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In this issue, Weatherburn et al and Pakianathan et al provide a combination of practical and empirical insights into ‘chemsex’. This is particularly relevant to clinicians working with gay and bisexual men who have sex with men (GBMSM). Here we outline further issues for practitioners working with GBMSM who engage in chemsex.
What is chemsex?
Chemsex describes GBMSM's use of new recreational drugs (primarily mephedrone, crystal methamphetamine and γ-hydroxybutyric/γ-butyrolactone) to enable, enhance and prolong sexual interactions. Unlike alcohol and most other recreational substances, chemsex drugs provide men with the ability to improve their sexual performance and experiences, by increasing arousal, stamina and pleasure.1 Arising in tandem, the proliferation of geospatial sociosexual networking apps provide access to local sexual activities and drug procurement on demand.2 Together, these developments allow multiple and group sexual hook-ups to be arranged, outside the spatiotemporal constraints of the commercial (gay) scene, which usually last many hours or even several days. As well allowing increased partner numbers and turnover, chemsex users operate within a distinct cultural ‘bubble’, where risky sex and recreational drug use are normalised and advance negotiation of drug supply/use, intravenous drug taking, specific sexual behaviours, sexual safety, HIV serostatus, pre-exposure prophylaxis (PrEP) and condom use/non-use may all take place online. These online sociosexual networks and chemsex sexual cultures are disconnected from the commercial gay scene and, therefore, associated health promotion. In addition, difficulties in engaging men via sociosexual media—and in particular men within the chemsex culture—mean that presentations at sexual health and HIV care clinical interactions may provide the only opportunity for initiating harm minimisation interventions with this population.
Addressing chemsex within clinical interactions
Weatherburn et al explain how chemsex attracts a high level of opprobrium, concern and comment in relation to a population for whom recreational drugs are more prevalent and socially acceptable than for wider society. For professionals, multiple challenges exist around familiarity, understanding, language use and a rapidly changing environment in terms of local and national drug supply and app-based sexual negotiation. Pakianathan et al explain that, in order for men to feel comfortable to disclose and discuss their sexualised drug misuse, clinics must adopt a chemsex-friendly policy. This can be achieved by providing chemsex normalising materials (eg, posters, fliers etc) within the clinic, as well as addressing chemsex as part of the routine clinical consultation using the helpful proforma that Pakianathan et al provide. An informed refinement of core sexual health consultation skills, including non-judgemental language, is also necessary to aid full and candid disclosure. Moreover, formal training can be enhanced through colleagues and services sharing information regarding appropriate terminology and local colloquialisms learnt from patients, so men can discuss these issues using familiar, non-threatening language.
Weatherburn et al and Pakianathan et al, provide little discussion of interventions to reduce chemsex, reflecting the paucity of relevant evidence. To address how GBMSM might modify their drug misuse, the underlying psychological aspects of chemsex and the complex reasons that drive it must be understood, including the perceived benefits of chemsex and not just the potential harms associated with it. Weatherburn et al explain that chemsex offers men a positive sexual narrative, enabling them to have the kinds of sex they want, as well as enhancing the sexual qualities they value. Chemsex may also represent a form of self-medication, which counteracts negative issues of self-consciousness and doubt arising from societal homophobia, coping with an HIV-positive diagnosis, guilt around having sex with men and feeling unattractive. These issues, which are linked with other risk-taking behaviours and mental health issues, may be addressed through counselling interventions to help men deal with the underlying psychological dimensions of (chem)sex, as well as their potentially harmful recreational drug misuse. The enhancement of others' sexual attractiveness and intensified sexual arousal that chemsex offers may provide a powerful motivation to combine sex and drugs in the future. This is strengthened by the acceptance and normalisation of drug misuse among peers and sometimes a restriction of the peer group to include only drug-misusing individuals. Avoiding collusion, while providing a non-judgemental, supportive environment, is a delicate balance for individual clinicians and services.
Given the powerful positive motivations around chemsex that Weatherburn et al describe, clinicians should adopt a harm minimisation approach, discussing risk reduction strategies that work with clients' existing sexual repertoire and may include practical measures to minimise biomedical harms including STIs and the multiple potential consequences of overdose. A highly personalised approach is required, recognising the complexities of sexual and substance use risk reduction strategies (eg, sero-sorting, treatment-as-prevention, PrEP, condom use, safer injecting, safer drug use, etc). This tailored approach might include; frequent regular STI testing; for HIV-negative men, HIV testing; and for HIV-negative chemsex users who struggle with condom use and safer injecting practices, access to post-exposure prophylaxis and information on and support with PrEP (whether funded or self-sourced). Regular review to address these issues over time also offers the opportunity to follow-up and support men through the different trajectories observed, including intermittent, stable or increasingly frequent chaotic and harmful drug misuse, offering additional interventions to address underlying issues as appropriate.
Where is chemsex?
Chemsex is currently concentrated in certain cities and countries in Europe, primarily the UK.3 Much UK chemsex research and targeted service provision has focused on large cities, principally London, and reported UK rates among GBMSM vary from 16.5% (Brighton), 15.5% (Manchester), 13.1% (London) to 3.0% (Birmingham).3 Within clinical populations, chemsex use varied from 6.3% within gay-specific clinic interactions in Dorset4 to 38% of GBMSM surveyed in a Nottingham STI clinic,5 with more recent evidence suggesting that chemsex consultations within STI clinics are equally likely within and outside major conurbations.6 The frequency of chemsex presentations is also rapidly rising; chemsex drug misuse was disclosed in 13.7% of interactions across two London clinics7 but had increased to 17.3% by the next year.8 It is likely to become more widespread over the next few years such that services in all areas will need to address the issue. To supplement these data, two major UK studies of chemsex use of GBMSM sampled in sexual health clinics9 and online10 will be published in 2017.
Providing appropriate services
Chemsex users may not see themselves as ‘typical’ drug misusers (particularly with respect to injecting drug misuse) and may be averse to the social stigma that using drug treatment services entails. Providing a dedicated chemsex service within a gay-specific sexual health clinic is acceptable to clients11 and may be more appropriate than referring men to generic drug services.2 Such ‘Chemsex Clinics’, which currently operate primarily in London, also offer service provider training to support the development of local expertise and competence, along with the use of national support such as NEPTUNE.12 Where the local funding environment is less favourable and/or the demand is less obvious, the development of in-house services may not be practicable. Although generic drug services may not be equipped to deal with the specific needs of the GBMSM population and the complex issues of sexualised drug misuse in particular, many have high levels of knowledge relating both to the new recreational substances involved and to the appropriate management of psychological and physical addiction. This, combined with street-level knowledge of local availability, cost and purity of chemsex drugs suggests that collaboration between sexual health clinicians and local drug services to exchange knowledge and skills, develop training, monitor demand and develop referral pathways is critical. As chemsex use is significantly higher in HIV-positive men, sexual health clinicians must also engage with other local HIV care providers to ensure that all relevant care services are appropriately equipped to address this issue.
Competing interests None declared.
Provenance and peer review Commissioned; internally peer reviewed.