Chemsex behaviours among men who have sex with men: A systematic review of the literature

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Abstract

Background

‘Chemsex’ is the use of drugs before or during planned sexual events to facilitate, enhance, prolong and sustain the experience. Drugs associated with chemsex are methamphetamine, GHB/GBL, mephedrone, cocaine and ketamine. This review syntheses published research on the antecedents, behaviours and consequences associated with chemsex behaviours among men who have sex with men (MSM).

Methods

Papers from high income countries which were published between January 2000 and September 2018 reporting the use of chemsex drugs before or during sex were identified through Medline, Web of Science, CINAHL and Central. Results were synthesised using a narrative approach and conceptualised using a behavioural analysis framework.

Results

The search identified 2492 publications, of which 38 were included in the final synthesis. There were wide variations in chemsex prevalence estimates due to the heterogeneous sampling in the studies. Chemsex participants have expectations that the drugs will positively affect their sexual encounters and HIV positive MSM are more likely to engage in the behaviour than HIV negative MSM. There were wide ranging prevalence estimates on injecting drugs for sexual purposes and the sharing of injecting equipment with some evidence of unsafe injecting practices. Participants were more likely to engage in condomless anal intercourse than men who do not engage in chemsex. This may increase the risk of transmission for HIV and other sexually transmitted infections.

Conclusion

A minority of MSM appear to engage in chemsex behaviours but they are at risk of this negatively impacting on their health and well-being. Further research is required to examine high risk chemsex behaviours, impact of chemsex on psycho-social well-being and if chemsex influences uptake of PrEP, PEP and sexual health screening.

Introduction

Men who have sex with men (MSM) can have significant and multi-faceted relationships with drugs and alcohol. Public Health England (2014) identify an alcohol dependence rate among MSM that is double that of the non-MSM male population. The Office for National Statistics (2014) report gay and bisexual men to be three times more likely to use illicit substances than their heterosexual counterparts. One quarter of a sample of MSM drawn from twenty sexual health clinics in England report using three or more recreational drugs in the previous three months (Sewell et al., 2017). However, sexual health clinic samples are likely to provide over-estimates for substance use behaviours and differences would also be expected between metropolitan samples of MSM and country-wide estimates. However, poly drug use is a recognised concern among MSM particularly those who use drugs before or during sex.

Sexualised drug use (SDU) refers to the use of any illicit drug just before or during sex and a subset term of SDU is referred to as ‘chemsex’ (Edmundson et al., 2018). Chemsex behaviours are described as the use of specific drugs before or during planned sex to facilitate, initiate, prolong, sustain and intensify the encounter (Public Health England, 2015; Bourne, Reid, Hickson, Torres-Rueda, & Weatherburn, 2015). Certain drugs have been associated with chemsex behaviours including mephedrone, methamphetamine, and GHB/GBL (Gamma hydroxybutyrate/Gamma butyrolactone) (Public Health England, 2015). In a London based study cocaine and ketamine were also linked to the behaviours (Bourne, Reid, Hickson, Torres Rueda, & Weatherburn, 2014). A high-risk behaviour associated with chemsex involves the injecting of a drug for sexual purposes (Public Health England, 2015). The concept of ‘chemsex’ is socially constructed and as such is subject to the preferences of participants and the popularity and availability of specific drugs. Furthermore, these features are likely to vary across countries and among sub-cultures within countries, as well as across time.

There have been growing concerns about the interconnected nature of high risk drug/sexual behaviours and the increased transmission risk of blood borne viruses (BBV) and sexually transmitted infections (STIs) (Public Health England, 2015). In the United Kingdom (UK) MSM account for more than half of all new human immunodeficiency virus (HIV) infections which demonstrates that they are disproportionately affected by the disease in comparison to the general population (Public Health England, 2016). The advent of HIV antiretroviral therapy and pre-exposure prophylaxis (PrEP) provide protection by reducing the risk of onward transmission and acquisition. However, the effectiveness of these medicines is reliant on patient adherence and there is limited evidence on the impact of chemsex behaviours on medication adherence. In addition to the biological risk, there is increasing concerns that chemsex may be associated with psychosocial risks. Tomkins, George, and Kilner, (2018) identified that there is growing evidence which indicates that chemsex is potentially associated with the mental ill health of MSM who engage in the activity. This highlights that there are potentially multiple biopsychosocial risk factors for MSM that engage in chemsex behaviours.

Chemsex has attracted international clinical and research attention from which there is an emerging body of knowledge on different aspects of the behaviour. For example, its prevalence (Heiligenberg et al., 2012), sociodemographic characteristics associated with the behaviour (Ober et al., 2009), patterns of drug use and sexual behaviours (Benotsch, Lance, Nettles, & Koester, 2012), biopsychosocial impact of the behaviour (Hegazi et al., 2017), and associations with HIV (Bourne et al., 2015). In early 2018 two published literature reviews (Edmundson et al., 2018; Tomkins et al., 2018) examined some aspects of chemsex but had a wider focus on MSM sexualised drug use. To date, we are not aware of a literature review that has specifically examined the research related to chemsex drug use before or during sex. As chemsex participants health is potentially at high-risk there is a need to systematically interrogate the literature on chemsex drug use within a sexualised setting. This review will comprehensively analysis the behaviours involved in chemsex activities, including the risks they present to participants. The review will help inform the development of evidence-based risk reduction strategy and provide recommendations on the need for further research.

Section snippets

Methods

The research team anticipated that different methods and means of measurement would characterise the literature in the emerging evidence base on chemsex behaviours. This review was conducted as a narrative review, guided by a conceptual framework and drawing on systematic methodology as far as possible to promote transparency and replicability with results reported according to PRISMA guidelines (Liberati et al., 2009).

Chemsex behaviours are activities for which the

Study selection

The number of studies identified, reviewed and selected with reasons for exclusion are summarised in Fig. 1. The initial total number of articles captured from the search was 3438, which after removing duplicates was 2653. On reviewing article titles there were 2362 excluded which left 291 articles for abstract screening. Eighty articles met final inclusion and at full reading there were forty-two excluded, one was not English language, five did not fully published primary research data and 36

Discussion

To our knowledge, this is the first systematic review on chemsex behaviour to exclusively incorporate and examine research on chemsex drug use before or during sex. Two literature reviews (Edmundson et al., 2018: UK research; Tomkins et al., 2018: research from every country) have examined the wider issue of sexualised drug usage among MSM; but did not provide an in-depth analysis of the behaviours involved in the sexualised setting of chemsex drug use. In early 2018 two special journal

Conclusion

It appears a minority of MSM engage in chemsex behaviour, but there are inter-connected high-risk behaviours associated with the activity. The examination of chemsex is limited due to the challenge in defining the activity and there are limitations in comparing prevalence estimates due to the use of different sampling frameworks. However, there are potentially multiple consequences associated with chemsex behaviour although this remains an under researched area. With the increasing availability

Funding

This research did not receive any specific grants or awards.

Conflict of interest

The authors whose names are listed immediately below certify that they have NO affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in

Acknowledgements

The authors would like to thank Jane Sedgwick and Iain Ryrie of King’s College London for their support with the review.

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