Attitudes and Perceived Social Norms toward Drug Use among Gay and Bisexual Men in Australia

[Chemsex: Harm reduction and support for users]

The phenomenon of chemsex, or the use of psychoactive substances in a sexual context, is increasing in communities of men who have sex with men (MSM), and carry along significant risks and consequences. No specific treatment approach has yet been established, but risk and harm reduction strategies are at the forefront. Multi-disciplinary treatment, care and support need to be based on a non-judgmental attitude, offered by trained professionals who take into account the cultural specificities of users.

Sexualised drug use among gay and bisexual men in New Zealand: Findings from a national cross-sectional study

INTRODUCTION

New Zealand has a unique illicit drug market, gay cultures and drug use patterns. Minimal attention has been given to how drug use shapes sexual practice, especially in the era of biomedical HIV prevention among gay and bisexual men (GBM).

METHODS

An online cross-sectional study of GBM ('Flux NZ') adapted from an Australian study was undertaken to explore connections between drug use, sexual practice, health and community. We describe drug use patterns, then identify three discrete groups determined by intensity of recent (past 6 months) sexual practice: no recent sex, recent sex and recent sexualised drug use. We examine factors associated with these groups and identify factors independently predicting sexualised drug use.

RESULTS

Of 739 participants, almost a third had engaged in group sex (29%), 17.5% were taking pre-exposure prophylaxis (PrEP), 6.5% were HIV positive. Overall, 59.5% had recently used illicit drugs (16.9% methylenedioxymethamphetamine, 6% methamphetamine, 3.3% gamma-hydroxybutyrate acid, 1.4% ketamine). Sexualised drug use was common (35.7%). Those engaged in sexualised drug use were connected to gay community and had a high uptake of biomedical HIV prevention. Independent predictors of sexualised drug use included being sexually adventurous, knowing their HIV status, having more than 10 recent sexual partners, engaging in group sex and sex at a sex-on-site venue.

DISCUSSION AND CONCLUSIONS

Many GBM engaging in sexualised drug use manage HIV transmission risks through regular testing, PrEP and HIV treatment. HIV prevention efforts should target GBM with less intensive sexual behaviour but who may be at comparatively higher risk of HIV transmission.

Attitudes of Gay, Bisexual, and Other Men Who Have Sex with Men (GBM) toward Their Use of Amphetamine-Type Stimulants and Relation to Reducing Use in Three Canadian Cities

BACKGROUND

We explored attitudes of gay, bisexual, and other men who have sex with men (GBM) toward their amphetamine-use and associations with reduced use over time.

METHODS

We recruited sexually-active GBM aged 16+ years in Montreal, Toronto, and Vancouver, Canada, from 02-2017 to 08-2019, with follow-up visits every 6-12 months until November 2020. Among participants who reported past-six-month (P6M) amphetamine-use at enrollment, we used logistic regression to identify demographic, psychological, social, mental health, other substance-use, and behavioral factors associated with reporting needing help reducing their substance-use. We used mixed-effects logistic regression to model reduced P6M amphetamine-use with perceived problematic-use as our primary explanatory variable.

RESULTS

We enrolled 2,449 GBM across sites. 15.5-24.7% reported P6M amphetamine-use at enrollment and 82.6 - 85.7% reported needing no help or only a little help in reducing their substance use. Reporting needing a lot/of help or completely needing help in reducing substance-use was associated with group sex participation (AOR = 2.35, 95%CI:1.25-4.44), greater anxiety symptomatology (AOR = 2.11, 95%CI:1.16-3.83), greater financial strain (AOR = 1.35, 95%CI:1.21-1.50), and greater Escape Motive scores (AOR = 1.07, 95%CI:1.03-1.10). Reductions in P6M amphetamine-use were less likely among GBM who perceived their amphetamine-use as problematic (AOR = 0.17 95% CI 0.10 - 0.29).

CONCLUSIONS

Most amphetamine-using GBM did not feel they needed help reducing their substance use, and many reported reduced amphetamine-use at subsequent visits. Those who perceived their use as problematic were less likely to reduce their use. Further interventions to assist GBM in reducing their use are needed to assist those who perceive their use as problematic.

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.

Illicit drug use among lesbian, gay, bisexual, pansexual, trans and gender diverse, queer and asexual young people in Australia: Intersections and associated outcomes

INTRODUCTION

High rates of illicit drug use have been reported among gay and bisexual young men, however limited research has examined patterns of drug use among the broader population of lesbian, pansexual, trans and gender diverse, asexual and queer (LGBTQA) young people. We examined factors associated with illicit drug use in the past 6 months and lifetime experiences of self-reported concern with drug use among LGBTQA youth in Australia.

METHODS

A cross-sectional survey was conducted involving 6418 LGBTQA participants aged 14-21 years, 5914 of whom provided information relating to their use of illicit drugs. Multivariable logistic regressions examined demographic factors and life experiences associated with drug use in the past 6 months and lifetime experiences of self-reported concern with drug use.

RESULTS

Overall, 26.4% of participants aged 14-17 and 41.9% aged 18-21 reported any drug use in the past 6 months, of whom 23.5% had ever been concerned about their drug use. Cannabis use was most commonly reported (28.3%), followed by ecstasy/MDMA (7.1%), antidepressants (5.6%) and LSD (3.5%). Higher odds of drug use were reported among cisgender men and those who had experienced homelessness or sexual harassment in the past 12 months. Higher odds of self-identified concern about drug use were observed among participants reporting challenging life experiences.

DISCUSSION AND CONCLUSIONS

Rates of illicit drug use among LGBTQA young people in this study were considerably higher than those observed in general population youth studies in Australia and were further elevated among those who had experienced LGBTQA-related prejudice or harassment, or homelessness.

"It's not just the hit itself": the social practice of injecting drug use among gay and bisexual men in Australia

BACKGROUND

Injecting drug use is purportedly more common among gay and bisexual men (GBM) than the general Australian population. Approaches designed to support the wellbeing of people who inject drugs may not be effective for GBM who inject, due to divergent settings, substances, and/or symbolism. We sought to identify the critical elements shaping injecting among GBM as a social practice and the implications for health and psychosocial wellbeing.

METHODS

We conducted 19 in-depth interviews with GBM in Australia with lifetime experience of injecting drug use, adopting the Frameworks Method for data analysis. Framed by social practice theory, transcripts were coded to delineate the constituent material, competency, and meaning elements of GBM's injecting practices. We developed themes encompassing the dynamic interrelationship between practice elements and wellbeing aspects.

RESULTS

Of 19 participants interviewed (aged 24-60 years), 17 identified as gay, two as bisexual. Injecting histories ranged from 2-32 years; most injected methamphetamine (n = 18). Injecting involved the integration of sexual function with substances and injecting skills in dyadic/communal settings. Beyond traditional harm reduction aspects, 'safe injecting' concerned trustworthiness of fellow practitioners, preventing addiction, and maintaining a solid self-concept. Injecting occurred as a dyadic/communal practice, in which an uneven distribution of materials (substances, sexual capital) and competencies (self-injecting) influenced risk and power dynamics. Pleasurable meanings of belonging, desirability and self-actualisation - gained from communities of practice - conflicted with injecting-related stigma, social dependencies, and fear of harms to body, mind, and sense of self.

CONCLUSION

Injecting is a heterogenous practice, including among GBM. Shifting configurations of its composite elements influence GBM's perceptions and experiences of pleasure, risk, and harms. Efforts to support their wellbeing should take a dyadic/communal approach and seek to rectify the uneven distribution of material and competency elements in these settings.

Disparities in Use/Misuse of Specific Illicit and Prescription Drugs among Sexual Minority Adults in a National Sample

Background: Compared to heterosexual adults, lesbian, gay, and bisexual (LGB) adults have higher rates of any illicit drug use and any prescription drug misuse, yet disparities regarding specific drugs remain poorly characterized. Methods: We examined disparities by sexual identity and sex for 8 illicit and prescription drugs using 2015-2019 National Survey on Drug Use and Health data. Outcomes included past-year use/misuse of cocaine/crack, hallucinogens, inhalants, methamphetamine, heroin, prescription opioids, prescription stimulants, prescription tranquilizers/sedatives, and level of polydrug use/misuse (2 substances; 3+ substances). For each outcome, odds ratios relative to heterosexual adults of same sex were estimated using logistic regression controlling for demographics; significant estimates were interpreted as a disparity. Results: Among gay men, significant disparities were present for all drugs except prescription stimulants and heroin; inhalant use was particularly elevated. Bisexual women exhibited significant disparities for every drug examined, as did bisexual men (except heroin). Among lesbian/gay women, disparities were only present for prescription opioids and stimulants. Relative to heterosexual peers, use of 3+ substances was 3 times higher among gay men and bisexual women and 2 times higher among bisexual men. Conclusions: Consistent with minority stress theory, prevalences of illicit and prescription drug use/misuse were 2-3 times higher among LGB adults than heterosexual adults. Illicit drug use should not be perceived as only impacting gay/bisexual men - bisexual women had similar - or higher - prevalences of hallucinogen, cocaine, methamphetamine, and heroin use. Yet, in contrast to bisexual women, lesbian/gay women did not exhibit disparities for any illicit drugs.

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.

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.

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.

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.

Normative Substance Use Antecedents among Sexual Minorities: A Scoping Review and Synthesis

Although sexual minority stress remains the dominant perspective for understanding disproportionate substance use among lesbian, gay and bisexual (LGB) populations, social norms are among the most predictive and commonly targeted substance use antecedents in other high-risk groups. This scoping review seeks to bring clarity to the body of norms-focused alcohol, tobacco, and other drug (ATOD) research conducted with LGBs over the past 20 years, identify intervention implications, and present priority directions for future research. Fifty-two peer-reviewed studies published between June 1999 and June 2019 were identified from searches of PubMed, PsycInfo, and Medline databases using combinations of terms related to: social norms; sexual orientation or sexual minority status; and, the use of alcohol, tobacco, and other drugs. A far greater number of studies focused on actual ATOD norms than perceived ATOD norms or discrepancies between actual or perceived norms, illuminating the need for additional research focused on these levels of analysis. Taken together, this literature suggests that: (1) perceived ATOD norms are reliable predictors of LGBs' ATOD use; (2) actual ATOD use norms are low among LGBs participating in representative, population-based survey studies; and, (3) LGBs over-estimate the ATOD use of peers. Thus, intervention strategies including personalized normative feedback, psychoeducation, and social branding may hold promise in reducing LGBs substance use. However, additional research is needed to increase our understanding of injunctive ATOD norms, identify meaningful LGB reference groups, elucidate environmental influences on ATOD norms, and examine relationships between stigma experiences, perceived norms, and ATOD use.

Chemsex and Mental Health of Men Who Have Sex With Men in Germany

Background: Chemsex is defined as using certain substances immediately before or during sexual activities to facilitate, prolong and/or intensify sexual experience, mainly by some communities of men who have sex with men (MSM). Four substances are typically associated with chemsex: methamphetamine, mephedrone, GHB/GBL, and ketamine. While there is a lot of evidence for increased prevalence of HIV, sexually transmitted infections and other sexual health measures among MSM, who engage in chemsex, there has been little research on mental health aspects. This study aims to describe aspects of mental health among a sample of German men who have sex with men (MSM) who engage in chemsex and to describe potentially adverse consequences of chemsex behavior. Method: This paper refers to a subset of participants from the German Chemsex Survey, an MSM-community recruited, self-completed online survey with a self-selected convenience sample. The survey comprised 420 different items considering recreational substance use, substance use in sexual settings, mental health, sexual transmitted infections, adverse consequences of chemsex behavior, and experiences of non-consensual sex acts. A group of participants who used methamphetamine, mephedrone, GHB/GBL, and/or ketamine in a sexual setting in the last 12 months (n = 280, chemsex group) was analyzed regarding symptoms of depression (PHQ-9), general anxiety disorder (GAD-7), somatization (PHQ-15), and PTSD (Primary Care PTSD Screen). Group comparisons were conducted between the chemsex group and men who did not use substances in a sexual context (n = 177, non-chemsex group). Mean scores of mental health measures were compared, as well as scores above a cut-off that indicates clinically relevant symptoms. Logistical regression was utilized to determine whether mental health measures can predict adverse consequences of engagement in chemsex behaviors. Results: A total of 1,583 men started the survey; 1,050 participants provided information on substance use. Twenty-seven percent of participants (n = 280) reported that they used methamphetamine, mephedrone, GHB/GBL and/or ketamine in a sexual setting in the last 12 months. The chemsex group showed significantly higher mean scores for depression, anxiety, and somatization than the non-chemsex group, but effect sizes were low. Even though mean scores were heightened, they were still far below the cut-off for clinically relevant symptoms. The chemsex group reported significantly higher incidences of non-consensual sex acts compared with the non-chemsex group. Some men in the chemsex-group experienced potentially adverse consequences, such as loss of control regarding time and money spent for chemsex activities or amount of substances used at one occasion (49.6%), negative impacts on social functioning (33.6%), psychotic symptoms (13.2%), and physically aggressive behavior toward others (2.9%). Clinically relevant symptoms did not predict a higher likelihood for adverse consequences. Discussion: Mean scores for depression, anxiety, and somatization were significantly higher in the chemsex-group, but effect sizes were low. Both groups reported poorer mental health compared to men in the German general population. Mental health measures did not contribute to predict potentially adverse consequences of chemsex behavior.

Let’s talk about chemsex and pleasure: the missing link in chemsex services

Purpose

The purpose of this paper is to document the experience of current and former methamphetamine users on their crystal meth use patterns and on their use of services related to their chemsex practice.

Design/methodology/approach

For qualitative component, two focus groups were formed with nine current users of methamphetamine and eight former users. Thematic analysis was performed to know their experiences.

Findings

All participants were already engaging in chemsex with various substances before they first started using methamphetamine. Methamphetamine use led some to slam (methamphetamine or mephedrone injection). Some participants report that their sexual experiences were intensified early in their chemsex practice. They reported feeling more confident with their partners, feeling like they are sexually attractive and overcoming their barriers to sexuality. The intensification of methamphetamine use and, in particular, injection change the positive perception of sexual life. Thus, for some participants, substance use takes more space and their sexual experiences become less satisfactory.

Practical implications

Participants report the services that address the phenomenon of chemsex are still scarce in Quebec province. In addition, the few services available aim to relearn a sober sexuality. However, the mourning of the positive aspects of chemsex on sexual experiences seems still very little discussed. Greater consideration of positive chemsex experiences is needed in services that address this issue.

Originality/value

This project documented the perception of pleasure related to sexual practices among regular methamphetamine users. Their perception of pleasure will help develop services adapted to their reality.