One “chemsex” or many? Types of chemsex sessions among gay and other men who have sex with men in Madrid, Spain: findings from a qualitative study

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.

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.

Spatiotemporal cluster of mpox in men who have sex with men: A modeling study in 83 countries

Mpox outbroke globally during 2022-2023, with more than 90% of cases occurring in men who have sex with men (MSM). However, the spatiotemporal distribution of mpox is not well established yet. This study aimed to explore the spatiotemporal clustering of mpox cases in MSM worldwide. We obtained the numbers of mpox cases from Our World in Data, the number of MSM from the Joint United Nations Programme on HIV/AIDS (UNAIDS), UNAIDS DATA 2021 and UNAIDS Global AIDS Update 2022 and literature. We evaluated the spatiotemporal cluster of mpox in MSM using retrospective space-time analyses method. The total number of mpox cases was 85 795 during May 1, 2022 to March 31, 2023. The most likely cluster was Spain (likelihood ratio = 4764.97; p < 0.001), with a cluster period from July 26 to August 14, 2022. There were 11 secondary clusters, which included 46 countries located in western Europe, eastern and northern South America, northern Europe, Canada, Central Africa, southern and central Europe, Latin America, Turkey, Dominican Republic, New Zealand, and Australia. The findings may inform current and future control strategies of mpox and might provide references for the identification of the spatiotemporal distribution of new and emerging infectious diseases in specific populations.

Hepatitis C antibody prevalence and active hepatitis C infection in HIV-negative gay, bisexual, and other men who have sex with men in Barcelona and Madrid, Spain (March 2018-March 2021)

OBJECTIVES

Hepatitis C virus (HCV) has been recognized as a sexually transmitted infection (STI) in HIV-positive men who have sex with men (MSM), with an increased notification in HIV-negative MSM. The aim of this study was to determine the prevalence of HCV antibody and active HCV infection in HIV-negative gay, bisexual, and other MSM (GBMSM), and their characteristics, in Barcelona and Madrid, from March 2018 to March 2021.

METHODS

Cross-sectional study conducted on 3548 HIV-undiagnosed GBMSM, across four HIV/STI testing centers. Respondents submitted an online, self-administered questionnaire after consultation, which collected information on sociodemographics, sexual health history, HCV knowledge, and substance consumption. Prevalence of HCV antibodies was determined by a reactive result in a rapid anti-HCV test or enzyme-linked immunosorbent assay (ELISA), while active HCV infection was determined by participants who were also positive on an HCV-RNA test. Crude and adjusted Poisson analyses with robust variance are presented for both prevalence and active infection.

RESULTS

In total, 97.6% of participants (n = 3463) were HIV-negative. Of those, 18 were found to have HCV antibodies (0.52%), of which nine (0.26%) were also HCV-RNA positive. Those with HCV antibodies were associated to have lived with an HCV (+) person (adjusted prevalence ratio [APR]: 7.84, [95% confidence interval: 2.50-24.53]), using injectable drugs for sex (APR: 6.92, [1.20-39.79]) and testing positive for an STI in the previous year (APR: 4.06, [1.09-15.12]). Presenting an active infection was strongly associated with a previous HCV diagnosis (APR: 100.82 [22.16-458.76]), sexualized injectable drug use (APR: 17.53 [2.70-113.76]), and sharing douching material (APR: 7.45, [2.12-25.95]).

CONCLUSION

Sexual practices with a higher risk of bleeding and sexualized drug use, particularly sexualized injectable drug use, were associated with higher rates of HCV diagnosis in GBMSM. Identifying these practices during consultation, contact tracing new cases and regularly testing those with a previous history of HCV, will facilitate HCV eradication.

Monkeypox: Risks and Approaches to Prevention

Since early May 2022, an outbreak due to Mpox virus (formerly called monkeypox) has occurred in many countries around the world. On July 23, the World Health Organization declared the outbreak ‘Public Health Emergency of International Concern’. In order to combat the outbreak, it is important to have effective infection prevention and control plans. The first step is to qualitatively and quantitatively determine the risks of infections, followed by the design and implementation of infection prevention and control measures. Mpox is transmitted through direct, indirect, and prolonged contact, through sexual transmission, and via the respiratory route. Men who have sex with men are identified as the most vulnerable population. Home pet-raisers, and health care workers are at risk of catching the disease. The outcome of infection is catastrophic among the elderly, immunocompromised individuals, pregnant female and children. The spillover to animals is of great concern. It is important to communicate the risks and have community engagement in the control of this outbreak. The availability of vaccines will add to the capability of containing the outbreak. It is critical to prevent the virus from spreading further. Hence, we review the recent findings on the risk management of Mpox along with the preventive strategies.

Understanding Sexualized Drug Use: Substances, Reasons, Consequences, and Self-Perceptions among Men Who Have Sex with Other Men in Spain

Sexualized drug use (SDU) has been identified as a health risk factor among gay, bisexual, and other men who have sex with men (GBMSM). This study aimed to analyze the associations between SDU frequency and a broad set of substances, motives, consequences, and self-perceptions. Sampling was conducted through an online survey. The final sample consisted of 185 GBMSM aged between 18 and 78 years old (mean age = 38.38, SD = 11.52) who engaged in SDU. We analyzed the frequency of SDU in terms of practicing it "once," "moderately" ("once a month or less" or "a few times a month"), or "frequently" (from "once a week" to "daily") during the previous 18 months. A questionnaire was administered through which sociodemographic variables, substances, reasons, consequences, and self-perceptions of SDU practice were analyzed. Participants who did so frequently were significantly more likely to use mephedrone, methamphetamine, and GHB/GBL than those who performed SDU less often (large effect sizes). In addition, habitual SDU was associated with motivations to achieve pleasurable emotions and sensations and manage negative feelings. Health implications, such as blackout moments, were also significantly related to frequent SDUs. Finally, those who practiced frequent SDU perceived it as a severe problem and wanted to control it. These data indicate the importance of raising awareness of chemsex as a public health problem among GBMSM. Specific identification, education, and prevention programs need to be strengthened to reduce the incidence of the most undesirable implications of SDU among GBMSM.

Chemsex and incidence of sexually transmitted infections among Canadian pre-exposure prophylaxis (PrEP) users in the l'Actuel PrEP Cohort (2013-2020)

OBJECTIVES

Use of illicit substances during sex (chemsex) may increase transmission of HIV and other STIs. Pre-exposure prophylaxis (PrEP) is highly effective at preventing HIV transmission, providing an important prevention tool for those who practise chemsex. However, it does not prevent acquisition of other STIs. We aim to examine the impact of chemsex on STI incidence among gay, bisexual and other men who have sex with men (gbMSM), and transgender women using PrEP in Montréal, Canada.

METHODS

We linked baseline sociodemographic and behavioural data with follow-up STI testing from 2013 to 2020 among PrEP users in the l'Actuel PrEP Cohort (Canada). Focusing on the 24 months following PrEP initiation, we estimated the effect of chemsex reported at baseline on cumulative incidence of gonorrhoea and chlamydia using Kaplan-Meier curves and survival analyses. We investigated the role of polysubstance use and effect modification by sociodemographic factors.

RESULTS

There were 2086 clients (2079 cisgender gbMSM, 3 transgender gbMSM, 4 transgender women) who initiated PrEP, contributing 1477 years of follow-up. There were no incident HIV infections among clients on PrEP. Controlling for sociodemographic confounders, clients reporting chemsex at baseline had a 32% higher hazard of gonorrhoea/chlamydia diagnosis (adjusted HR=1.32; 95% CI: 1.10 to 1.57), equivalent to a risk increase of 8.9 percentage points (95% CI: 8.5 to 9.4) at 12 months. The effect was greater for clients who reported polysubstance use (adjusted HR=1.51; 95% CI: 1.21 to 1.89). The strength of the effect of chemsex on STI incidence varied by age, education and income.

CONCLUSION

Among PrEP users, chemsex at baseline was linked to increased incidence of gonorrhoea and chlamydia. This effect was stronger for people reporting multiple chemsex substances. The high STI incidence among gbMSM who report chemsex highlights the importance of PrEP for this population and the need for integrated services that address the complexities of sexualised substance use.

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.

HIV, chemsex, and the need for harm-reduction interventions to support gay, bisexual, and other men who have sex with men

Numerous studies have identified an association between the use of drugs in sexual contexts (chemsex) and HIV among gay, bisexual, and other men who have sex with men (GBMSM), although whether a causal relationship exists is contentious. An intricate relationship exists between chemsex, HIV treatment and prevention, harm reduction, and the provision of community-grounded health services. Furthermore, potential harms exist beyond HIV, such as intoxication and overdose. Community-engaged responses to chemsex involve social and cultural strategies of harm reduction and sexual health promotion before, during, and after a chemsex session. Ultimately, this Review calls for actions and collaborations aimed at developing a greater understanding of chemsex as a practice within different GBMSM subpopulations and to develop tailored harm-reduction models that can accommodate GBMSM who engage in chemsex in various ways and with varied effects.

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.

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.

Increase in recreational drug use between 2008 and 2018: results from a prospective cohort study among HIV-negative men who have sex with men

AIMS

To test whether recreational drug use (RDU) and sexualized drug use (SDU) changed in the Amsterdam area between 2008 and 2018 and quantify associations of SDU with condomless anal sex (CAS), recent human immunodeficiency virus (HIV) or sexually transmitted infections (STI) among human immunodeficiency virus (HIV)-negative men who have sex with men (MSM).

DESIGN

Open prospective cohort study.

SETTING

Public Health Service of Amsterdam, the Netherlands.

PARTICIPANTS

A total of 976 HIV-negative MSM, aged ≥ 18 years.

MEASUREMENTS

Self-reported RDU and sexual behaviour in the past 6 months. Laboratory-confirmed HIV and STI (chlamydia, gonorrhoea and syphilis). We studied: any RDU; any SDU (i.e. any RDU during sex); specific SDU (i.e. use of mephedrone, methamphetamine, gamma-hydroxybutyric acid/gamma-butyrolactone, ketamine, amphetamine, cocaine and/or ecstasy during sex); use of individual drugs; and use of individual drugs during sex. We evaluated changes over calendar years in the proportion of individuals with these end-points [using logistic regression with generalized estimating equations (GEE)] and number of drugs (using negative binomial regression with GEE), adjusted for current age, country of birth and education level.

FINDINGS

Median age of participants in 2008 was 33.2 years (interquartile range = 27.8-40.1); 83.1% were born in the Netherlands. The proportion of any RDU increased from 67.2% in 2008 to 69.5% in 2018 [adjusted odds ratio (aOR) = 1.25; 95% confidence interval (CI) = 1.03-1.51]. Any SDU increased from 53.8% in 2008 to 59.8% in 2013 (aOR = 1.23; 95% CI = 1.07-1.42) and remained stable afterwards. Specific SDU increased from 25.0% in 2008 to 36.1% in 2018 (aOR = 2.10; 95% CI = 1.71-2.58). The average number of drugs used increased for those reporting any RDU, any SDU and specific SDU (all P < 0.05. Among those engaging in sex, any SDU was associated with CAS (aOR = 1.36; 95% CI = 1.19-1.55), HIV (aOR = 5.86; 95% CI = 2.39-14.4) and STI (aOR = 2.31; 95% CI = 1.95-2.73). Specific SDU was associated with CAS (aOR = 1.58; 95% CI = 1.37-1.81), HIV (aOR = 6.30; 95% CI = 3.28-12.1) and STI (aOR = 2.15; 95% CI = 1.81-2.55).

CONCLUSIONS

Among human immunodeficiency virus (HIV)-negative men who have sex with men in Amsterdam, recreational drug use, including sexualized drug use, increased between 2008 and 2018. Sexualized drug use was strongly associated with condomless anal sex, HIV and sexually transmitted infections.

Mental Health Symptoms Associated with Sexualized Drug Use (Chemsex) among Men Who Have Sex with Men: A Systematic Review

Background: Sexualized drug use (SDU), also known as chemsex, refers to the use of psychoactive substances for sexual purposes among men who have sex with men (MSM), which has been associated with mental health symptoms. The objective of this review is to systematically review the available evidence on mental health outcomes in MSM who use sexualized drugs. Methods: To prepare this systematic review, search strategies were developed and applied to the Web of Science, Science Direct, PubMed, and Scopus databases. A total of 117 articles were found, of which 12 were selected for the final review. Results: Those MSM who practiced SDU were more likely to experience from depression, anxiety, or a substance dependence, although these results were not found in all the studies analyzed. Among those who practiced the administration of intravenous drugs (referred to as slamsex), the mental health symptoms were more severe. Conclusions: This systematic review contributes to a fuller understanding of the mental health symptoms present in MSM who consume drugs for sexual purposes. Greater uniformity in data collection instruments is required, as well as the need to conduct a more in-depth assessment of the psychosocial adjustment of people who practice chemsex.

Substance use among sexual minorities in the US - Linked to inequalities and unmet need for mental health treatment? Results from the National Survey on Drug Use and Health (NSDUH)

BACKGROUND

Sexual minorities (SM) have specific substance use patterns and show elevated rates of substance use and substance use disorders. We investigated the potential association between substance use - including chemsex drug use - among SM adults in the United States (US) and social inequality, with an additional focus on disparities in unmet need for mental health treatment.

METHODS

A secondary cross-sectional data analysis was performed using National Survey on Drug Use and Health (NSDUH) data from 2015 to 2017 and including 126,463 individuals with 8241 identifying as SM. Multivariable logistic regression models were implemented to quantify disparities in substance use, to calculate the effect of sociodemographic variables on substance use, and to examine associations with socioeconomic vulnerability.

FINDINGS

SM showed higher odds of past-year substance use and lifetime chemsex drug use. All SM except for bisexual men exhibited higher odds of past-month binge drinking relative to heterosexuals. Bisexual women had higher odds for use of all analysed substances relative to heterosexual women. Being older and being a woman were shown to be protective factors. Urbanity, being uninsured, and unmet need for mental health treatment were associated with significantly higher odds of substance use, chemsex drug use and binge drinking. A link was established between drug use and health indicators, with higher odds of drug use for lower health ratings. SM experienced significantly higher levels of socioeconomic vulnerability. Higher vulnerability indices were associated with increased odds for drug use.

INTERPRETATION

This study is among the first nationally representative samples that analysed the link between sociodemographic factors and unmet need for mental health treatment and substance use in SM. It emphasises the multifactorial aetiology of substance use exposure, highlights the underlying mechanisms for substance use among SM while underscoring disparities among them. Approaches tailored to SM subgroups may be needed to address comorbidities and negative health outcomes of substance use in the long-term. However, critical gaps in the literature remain and large-scale studies inclusive of SM individuals are needed to present causal links.

FUNDING

Gillings Fellowship SYOG054 to ARU.