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Sexualised drug use by MSM (ChemSex): A toolkit for GUM/HIV staff

Sexualised*drug*use*by*MSM*
(ChemSex):*
A*toolkit*for*GUM/HIV*staff*
Author;*David*Stuart*
David.Stuart@me.com*
davidstuart.org*
@davidastuart*
... Currently, there is no 'best practice' toolkit or 'gold standard' intervention for chemsex however some local authorities and practitioners have adopted ad hoc responses to deal with this public health crisis (Stuart, 2014). Bourne and Weatherby consider that ' … equal access to existing harm reduction services' that understand the specific health and social care needs of MSM who use substances will have the greatest benefit and impact in reducing harm (Bourne & Weatherburn, 2017, p. 345). ...
... A key debate in response to new emerging drug trends in the last ten years concerns whether existing services should be able to meet the needs of individuals who engage in sexualized drug use or whether they should be referred to specialist support services (Chatwin et al., 2018). Evidence shows that MSM engage better and more often with sexual health and/or LGBTQ specialist services (Stuart, 2014). Our study found that London practitioners often referred to LGBTQ specialist services as better environments to provide interventions. ...
... Many of the prompts in the 2015 'Chemsex Briefing' by Public Health England remain outstanding and there continues to be an 'urgent need' to define the appropriate care pathways and provision, with the funding mechanisms to do so (Moncrieff, 2018;PHE, 2015). The significant physical, mental, and social harms associated with chemsex have not dissipated however, needle, syringe, and harm reduction programs in the UK could provide ample opportunity for intervention and harm reduction support (Stuart, 2014). ...
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Needle exchange and harm reduction programs in the UK provide a range of interventions which could be effective in reducing the risk of physical and psychological harm and minimizing the spread of blood-borne viruses for men who have sex with men (MSM) who engage in chemsex. To understand the existing practice, this qualitative study was undertaken using semi-structured interviews with 17 harm reduction practitioners working in needle exchange services in two UK cities. The following four themes were identified during data analysis: chemsex understanding and existing practice; drugs, sex, and pleasure; visibility; and inclusivity. Findings indicate that these harm reduction and needle exchange services are not equipped to meet the needs of MSM who inject drugs associated with chemsex. The heteronormative perceptions of needle exchange programs, coupled with the uncomfortableness of exploring pleasure, challenge the inclusive environment and universal offer these services promote. Practitioner perceptions of sexualized drug use and pleasure may be a barrier to reducing harm to MSM who engage in chemsex. Further research into interventions for chemsex is needed to inform a best practice model to be used across all drug and alcohol provisions in the UK.
... psychosexual support, sexual assault 24 services), which is a barrier to care at a time when people may be particularly vulnerable. 25 Poor access to NHS mental health services has been reported across the UK (Care Quality 1 Commission, 2019), therefore this finding is likely to be reflective of a lack of access 2 generally, rather than being specific to MSM engaging in SDU. The lack of knowledge of 3 chemsex and SDU outside of sexual health settings was raised as a barrier to care. ...
... Moors, 2019), which are in themselves linked to same-sex sexual stigma for men (Herek,22 2004), in addition to the stigma and marginalisation of people who use drugs (Room, 2005), 23 all interact in the case of SDU resulting in the behaviour being highly stigmatised. Although 24 the Minority Stress Model suggests internalised homophobia may be a factor in influencing 25 health behaviour among MSM (Meyer, 2003), it may not be as useful when discussing 1 chemsex and SDU, as it can be off-putting to MSM who are experiencing problems relating 2 to drug use but do not see their sexuality as a contributing factor. 3 Study findings also highlighted a potential problem of defining chemsex as a 4 behaviour exclusive to MSM, as a SP recalled a heterosexual woman with problems related 5 to GHB who could not access support services because these are specific to MSM. ...
... Both MSM who were currently engaging in SDU and MSM who had stopped 24 engaging were recruited in an attempt to provide multiple narratives and experiences. 25 However, it is possible that those who wanted to voice their experiences were more likely to 1 volunteer, but as with all qualitative research, the aim was to explore people's personal 2 experiences of SDU and chemsex, rather than the representativeness of these viewpoints. 3 Whilst not all barriers to care identified were specific to MSM engaging in SDU (such as 4 funding and access), these are likely to impact on MSM engaging in SDU and chemsex, and 5 are therefore still important and valid to highlight. ...
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Background Chemsex and sexualised drug use (SDU) among men who have sex with men (MSM) has become a public health issue because of its associated sexual risks. Some MSM engaging in SDU require further help and support, but it is not clear if this need is being met. This research seeks to understand MSM and service provider (SP) perspectives of the current standard of service provision for MSM engaging in SDU. Method Semi-structured interviews were conducted with 13 MSM and 16 SPs in England (January-December 2019). MSM who reported taking one of ten substances for sex in the past 12 months were recruited from a mailing list or a community organisation providing chemsex support. Potential SP participants were recruited via an email sent from their local healthcare NHS Trust. Data for MSM and SPs were analysed separately using thematic analysis. Results MSM participants had a median age of 34 years (range 23–66).The majority of SPs recruited were genitourinary medicine (GUM) consultants. We found that the main reason for engagement in SDU was because of the enhanced sexual experience. Most MSM recruited were satisfied with their sexual health service provision, but barriers to care were highlighted by both MSM and SPs. Four themes relating to barriers to care were identified: accessibility of sexual health services, funding of services, SP's attitudes towards MSM who engage in SDU, and services outside sexual healthcare. Conclusion SPs appeared to have adopted a harm reduction approach to MSM engaging in SDU, but for MSM wanting further help and assistance in relation to their SDU additional barriers to care existed. Training healthcare providers outside of sexual health services regarding chemsex and SDU may reduce some of these barriers, but funding for sexual health services needs to be improved to maintain and further develop services.
... Participants were recruited via purposive and snowball sampling -techniques typical for accessing 'hidden populations' like people who use drugs (e.g. Stuart, 2014). Participants were between 21 and 52 years of age. ...
... Given drug use is often associated with leisure time -something 'for the weekend' (Dennis, 2019, 27) -participants' language might reflect their desire to present sobriety as their normal state, implicitly framing their drug use as 'unproblematic' (Room, 2005). Participants often stressed that while they did enjoy sex on drugs, this did not detract from their enjoyment of sober sex: Retaining the capacity to enjoy sober sex may have been significant to participants because not enjoying sober sex is often cited as evidence of dependency on substances (Stuart, 2014;Evers et al., 2019). Only one spoke explicitly about this: ...
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Sex involving illicit drugs is currently receiving close academic attention. For the most part, research in this area is public health orientated and focuses on the experiences of men who have sex with men engaging in ‘chemsex’. In the current article, I use in-depth interview data from 14 participants across a range of gender and sexual identities to undertake a queer criminological analysis of sex on drugs. Taking Gayle Rubin’s foundational Thinking Sex as a starting point, I argue that participants’ narratives construct a sober/drug-involved sex hierarchy in which the former is afforded a higher status. I then utilise critical work on drug ‘effects’, Tim Dean’s work on ‘raw sex’ and notions of stigma to interrogate assumptions underpinning this hierarchy. I argue that the perceived artificial nature of intoxicated intimacy, the unmediated appeal of sober sexual intimacy and stigma connected to certain drugs and certain sex-on-drug-practices underlie participants talk. I conclude that ‘thinking sex on drugs’ demonstrates the productive potential of criminological engagement with queer theory, and vice versa.
... ChemSex intervention There is an emerging body of literature examining the development of educational and counseling interventions targeted at MSM who use crystal methamphetamine with sex ("ChemSex"), [47][48][49] which may reduce the risk of acquiring HCV among this population. ChemSex is associated with HCV infection, as well as high-risk behaviors such as multiple sexual partners, transactional sex, group sex, fisting, sharing sex toys, injecting drug use, higher alcohol consumption, and the use of 'bareback' sexual networking applications. ...
... 50 In 1 HIV/genitourinary medicine clinic in London, after completion of HCV treatment, clinicians provide MSM with harm reduction messages, education on HCV transmission risks related to ChemSex, ChemSex packs including safe injecting equipment and educational information, and a referral to on-site, ChemSex behavior change support. 49 It has been reported that ChemSex motivations are often associated with internalized homophobia and shame surrounding homosexual sex, gay cultural/societal norms, sexual performance anxieties, and body image concerns. Successful behavioral interventions for MSM at risk of acquiring or transmitting HCV in ChemSex environments would need to address these sensitive issues. ...
Article
Hepatitis C virus reinfection rates among men who have sex with men are high. Factors associated with infection point to varied sexual and drug-related risks that could be targeted for interventions to prevent infection/reinfection. Modeling indicates that tackling increasing incidence and high reinfection rates requires high levels of hepatitis C virus treatment combined with behavioral interventions. Enhanced testing strategies and prompt retreating of reinfection may be required to promptly diagnosed reinfections. Behavioral interventions studies addressing reinfection are required. Other interventions include traditional harm reduction interventions, adapted behavioral interventions, and interventions to prevent harms related to ChemSex and other risk factors.
... 50 4-methylmethcathinone became popular in Europe, especially the UK, in the early 2010s and has an effect similar to amphetamines and cocaine (Schifano et al. 2011). substances (particularly meth, GHB, phosphodiesterase (PDE5) inhibitors 51 , amyl nitrates, mephedrone) to facilitate & enhance sex with other men over an 'extended period' (Giorgetti et al., 2017;McCall, Adams, Mason, & Willis, 2015;Race, 2018;Stuart, 2014). Grindr and other hook-up apps are also referenced occasionally as a quintessential feature of chemsex (Hakim, 2019;Stuart, 2019). ...
Thesis
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Gay and queer men tend to experience higher rates of mental health issues, STIs/HIV, suicide, substance dependency, and poor well-being than other demographics. Despite sustained public health efforts internationally, many of these issues continue to disproportionately affect members of the gay community. This thesis presents a new approach to the health issues gay and queer men face. It examines how 'risky' health-related practices including condomless sex and the use of illicit drugs might be legitimate ways of performing self-care and pursuing well-being. In order to address this aim, I conducted 16 interviews over a 12-month period in New Zealand and Australia using a constructionist grounded theory approach and a theoretical framework that draws upon the work of Judith Butler, Elizabeth Grosz, Michel Foucault, Homi Bhabha, Kane Race, Nikolas Rose, and Pierre Bourdieu. My participants and I explore a wide range of topics including the performative nature of sex and the notion of 'play', how pleasure and the emotional significance of sex might be related to self-care, the ways in which space might influence sexual practices and experiences, and to what extent having sex outside the home might be a form of self-care. I also cover safer sex practices and the experience of disease, how PrEP has radically changed the way gay men approach sex, the way drugs are bound up in self-care practices, and the relationships between self-care and community. The concept of 'wild self-care' emerged from these interviews and describes how practices or behaviours which appear risky, dangerous, or unhealthy can also be seen as legitimate ways of caring for the body and the self. I demonstrate how my participants used creative, unexpected, ii and alternative methods of caring for themselves using substances or 'risky' forms of sex and describe the way self-care is communal nature rather than a solitary practice. I also present the notion of health-as-process. This concept allows researchers to approach health as an ongoing process rather than a state of being that might be achieved. This speaks to the emotional and personal way that risk is constructed and experienced. All these facets come together to articulate the deeply complicated ways that people care for themselves.
... "SIDU" appears to be associated with several potentially harmful drugrelated practices including polydrug use; poor injection technique; injection by partners; sharing (sometimes intentionally) of equipment; people not filtering solutions; mixing in syringe barrels; using blood as a solvent; frequent redosing and prolonged use (Bourne et al., 2014;Knoops et al., 2015). "SIDU" has also been associated with several potentially harmful sex-related practices to obtain sexual arousal such as fisting (Knoops et al., 2015;Stuart, 2014a;Weatherburn et al., 2017). ...
Article
Sexualized injecting drug use ("SIDU") is a phenomenon associated with a wide array of high-risk injecting and sex-related practices. This scoping review establishes what is known about MSM and SIDU to assess implications for health care and policy. Characteristics of MSM for "SIDU" may include being on anti-retroviral treatment and urban residency with drivers being challenging social taboos; a search for intimacy; convenience of administration; relationship breakdown and increased restrictions in clubs and saunas. Attraction for use appears to be enhancement or prolongation of sexual experiences/pleasure; intimacy and the facilitation of a range of potentially "unsafe" sexual activity. Traditional services are ill-equipped to address "SIDU" because of a lack of knowledge of practices, lack of associated vocabulary, and a failure to integrate sexual health with drug services. For effective responses, these issues need to be addressed.
... It is possible that some interventions developed to prevent HIV transmission among MSM may also be effective against HCV, particularly those targeting unprotected anal intercourse [29,92]. There is an emerging body of literature examining the development of educational and counselling interventions targeted at MSM who engage in ChemSex [93][94][95], which may reduce the risk of acquiring HCV among this population. Further research is needed examining the development, acceptability, and efficacy of culturally sensitive behavioural change interventions for preventing HCV infection. ...
Article
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Introduction The World Health Organization targets for hepatitis C virus (HCV) elimination include a 90% reduction in new infections by 2030. Our objective is to review the modelling evidence and cost data surrounding feasibility of HCV elimination among people living with HIV (PLWH), and identify likely components for elimination. We also discuss the real‐world experience of HCV direct acting antiviral (DAA) scale‐up and elimination efforts in the Netherlands. Methods We review modelling evidence of what intervention scale‐up is required to achieve WHO HCV elimination targets among HIV‐infected (HIV+) people who inject drugs (PWID) and men who have sex with men (MSM), review cost‐effectiveness of HCV therapy among PLWH and discuss economic implications of elimination. We additionally use the real‐world experience of DAA scale‐up in the Netherlands to illustrate the promise and potential challenges of HCV elimination strategies in MSM. Finally, we summarize key components of the HCV elimination response among PWLH. Results and discussion Modelling indicates HCV elimination among HIV+ MSM and PWID is potentially achievable but requires combination treatment and either harm reduction or behavioural risk reductions. Preliminary modelling indicates elimination among HIV+ PWID will require elimination efforts among PWID more broadly. Treatment for PLWH and high‐risk populations (PWID and MSM) is cost‐effective in high‐income countries, but costs of DAAs remain a barrier to scale‐up worldwide despite the potential low production price ($50 per 12 week course). In the Netherlands, universal DAA availability led to rapid uptake among HIV+ MSM in 2015/16, and a 50% reduction in acute HCV incidence among HIV+ MSM from 2014 to 2016 was observed. In addition to HCV treatment, elimination among PLWH globally also likely requires regular HCV testing, development of low‐cost accurate HCV diagnostics, reduced costs of DAA therapy, broad treatment access without restrictions, close monitoring for HCV reinfection and retreatment, and harm reduction and/or behavioural interventions. Conclusions Achieving WHO HCV Elimination targets is potentially achievable among HIV‐infected populations. Among HIV+ PWID, it likely requires HCV treatment scale‐up combined with harm reduction for both HIV+ and HIV‐ populations. Among HIV+ MSM, elimination likely requires both HCV treatment and behaviour risk reduction among the HIV+ MSM population, the latter of which to date has not been observed. Lower HCV diagnostic and treatment costs will be key to ensuring scale‐up of HCV testing and treatment without restriction, enabling elimination.
Article
Objectives: The study aims to investigate rates of sexualized drug use (SDU) and chemsex, a type of SDU involving specifically the use of crystal methamphetamine, mephedrone, or GHB/GBL and their association with the rates of negative sexual health outcomes among men who have sex with men (MSM) in Greece. Methods: Survey of 485 MSM in internal disease departments and community testing centers. Results: Twenty-eight percent of participants were involved in SDU and 20.4% in chemsex. HIV positive status and recent STI diagnoses were associated with SDU involvement. Conclusion: SDU and chemsex rates and their impact on health reveal the need for informed community-based services.
Article
Background: Despite high hepatitis C virus (HCV) treatment rates, HCV incidence among HIV-positive men who have sex with men (HIV+ MSM) in Germany rose prior to HCV direct-acting antivirals (DAAs). We model what intervention can achieve the World Health Organization (WHO) elimination target of 80% incidence reduction by 2030 among HIV+ MSM in Berlin. Methods: An HCV transmission model among HIV-diagnosed MSM was calibrated to Berlin (rising HCV incidence and high HCV testing/treatment). We modelled HCV incidence among HIV-diagnosed MSM in Berlin until 2030 (relative to 2015 WHO baseline) under scenarios of DAA scale-up with/without behavior change (among HIV-diagnosed MSM and/or all MSM). Results: Continuing current treatment rates will marginally reduce HCV incidence among HIV-diagnosed MSM in Berlin by 2030. Scaling-up DAAs to 100% within 3 months of diagnosis and 25%/year of previously diagnosed and untreated from 2018 could reduce incidence by 61% (2.5-97.5%Interval 55.4-66.7%) by 2030. The WHO target would likely be achieved by combining DAA scale-up with 40% HCV transmission risk reduction among HIV-diagnosed MSM and 20% transmission reduction from HIV-undiagnosed or negative MSM. Discussion: HCV elimination among HIV+ MSM in Berlin likely requires combining DAA scale-up with moderately effective behavioral interventions to reduce risk among all MSM.
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Gamma-hydroxybutyrate (GHB) has been used as a recreational drug since the 1990s and over the last few years there has been increasing use of its analogues gamma-butyrolactone (GBL) and to a lesser extent 1,4-butanediol (1,4BD). This review will summarize the literature on the pharmacology of these compounds; the patterns and management of acute toxicity associated with their use; and the clinical patterns of presentation and management of chronic dependency associated with GHB and its analogues.