Chemsex behaviours among men who have sex with men: A systematic review of the literature
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.
References (54)
- et al.
Prevalence and correlates of recent injecting drug use among gay bisexual men in Australia: Results from the FLUX study
The International Journal of Drug Policy
(2018) - et al.
Sexualised drug use in the United Kingdom: A review of the literature
The International Journal of Drug Policy
(2018) - et al.
Chemsex, risk behaviours and sexually transmitted infections among men who have sex with men in Dublin
Ireland. International Journal of Drug Policy
(2018) - et al.
HIV risk in group sexual encounters: An event-level analysis from a national online survey of MSM in the U.S
The Journal of Sexual Medicine
(2013) - et al.
The new MTV generation: Using methamphetamine, Truvada (TM), and Viagra (TM) to enhance sex and stay safe
The International Journal of Drug Policy
(2018) - et al.
Drug, sex and sociality: Factors associated with the recent sharing of injecting equipment among gay and bisexual men in Australia
The International Journal of Drug Policy
(2015) - et al.
Factors associated with event-level stimulant use during sex in a sample of older, low-income men who have sex with men in Los Angeles
Drug and Alcohol Dependence
(2009) - et al.
Mental health, drug use and sexual risk behaviour among gay bisexual men
The International Journal of Drug Policy
(2018) - et al.
Prevalence of drug use during sex amongst MSM in Europe: Results from a multi-site behavioural survey
The International Journal of Drug Policy
(2018) - et al.
Poly drug use, chemsex drug use, and associations with sexual risk behaviour in HIV-negative men who have sex with men attending sexual health clinics
The International Journal of Drug Policy
(2017)
Social norms related to combining drugs and sex ("chemsex") among gay men in South London
The International Journal of Drug Policy
Attitudes toward methamphetamine use and HIV risk behavior in men who have sex with men
The American Journal on Addictions
The Chemsex study: Drug use in sexual settings among gay & bisexual men in Lambeth, Southwark & Lewisham
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
Prevalence of HIV risk-related drug use and sexual activity among men who have sex with men attending a specialist UK club drug clinic
Drugs and Alcohol Today
Exploring strategies for PrEP adherence and dosing preferences in the context of sexualized recreational drug use among MSM: A qualitative study
Aids Care-Psychological and Socio-Medical Aspects of Aids/HIV
Drug use and health behaviour among German men who have sex with men: Results of a qualitative, multi-centre study
Harm Reduction Journal
An analysis of baseline data from the PROUD study: An open-label randomised trial of pre-exposure prophylaxis
Trials
Chemsex among men who have sex with men: A sexualized drug use survey among clients of the sexually transmitted infection outpatient clinic and users of a gay dating app in Amsterdam, the Netherlands
Sexually Transmitted Diseases
Poly-drug use: Patterns and responses
Low levels of chemsex among men who have sex with men, but high levels of risk among men who engage in chemsex: Analysis of a cross sectional online survey across four countries
Sexual Health
Response to the Hammoud et al. papers on ‘the new MTV generation’
The International Journal of Drug Policy
Sex, drugs and smart phone applications: Findings from semistructured interviews with men who have sex with men diagnosed with Shigella flexneri 3a in England and Wales
Sexually Transmitted Infections
Crystal methamphetamine and sexual sociality in an urban gay subculture: An elective affinity
Culture, Health & Sexuality
Intensive sex partying with gamma-hydroxybutyrate: Factors associated with using gamma-hydroxybutyrate for chemsex among Australian gay and bisexual men results from the Flux Study
Sexual Health
Chemsex and the city: Sexualised substance use in gay bisexual and other men who have sex with men attending sexual health clinics
International Journal of STD & AIDS
Recreational drug use during sex and sexually transmitted infections among clients of a city sexually transmitted infections clinic in Amsterdam, the Netherlands
Sexually Transmitted Diseases
Cited by (274)
Clinical manifestations and analytical reports for MDPHP acute intoxication cases
2024, Journal of Pharmaceutical and Biomedical AnalysisSharpen the focus on chemsex
2024, Addictive BehaviorsChemsex practice as a cause of death: About a case series
2024, Toxicologie Analytique et CliniquePrevalence of methamphetamine use among gay, bisexual and other men who have sex with men: A systematic review and meta-analysis
2024, International Journal of Drug Policy