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.

Effectiveness of Harm Reduction Interventions in Chemsex: A Systematic Review

The phenomenon of chemsex has emerged as an essential public health issue in recent years. This systematic review aimed to investigate currently available harm reduction strategies and to evaluate the efficacy of the corresponding interventions.

METHODS

A systematic review of the scientific literature related to harm and risk reduction strategies and the effectiveness of chemsex interventions. Between January 2024 and May 2024, the articles were retrieved from the electronic databases Pubmed, Web of Science, Scopus, PsycInfo, Cochrane, Dialnet, CUIDEN, and SciELO. The review protocol was registered in the PROSPERO database (registration number CRD42024508953). The inclusion criteria were as follows: (I) original studies published in peer-reviewed journals, (II) studies exploring harm reduction interventions for chemsex, and (III) studies reflecting the efficacy of harm reduction interventions for chemsex. Two reviewers independently selected articles by title, abstract, and full paper review and extracted data. Two authors described the selected studies and assessed their methodological quality.

RESULTS

The systematic review comprised six scientific papers that met the selection criteria and were obtained from five countries. Although a limited number of studies were included, it was observed that they presented a medium-high methodological quality. Programs evaluated interventions to reduce harm from chemsex, such as a web-based intervention that improved self-efficacy to refuse risky behaviors and accept HIV testing. The studies suggested that peer-led programs can be effective, especially with facilitators who have experienced chemsex dependence.

CONCLUSION

Harm reduction strategies in chemsex are effective and should be promoted by health professionals. Interventions should be accessible, personalized, and non-judgmental to provide appropriate care and support, ensuring a comprehensive and effective public health response.

Chemsex Among Men Who Have Sex With Men: A Systematic Scoping Review of Research Methods

Chemsex refers to the use of psychoactive substances with sex. We carried out a systematic scoping review of methodological characteristics of chemsex research among men who have sex with men (MSM), published between 2010 and 2020. For inclusion, chemsex had to be the main focus, and studies had to specify GHB/GBL, stimulant (amphetamine, crystal meth, ecstasy/MDMA, cathinones, cocaine) and/or ketamine use with sex as a variable. From 7055 titles/abstracts, 108 studies were included, mostly cross-sectional, and from Western countries. About one-third of studies recruited exclusively from clinical settings. A majority of these recruited from sexually transmitted infection (STI) clinics. The included quantitative studies analyzed possible associations between chemsex and STI health (40%), mental health (15%), drug health (12%), sexological health (10%), and post-diagnostic HIV health (7%). Most studies included GHB/GBL and crystal meth in their operationalization of chemsex. Definitions and operationalizations of chemsex vary greatly in the literature, and researchers of chemsex among MSM should consider ways in which this variation impacts the validity of their results. More studies are needed among MSM in non-high income and non-Western countries, and examination of possible links between chemsex and post-diagnostic HIV health, sexological health, and mental health.

Considerations and recommendations for mHealth interventions for substance use among Sexual and Gender Minority (SGM) individuals: A narrative review of the past 5 years

Purposeof Review

The prevalence of problematic substance use is disproportionately higher among sexual and gender minority (SGM) adults compared to adults in the general population. mHealth as a treatment modality could reduce barriers to accessing substance use treatments among SGM populations. Through a qualitative literature search, the current narrative review aimed to understand the lived experiences of SGM individuals who use substances and to synthesize recommendations made in the literature to inform future mHealth interventions.

Recent Findings

Positive and negative reinforcement motives were prominent reasons for substance use, which included SGM identity expression and conformity motives. Individual- and system-level treatment barriers included a lack of safe and nonjudgmental environment, shame and stigma, and limited knowledge about treatment options. Barriers were directly linked to the reported substance use treatment needs in this population.

Summary

On-demand app features, real-time intervention and assessment, and anonymity should be considered in future mHealth trials.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40429-023-00497-0.

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.

Sexual behavior and drug use impact in gay, bisexual, and other men who have sex with men

BACKGROUND

The emergence of chemsex has raised several concerns about gay, bisexual, and other men who have sex with men's (GBMSM) health. In this study we aim to analyze illicit drugs and chemsex use, sexual behavior and sexually transmitted infections (STI) in GBMSM who attended to a sexual health clinic and to explore any potential association between drug use and STI.

METHODS

We conducted an observational study between January and June 2019 among GBMSM population attending to a STI clinic in Barcelona, Spain. An anonymous self-administered questionnaire was given consecutively to all participants older than 18 years who accepted to participate.

RESULTS

A total of 514 GBMSM (median age of 34 years-old) were included. The median number of sexual partners in the last year was 20. Seventy-one percent did not use condoms consistently for receptive anal intercourse. Drug abuse prevalence in the preceding year was 64.2%, and 26.5% of the individuals practiced chemsex. Gamma-hydroxibutyrate/gammabutyrolactone, poppers and methamphetamine were the most common drugs in chemsex. Chemsex was associated to group sex (OR 9.8 [95 CI: 4-24]), HIV infection (OR 2.5 [95 CI: 1.1-5.8]), taking pre-exposure prophylaxis (OR 3.2 [95 CI: 1.5-7.1]), developing gonorrhea (OR 3.7 [95 CI: 1.5-8.8]) or syphilis (OR 6.7 [95 CI: 2.4-18.7]).

CONCLUSIONS

The prevalence of drug use and chemsex was high among GBMSM in Barcelona. Chemsex was associated with group sex, taking PrEP, and contracting syphilis, gonorrhea, and HIV.

Support, care and peer support for gay and bi men engaging in chemsex

The objective of this research was to explore how gay men use drugs in their sex lives, colloquially called "chemsex". This paper reports on a sub-theme within the research about support, care and peer support. Longitudinal interviews were conducted with 20 gay and bi men between April 2017 and July 2019. Participants were recruited via geolocated dating apps (n = 17) and snowball sampling (n = 3). The main findings of this research are that medicalised forms of support for gay and bi men engaging in chemsex are often tardy in their responses to need, and whilst helpful for cessation of drug use, fail to address the holistic needs of the participants. A wide variety of peer support was practiced amongst the sample which often echoed previous forms of peer support practiced in the LGBT+ community. It was offered by both people who engaged in chemsex and those who did not and was highly beneficial to people who experienced problems with chemsex. However, peer support was also limited by factors such as shame and the instability of those offering support. In conclusion, we suggest that medicalised forms of chemsex support could benefit from more rigorous and rapid forms of assessment for problematic chemsex, and also provide infrastructure and training to peer support initiatives. We also suggest that medical services could learn from patients and their peers about what support needs remain unaddressed by professional services, and engage in collaborative approaches to practice development.

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.

Self-Control as Conceptual Framework to Understand and Support People Who Use Drugs During Sex

Few theory-informed interventions to support people who use drugs during sex have been conceptualized and developed. We conceptualize sexualized drug use, also referred to as chemsex or pharmacosex, as a self-control challenge, and draw on extant theory and research to propose intervention approaches that can be tailored to meet the differing needs of people who engage in sexualized drug use. We draw on a continuum perspective of sexualized drug use, in particular chemsex, and discuss the role of reasoned and automatic processes in behavioral decisions, as well as critical components of effective self-control of behavior. A self-control approach can empower people to tackle their sexualized drug use, and classify their experienced sex-related drug use as problematic. Self-control encompasses clarifying one's goals and identifying strategies to mitigate behaviors to achieve these goals, despite competing pharmacosex desires. Our approach to self-control sexualized drug use contains three critical components: goal setting, goal enactment, and goal progress appraisal and goal adjustment. Goals should be formulated specific, ambitious yet realistic, and tailored to the individual's needs and wishes. Goals may target aspects of drug use, protecting sexual health and mitigating negative impacts. Implementing goal enactment implies translating goals into concrete (short-term) actions to move toward the higher-order goal via goal intentions and action/coping plans. During the goal progress appraisal and adjustment stage, people compare their actual with their planned behavior. This reflection may result in goal adjustment through feedback loops to adjust their goals and action/coping plans. We propose that our self-control approach can guide the development of interventions to effectively support people to prevent or limit pharmacosex, and helps to effectively mitigate or reduce negative impacts via self-help, peer support or professional support, offered via personal counseling or digital tools.

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.

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.

Harm Reduction Practices and Needs in a Belgian Chemsex Context: Findings from a Qualitative Study

Chemsex is a growing public health concern, with little evidence-based care and support available. The aim of this study is to understand current risk reduction practices, and the information and care needs of gay, bisexual, and other men who have sex with men (GBMSM) who engage in chemsex. Between January and March 2020, semi structured in-depth interviews with drug-using GBMSM (n = 20) were conducted. Data were analyzed thematically. The reported preparatory measures were: deliberately scheduling chemsex sessions, and discussing preferences regarding setting and attendees. During the event, a logbook is kept to monitor drugs taken by each participant. People try to take care of each other, but this is often counteracted. Respondents highlighted needs: reliable and easily-accessible information, anonymous medical and psychological healthcare, chemsex-specific care, and a value-neutral safe space to talk about chemsex experiences. Results imply two types of users: planned and impulsive users. Adherence to intended harm reduction practices are complicated by drug effects, peer pressure, and feelings of distrust among users.

Review of sexualized drug use associated with sexually transmitted and blood-borne infections in gay, bisexual and other men who have sex with men

PURPOSE

The aim of the present study was to quantify associations between sexualized drug use (SDU) and sexually-transmitted and blood-borne infection (STBBI) diagnoses in gay, bisexual and other men who have sex with men (GBMSM) with defined temporal proximity between SDU exposure and STBBI diagnoses.

METHODS

In May 2018 and June 2019, we searched the literature for primary studies that quantified the association between STBBI and SDU among GBMSM. A random-effects model was used to meta-analyze the data and estimate the association between SDU and STBBIs.

RESULTS

Nineteen studies met the inclusion criteria and fourteen studies were included in the meta-analyses. SDU was associated with higher odds of bacterial STI diagnoses, higher odds of HCV diagnoses, and higher odds of HIV diagnoses. Associations between SDU and diagnoses of bacterial STIs or HCV remained after adjustment for behavioral and sociodemographic factors.

CONCLUSIONS

Robust and consistent associations between SDU and STBBI identified in this review add to the evidence suggesting SDU is a potential contributor to bacterial STIs and HCV or a proxy indicator for other risk factors.

Digital chemsex support and care: The potential of just-in-time adaptive interventions

Chemsex among gay, bisexual and other men who have sex with men (GBMSM) has received increasing attention as a public health concern in recent years. Chemsex can affect a variety of aspects of the lives of GBMSM and contribute to physical, social and emotional health burden. Starting from a continuum perspective of chemsex, rather than a binary view of problematic vs. non-problematic use, we argue that men engaging in chemsex at different points in their chemsex journey may benefit from tailored and personalized support to cope with the various and evolving challenges and concerns that may be related to their chemsex behavior. To date, interactive digital communication technologies are not much used to provide support and care for GBMSM engaging in chemsex, neither for community-based support and care nor by health services. This suggests potential for missed opportunities, as GBMSM are generally avid users of these technologies for social connections and hookups, including in relation to chemsex. Recent research has provided emerging evidence of the potential effects of so-called just in time adaptive interventions (JITAI) to provide effective support and care for a variety of health issues. JITAI hold much promise for the provision of appropriate, tailored support and care for GBMSM at different points in the chemsex journey. Co-designing JITAI with potential users and other stakeholders (co-design) is key to success. At the Institute for Tropical Medicine, in Antwerp (Belgium), we initiated the Chemified project to develop an innovative digital chemsex support and care tool for GBMSM. This project illustrates how current understanding of chemsex as a journey can be integrated with a JITAI approach and make use of co-design principles to advance the available support and care for GBMSM engaging in chemsex.

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.

We know DAAs work, so now what? Simplifying models of care to enhance the hepatitis C cascade

Globally, some 71 million people are chronically infected with hepatitis C virus (HCV). Marginalized populations, particularly people who inject drugs (PWID), have low testing, linkage to care and treatment rates for HCV. Several models of care (MoCs) and service delivery interventions have the potential to improve outcomes across the HCV cascade of care, but much of the relevant research was carried out when interferon-based treatment was the standard of care. Often it was not practical to scale-up these earlier models and interventions because the clinical care needs of patients taking interferon-based regimens imposed too much of a financial and human resource burden on health systems. Despite the adoption of highly effective, all-oral direct-acting antiviral (DAA) therapies in recent years, approaches to HCV testing and treatment have evolved slowly and often remain rooted in earlier paradigms. The effectiveness of DAAs allows for simpler approaches and has encouraged countries where the drugs are widely available to set their sights on the ambitious World Health Organization (WHO) HCV elimination targets. Since a large proportion of chronically HCV-infected people are not currently accessing treatment, there is an urgent need to identify and implement existing simplified MoCs that speak to specific populations' needs. This article aims to: (i) review the evidence on MoCs for HCV; and (ii) distil the findings into recommendations for how stakeholders can simplify the path taken by chronically HCV-infected individuals from testing to cure and subsequent care and monitoring.