who may be subject to HIV-related stigma in other settings. Further research is needed to determine whether drug-use facilitates access to social networks or if people with more active social ties are more likely to engage in drug use.

Pleasure and HIV biomedical discourse: The structuring of sexual and drug-related risks for gay and bisexual men who Party-n-Play

Party-n-Play (PNP) is a social practice that refers to sex that occurs under the influence of drugs. This study critically examined the risk and pleasure discourses of gay and bisexual men who PNP to explore how epistemic shifts associated with advancements in HIV biomedical sciences influence gay and bisexual men's perceptions of HIV risks and their sexual and drug-related practices. This study also aims to provide a more nuanced understanding of how sexual and drug-related risk practices of gay and bisexual men are entangled with their search for pleasure. The study was framed within poststructural Critical Discourse Analysis (CDA) methodology. In-depth one-hour interviews were conducted with 44 self-identified gay, bisexual, queer, or Two-Spirit men, who lived in Toronto, and who reported using drugs before or during sex with another man. The findings from this study demonstrated the capacity of biomedical discourses to affect respondents' HIV risk perceptions and practices. The transition from condom-centered prevention to today's context where new highly effective biomedical tools for HIV prevention are available created possibilities for greater intimacy, increased pleasure, and less anxiety about HIV tranmission, while challenging many years of preventive socialization among gay and bisexual men. However, this new context also rekindled deep-seated fears about HIV risk and viral load verifiability, reinforced unequal forms of biomedical self-governance and citizenship, and reproduced practices of biopolitics. While discourses on risk and pleasure were interwoven within complex PNP assemblages, the notion of pleasure was mobilized as a discursive tactic of self-control, and the division between normative and non-normative pleasures highlighted the consequence of biopolitical forces governing the production of discourses on sex and drugs. Future HIV social science research needs to attend to the fluid nature of the discursive environments of HIV prevention science, and consider how both the material context of PNP and its social/discursive elements operate together.

Chemsex experiences: narratives of pleasure

Purpose

The purpose of this paper is to understand the dynamics of pleasure related to chemsex from the perspective of French gay men and other men who have sex with men (MSM). Recognising that participants in chemsex are social actors, the authors diverge from the prominent “pathology paradigm” used in public health.

Design/methodology/approach

In-depth interviews were conducted with gay men and other MSM engaging in chemsex via snowball sampling (n=33). The authors explored the definitions of pleasure and the role of stimulants, sexual activity, smartphones and partners in chemsex pleasures.

Findings

Chemsex pleasures encompass multiple dimensions that go far beyond bodily pleasures, such as love or romantic relationships, socializing with significant others and sexual discovery through disinhibition. Narratives of pleasure were also, simultaneously, stories of suffering and distress. This dissonance can pose challenges to the participants in chemsex, their entourages and care providers.

Practical implications

Given that the focus of care for gay men and other MSM is on risk behaviors, the findings of this paper help nurture discussions where pleasure is integrated into a new, value-neutral framework of care that incorporates chemsex pleasures.

Originality/value

This study examined the perspectives of those actually participating in chemsex, allowing gay men and other MSM to relate the entirety of their experiences, in which pleasure is often at the forefront, without restriction.

A latent class analysis of substance use and culture among gay, bisexual and other men who have sex with men

Assessments of gay and bisexual men's substance use often obscures salient sociocultural and identity-related experiences related to how they use drugs. Latent class analysis was used to examine how patterns of substance use represent the social, economic and identity-related experiences of this population. Participants were sexually active gay and bisexual men (including other men who have sex with men), aged ≥ 16 years, living in Metro Vancouver (n = 774). LCA indicators included all substances used in the past six months self-reported by more than 30 men. Model selection was made with consideration to model parsimony, interpretability and optimisation of statistical criteria. Multinomial regression identified factors associated with class membership. A six-class solution was identified representing: 'assorted drug use' (4.5%); 'club drug use' (9.5%); 'street drug use' (12.1%); 'sex drug use' (11.4%); 'conventional drug use' (i.e. tobacco, alcohol, marijuana; 25.9%); and 'limited drug use' (36.7%). Factors associated with class membership included age, sexual orientation, annual income, occupation, income from drug sales, housing stability, group sex event participation, gay bars/clubs attendance, sensation seeking and escape motivation. These results highlight the need for programmes and policies that seek to lessen social disparities and account for social distinctions among this population.

Chemsex as edgework: towards a sociological understanding

Sexual sessions between men, organised through mobile technologies and combined with stimulants intended to extend and intensify the session have been reified into the phenomena of ‘chemsex’. Understanding chemsex requires multiple levels of analysis and interpretation. This paper considers chemsex through the lens of edgework, a sociological category for voluntary risk taking identified in 1990 by Stephen Lyng. Edgework activities involve a clear and present danger to the self, intense emotions and sensations and an opportunity to exercise specialist skills. Using published research and other cultural products, this paper demonstrates that chemsex fully exhibits all the defining features of edgework. Chemsex is then positioned as an activity that epitomises the (gay) citizen as consumer in a technocapitalist age of pharmacopornographic consumption.