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An introduction to chemsex type behaviours DR STEVEN MAXWELL CHRISTOPHER WARD MSM a high-risk group Disproportionately affected by wider health inequalities and poorer health outcomes than compared to the general population: 1. Higher rates of smoking 2. Higher rates of some chronic diseases 3. Double the rates of anxiety/depression 4. Is the group most affected by HIV 5. 105,000 people currently living with HIV in the UK, approximately 45% are MSM (PHE, 2014; PHE, 2020) Defining chemsex What is chemsex? ‘Planned use of psychoactive drugs before and/or during sex to purposively initiate, prolong, facilitate and enhance the sexual encounter’ Wide ranging prevalence estimates: 3-29%, estimates from larger generalized MSM samples indicated 3% to 13% Varying definitions of chemsex, limitations in data specifically measuring drug use during sex and variable settings of data collection (PHE, 2015; Maxwell et al 2019; Edmundson et al, 2018)Motivators for engaging in chemsex Internal • Enhance sexual feelings sexual • Push sexual boundaries pleasure • Improve performance Inhibitions Chems Inter- • Enhance partner intimacy personal • Increase self-desirability dynamics Disinhibition Escapism • Diversion from daily worries • Immerse in the experience Motivators for engaging in chemsex Desired enhancements Sexual Experience Drug Effect PHYSICAL Facilitate receptive anal intercourse/esoteric acts and maximize sexual Decrease inhibitions performance/sensation Alter cognitive pathways MENTAL Alter perception which intensifies the’ in the moment’ sexual acts/experience Muscle relaxant effect Increased confidence and enhance the ability Increase energy SOCIAL to engage with partners Intensify self-emotion awareness and shared experience with partners EMOTION Chemsex context and risk behaviors u Commonly last several hours to one night, potentially 2-3 days u Mostly private residence, but also sex on premise venues u HIV positive MSM more likely to use chemsex drugs with sex u Injecting drugs: ‘slamming’, prevalence large MSM samples 1-9%, commonly crystal meth u Multiple sex partners: anonymous/non-anonymous: regular, main partners u Increased risk of condomless anal sex u Esoteric sexual acts: for example, fisting (Bourne et al, 2015; Maxwell et al, 2019) Common chemsex drugs Drug Effect Specific risks Method Specific advice Crystal meth Wide awake, Hypertension, risk of MI, Swallowed Avoid if on ARVs or anti-depressants, take ‘tina’ impulsive, aroused paranoia, hallucinations Snorted regular breaks between use injected GHB/GBL Aroused, relaxed, Highly addictive, risk of Swallowed Avoid mixing with other depressants, use a ‘G” warmth dependence, high risk of OD, Inject GHB pipette/syringe to measure dose, mix with Vulnerability/risk of sexual assault a non-alcoholic drink Mephedrone Confident, aroused, Anxiety, increased heart rate Snorting Stay well hydrated, avoid if issues with high ‘meow meow’ energetic and palpitations, hallucinations Swallowed blood pressure and heart problems and fits Cocaine Aroused, excited, Increased heart rate/ heart Snorted Stay well hydrated, avoid if issues with high ‘Charlie’ confident attack, paranoia, anxious and Injected blood pressure and heart problems panicky Ketamine Loss of feeling , With numbness left vulnerable to Snorted Stay well hydrated, avoid mixing with other ‘K’ hallucinations, out ofassault/injury, hypertension, Swallowed drugs: alcohol, GHB/GBL, psychedelics body experience agitation and confusion, Injected bladder/kidney problems Further information on drugs u Crystal meth: https://www.talktofrank.com/drug/methamphetamine u GHB/GBL: https://www.talktofrank.com/drug/ghb u Mephedrone: https://www.talktofrank.com/drug/mephedrone u Cocaine: https://www.talktofrank.com/drug/cocaine u Ketamine: https://www.talktofrank.com/drug/ketamine u MDMA: https://www.talktofrank.com/drug/ecstasy Potential biopsychosocial impact Biological Psychosocial u HIV: sexual risk key to CAS, injectingence up to 1/4 can experience impact on psychosocial risk wellbeing u Mental: decline in mental functioning, mild/moderate u HCV: injecting key factor, sexual rismental illness u Social: isolation from and loss of family/friends u HBV: snorting, injecting and sexuau Occupational: decline in productivity, absence from work, risks loss of employment u Some evidence the higher the frequency/intensity of chemsex, higher degree risk of problematic psychosocial u Bacterial STIs: associations with impact chemsex and STI diagnosis/treatment (Maxwell et al, 2019; Tomkins et al, 2019) Risk reduction 1. Use chems with someone that they trust as they can affect your judgement 2. Limit the different types and quantity of chems used 3. Avoid using chems for too long a period; more likely to experience hallucinations/paranoia 4. Avoid sharing all snorting or injecting equipment 5. Avoid letting anyone else inject them 6. Access injecting equipment provision from appropriate services 7. HBV/HAV immunisation 8. STIs, HIV and hepatitis C screening once every 3 months 9. Start on PrEP: it can reduce the risk of HIV acquisition by up to 99% Risk reduction Setting boundaries 1. Know what they are mixing: be cautious with mixing drugs as this can exacerbate the effects of forgetting where they are and who they are 2. Be clear about their limits: on websites/apps be clear about what they are not willing to do before they meet partners 3. Find about the type of session: check before they go what the session involves: is it bareback, fetish etc? 4. Do what they enjoy: Be confident and comfortable in only doing things they want 5. Change of mind: even though they may have started, they finish it when they want. They have a right to say no, it is their body Case study 1 24-year-old African GBMSM “Every time I feel sexy, I also feel scared. I worry about having sex and u Associates shame with his sexuality what that means !! I worry about the u Chemsex is the only time he feels sex I have and what that means!! I able to enjoy his sexuality think about god! I think about sin! Even wanking, I feel degraded. So, if I can’t u Feels pressure from the gay feel sexy on my own, how can I be community to perform certain hyper intimate with others? I want intimacy, I sexualised stereotypes want to feel close with someone. u Using crystal meth, GHB and chems make me feel naked- both ketamine internally and externally, I am free from u Physical trauma from sex parties my prejudice, the prejudice of people and I am free (naked)” Case study 1 Intervention Outcome u 3 monthly STI/BBV testing u Confidence u Discuss PrEP uptake u Awareness of triggers and healthy strategies to counter them u Check HBV/HAV immunization status u Approach relationships in a much healthy u Conversations around identity way u Safer practices in relation to chemsex u Reduced HIV acquisition risk u Consent and pleasure u Manage other STI risk/detection u Sexual health and mental health support u Peer support Case study 2 45-year-old GBMSM u Controlled use including GHB and crystal meth u Linked in for three monthly testing and uses event-based PrEP u Very selective about partners and had parties once every 3 months u Engaged in needle exchanges u Hadn’t impacted him financial u He was having difficulties having sex without the use ofchems Case study 2 Intervention Outcome u Re-advise around ongoing 3 monthly STI/BB u Better understanding of consent testing u Had reduces the regularity of his parties, u Review PrEP adherence: regimen/effective but he still wanted to engage u Check HBV/HAV immunization status u He was learning to engage with partners u Mixing chems advice emotionally without chems. He was still worried about sober sex u Safer practices u Ongoing reduction in HIV acquisition risk u Information around consent and healthy relationships u Risk management for other STIs u Conversations about pleasure Information SX Scotland Chemsex (s-x.scot) Video content u Community developed information from SX, Waverley Attitude Magazine Care’s service for gay and bisexual men and all men who have sex with men living Scotland. u The former chemsex addict helping other LGBTQ people overcome substance abuse issues - YouTube GMFA: Chemsex 2020 - High and Housebound? | GMFA u A man who previously engaged in chemsex talking u Survey into individuals experience of Chemsex, about the risk and pulls of the scene including types of drugs and situations. Terrence Higgins Trust: Let's Talk About Chemsex | TerreGay Star News Higgins Trust (tht.org.uk) u Online group for men who engage in Chemsex and u Slamming drugs: The 'raw horny sex' and incredible risks | Chemsex - YouTube would like to positively change their use of chems Dean Street: Chems - 56 Dean Street - Sexual Health Clinic Why pain, upset and anger is all the chemsex scene London can talk about - YouTube u Support and information for men who engage in u Two men with experience of Chemsex talking about Chemsex their relationship to drug use, sex and sexual health risks References/Further reading 1. Bourne, A., Reid, D., Hickson, F., Torres-Rueda, S. and Weatherburn, P. (2015) 'Illicit drug use in sexual settings ('chemsex') and HIV/STI transmission risk behaviour among gay men in South London: findings from a qualitative study’, Sexually Transmitted Infections, 91(8), pp. 564-8. 2. Edmundson, C., Heinsbroek, E., Glass, R., Hope, V., Mohamrned, H., White, M. and Desai, M. (2018) 'Sexualised drug use in the United Kingdom (UK): A review of the literature', International Journal of Drug Policy, 55, pp. 131 - 148. 3. Maxwell, S., Shahmanesh, M. and Gafos, M. (2019) 'Chemsex behaviours among men who have sex with men: A systematic review of the literature’, International Journal of Dug Policy, 63, pp. 74 -89. 4. Public Health England (PHE) (2014) 'Promoting the health and wellbeing of gay, bisexual and other men who have sex with men', Public Health England. 5. Public Health England (PHE) (2020) ‘Trends in HIV testing, new diagnoses and people receiving HIV-related care in the United Kingdom: data to the end of December 2019’, Public Health England. 6. Tomkins, A., George, R. and Kliner, M. (2019) 'Sexualised drug taking among men who have sex with men: a systematic review', Perspectives in Public Health, 139(1), pp. 22-33.