DRUG USE AMONG MEN
WHO HAVE SEX WITH MEN
Implications for harm
About the Author:
Dr. Adam Bourne is a Research Fellow with the Sigma Research group at the London
School of Hygiene & Tropical Medicine. His research focuses on understanding HIV risk
behaviour among men who have sex with men, as well as on health inequalities and the
broader health and well-being of people from marginalised communities.
The author would like to thank Monty Moncrieﬀ of Antidote @ London Friend for his
valuable contribution and Dr. George Ayala for reviewing an earlier version of this chapter.
Numerous studies have demonstrated that men who have
sex with men (MSM) experience disproportionate levels of
ill-health1-3 compared to the general population, and are one
of the highest risk groups for HIV in every part of the world.4,
5 MSM frequently face signiﬁcant stigma and discrimination
from their families, communities and, in some countries,
are the subject of systemic repression and persecution.7
Often this repression and stigmatisation can make accessing
appropriate health services, where they exist, problematic.8, 9
A signiﬁcant concern among health professionals and
advocates who work to improve the health and well-being
of MSM relates to the prevalence of drug use within the
population, its uses and its associated harms. The chapter
begins with an overview of the range of drugs taken by MSM,
followed by a description of prevalence across the world
(where such data exist) and a discussion of data quality. It then
assesses the reasons for drug use by MSM and the harms that
may be associated with such use. The ﬁnal section highlights
interventions to help reduce the harms associated with drug
use among MSM.
MSM, gay, homosexual, queer?
Terminology to describe men who are attracted to, or
have sex with, other men is often carefully selected.
Some men who are attracted to, or have sex with, other
men may describe themselves as ‘gay’, while others do
not. Some might use the term ‘homosexual’ (literally
meaning they have a sexual orientation towards people
of the same sex) or ‘queer’ (referring to a sexuality that
deviates from the ‘norm’). ‘Men who have sex with men’
(MSM) refers only to the act of sexual contact between
two men and is rarely used by men themselves to
describe their sexuality. Health professionals often use
the term MSM because it relates to behaviour which,
when considering issues such as HIV, other sexually
transmitted infections (STIs) or drug use, is more
important than the identity an individual might assign
themselves. When working with this population it is
important that you establish the term with which male
clients or service users are most comfortable.
The range of drug use among MSM
Studies indicate that MSM utilise a broad range of drugs.
This chapter relates only to non-prescription drugs that
are considered illegal or otherwise ‘recreational’ in most
countries. The following is a list of drugs known to be
used by MSM, and includes street names or regional
»Amphetamine (speed, uppers, sulphate, whizz)
»Cannabis (marijuana, Mary Jane, dope, pot, spliﬀ,
hash(ish), weed, puﬀ, grass, herb, draw, wacky
backy, ganja, hemp)
»Cocaine (coke, Charlie, C, snow, blow, a toot,
Bolivian/Peruvian/Colombian marching powder)
»Crack cocaine (rock, base) – essentially a super-
»Crystal methamphetamine (Crystal, Tina, meth, ice,
crank) – essentially a super-strength amphetamine
»Ecstasy (E, MDMA, X, XTC)
»GHB/GBL (Gina, G, liquid ecstasy)
»Heroin (smack, skag, junk, horse)
»Ketamine (K, special K, vitamin K)
»LSD (acid, a trip)
»Mephadrone (MCAT, Meow-meow)
»Poppers (amyl, butyl, isobutyl nitrate, aromas, liquid
incense) – the formula frequently changes, but they
are chemicals from the alkyl nitrite family.
Prevalence of drug use among MSM
Establishing the prevalence of drug use among MSM in
diﬀerent parts of the world is challenging. In a large number
of countries, homosexuality, or sex between men, is illegal,
making the collection of data relating to sexuality challenging
and complex. Even where research about MSM and drug
use has been conducted, it is often diﬃcult, or impossible,
to compare because of inconsistent methodologies, such as
diﬀerent recruitment methods, a focus on diﬀerent drugs or
use in diﬀerent settings or across varying time frames (e.g.
within the last month, the last three months, within the past
12 months or drug use ever in life). In addition, the use of
drugs may vary wildly not only from one region of the world
to another but from one country to the next, between cities
in the same country or even among diﬀerent venues within
the same city. As is the case with other populations, drug use
among MSM in various areas can change signiﬁcantly within
short spaces of time, meaning that data collected can quickly
The literature review that follows is written with the best data
publicly available in English.
a For a detail ed account of these d rugs commonly use d by MSM and their eﬀe cts, see
There has been relatively little research in general conducted
with MSM in African nations, and only a small number of
studies that have speciﬁcally explored drug use. Much of the
research that has been conducted relates solely to injecting
drug use (IDU), with rates among MSM ranging from 3.4 to 12%
in Malawi and 8% in Namibia,10 all within the last six months,
and 14% within the last year among MSM in Zanzibar.11 Drug
use among MSM in South Africa has received more attention
than in other countries, with one study reporting that 11% of
men described having sex while under the inﬂuence of drugs
within the previous 12 months,12 and further mixed-method
research suggesting signiﬁcant regional variation in drug use
across diﬀerent cities in the country.13, 14 For example, crystal
methamphetamine was the most commonly used drug
among MSM in Cape Town, but dipipanone hydrochloride was
more common in Durban.
The 2010 Asian MSM Internet Sex Survey15 included 10,861
respondents recruited online from China, Singapore,
Malaysia, Taiwan, Hong Kong, Thailand, Japan, Indonesia, the
Philippines, Korea and Vietnam. Table 1 displays the levels of
reported drug use within the past six months (ﬁndings are
not publicly available at country level). Data from this survey
also indicate that drug use was signiﬁcantly higher among
MSM with diagnosed HIV, particularly with respect to crystal
methamphetamine, ketamine and ecstasy. A 2009 study in
Thailand identiﬁed an association between HIV prevalence
and a history of drug use.16
Table 1: Levels of drug use among respondents in the Asian
MSM Internet Sex Survey
Stimulant drugs % Use in last 6 months
Crystal meth 4.0
Several other studies across the continent have explored
lifetime usage of drugs, with levels ranging from 6% in
Vietnam17 and 11.7% in Taiwan18 to nearly 65% in Japan19
(although much of this variation can be accounted for by
diﬀerences in sampling and recruitment).
Levels of IDU among MSM in Asia have generally been low.17,
20, 21 There are currently no data publically available on the
prevalence of drug use among MSM living in Central Asian
Frequent gay community surveys in Australia and New
Zealand provide a detailed picture of drug use among MSM in
these countries, as displayed in table 2.
In Australia, the proportion of men reporting any IDU in
the previous six months has remained stable at around
5–6% for the last ten years.26 While the percentage of men
using poppers has fallen slightly over the last nine years,
still in 2009 an average of 31.8% of MSM across the country
reported use within the previous six months. The Australian
surveys typically identify higher rates of all drug use in Sydney
compared to other parts of the country.
Table 2: Prevalence of drug use among MSM in Australasia within the previous 6 months
Cocaine % Poppers % Cannabis % Ecstasy % Methamphetamine % Ketamine % Source
(Sydney) 20.6 40.4 27.9 29.8 11.1 9.6 2011 Gay Community Periodic
(Melbourne) 12.4 35.4 27.6 21.5 8.9 6.0 2011 Gay Community Periodic
(Adelaide) 7.1 21.9 34.6 17.2 9.5 2.1 2011 Gay Community Periodic
(Auckland) 7.3 40 37.5 21.2 7.9 5.7 2006 Gay Auckland Periodic
Prevalence data for drug use among MSM in the Caribbean
is extremely scarce. Secondary analysis of a representative
general household survey data collected in Puerto Rico27
reported lifetime use of cannabis (63.4%), amphetamines
(20%) and heroin (20%). A quarter of MSM reported using
cannabis (24.4%) and cocaine (24.4%) in the past 12 months.
The UNAIDS-sponsored Caribbean Men for Men Internet Sex
Survey (CARIMIS) is underway at the time of writing and will
report its ﬁndings in the summer of 2012. This survey will
provide drug use data for each of the Caribbean nations and
territories and will be a useful source of information for the
development of future interventions.b
b See http://www.carimis.org
Comprehensive data on drug use among MSM was collected as
part of the European Man for Man Internet Sex Survey (EMIS).
This online survey was open for completion in 25 languages
in the summer of 2010 and recruited a total of 181,495 men.
It asked questions about use of a range of drugs within the
previous 4 weeks (as displayed in table 3). While country-level
data will become available in the near future, at present EMIS
data are reported on a European sub-regional level.
Research in the UK29 that explored drug use levels among
MSM within the previous 12 months reported levels ranging
from 39.4% for poppers, 27.7% for cannabis, 18.5% for ecstasy
and 4.7% for methamphetamine (with signiﬁcant regional
variations evident and highest usage in London.)30 Drug
use among MSM in Catalonia, Spain, within the previous 12
months followed a broadly similar pattern (poppers 40.8%;
cannabis 26.0%; ecstasy 10.2% and methamphetamine
Table 3: Use of drugs among MSM across Europe within the previous four weeks
Region of residence poppers use in last 4
cannabis (or LSD) use in
last 4 weeks
Heroin/crack use in last
party drugs* use in last
West: Belgium, France, Rep.
of Ireland, the Netherlands,
28.3 13.8 0.4 10.6
North West: Denmark,
Finland, Norway, Sweden 13.8 6.2 0.3 3.1
22.0 10.1 0.2 4.9
South West: Greece, Spain,
Italy, Portugal 10.9 13.6 0.4 6.6
North East: Estonia,
Lithuania, Latvia 6.2 4.9 0.2 2.3
Republic, Hungary, Poland,
15.2 10.2 0.3 4.9
South East (EU): Bulgaria,
Cyprus, Malta, Romania 7.9 5.9 0.3 3.0
South East (non-EU):
Bosnia & Herzegovina,
Croatia, Macedonia, Serbia,
7.7 8.6 0.4 2.5
East: Belarus, Moldova,
Russia, Ukraine 8.3 5.2 0.3 2.4
* Party drugs include ecstasy, amphetamine, methamphetamines, mephadrone, GHB, ketamine and cocaine. Adapted from EMIS
There are no publically available national MSM drug use
prevalence data for the USA: prevalence is reported only at
a city or state level. This approach is appropriate in terms of
inﬂuencing local harm reduction interventions but makes
country-level comparison diﬃcult. Table 4 provides a snapshot
of drug use prevalence in diﬀerent cities, established via
Similar levels of poppers use among MSM have been observed
A signiﬁcant body of research has addressed
methamphetamine use among MSM in the USA. This drug
is commonly associated with euphoria, decreased sexual
inhibition and hypersexual behaviour.36, 37 Analysis of data
collected annually between 1996 and 2007 in Los Angeles
found levels of methamphetamine use within the last 12
months varying from 11% to 53%.38 A longitudinal study of
club drug using gay and bisexual men in New York found that
64.6% of their sample reported using methamphetamine
within the previous four months.39
Levels of IDU among MSM in both Canada and the USA have
typically been very low.2, 40, 41, 42
Between 1999 and 2002 a series of 19 sero-epidemiological
cross-sectional surveys43 were conducted among MSM in
seven diﬀerent South American nations: Argentina, Bolivia,
Colombia, Ecuador, Paraguay, Peru and Uruguay. These
surveys asked about history of drug use (ever) and analysed
such usage in light of national HIV prevalence to identify
signiﬁcant associations. The surveys recruited a total of 13,847
MSM participants by opportunistic, community sampling,
although the number of participants varied considerably
between countries. Reported data from Peru appear
incomplete; therefore, Peru is not included in Table 5.
Table 4: Prevalence of drug use among MSM across the USA
(Year of data
(2007) 6.2 27.9 8.38 12.03 24.46 Community survey of
the last 3
(2002–2003) 6 28 13 12 -
Household survey. Data
from HIV-negative MSM
the last 6
(1999–2001) 23* - - 19 37
intervention of MSM
Colfax et al.
* Includes speed and any form of methamphetamine
Table 5: Reported drug use (ever) among MSM from six South American countries
Drug used (ever) Colombia % Ecuador % Bolivia % Argentina % Uruguay % Paraguay %
Cannabis 31.2 17.4 21.4 15.4 14.8 42.4
Heroin 2.4 0.6 0.0 0.4 0.2 4.3
Cocaine 14 4.9 17.2 6.7 21.9 26.4
[Adapted from Bautista et al.]43
Broad patterns of drug use among all
In reviewing this broad literature from across the globe,
several patterns in MSM drug use emerge. Firstly, most
drug use among MSM appears to be episodic, with weekly
or monthly use far higher than daily.15, 29, 44 This might
suggest that most MSM who report drug use are not drug-
dependent but instead use drugs for speciﬁc purposes (such
as when partying, socialising or when seeking or having sex).45
Episodic drug use may also reﬂect speciﬁc periods of stress or
uncertainty, such as an HIV diagnosis, struggles in the process
of ‘coming out’, or may occur in combination with periods of
depression or anxiety.
Secondly, MSM, or gay men, are not a homogenous group in
terms of drug use. Prevalence of use was very often higher
among further marginalised or minority groups, such as ethnic
minority gay men in the USA,46-48 and is often higher among
younger men.42, 49, 50 Use of most drugs (except cannabis)
tends to be higher among MSM living in large urban centres,
particularly those with large gay populations such as Berlin,
Sydney, London and San Francisco than it is among men in
more rural areas.26, 30
Thirdly, polydrug use (taking more than one drug during the
same session or within a ﬁxed time frame) is common among
MSM, particularly with regards to stimulants (‘party drugs’)
such as ecstasy, cocaine, amphetamines or ketamine.34, 51
Fourthly, across the world, the prevalence of IDU, especially
heroin, was generally very low. Other than in South Africa,
reported levels of IDU in non-purposive samples rarely
exceeded 5%. Previous authors52 have suggested that the
reason insuﬃcient attention has been paid to drug use
among MSM is speciﬁcally because levels of heroin use –
often the focus of drug harm reduction services – have been
comparatively low. In the absence of heroin-related health
concerns, and those social or community harms such as crime
which are often associated with problematic heroin use, the
harm reduction needs of gay men have not always featured
on the radar of policymakers.
Harms associated with drug use
Harms to physical and mental health
The physical and mental health harms associated with
cocaine, heroin, ecstasy, cannabis, LSD and amphetamines are
well documented, and are likely to be similarly represented in
Crystal methamphetamine is a super-strength amphetamine
stimulant, which results in high-energy feelings of conﬁdence,
invincibility or impulsiveness. Continuous stimulation of the
nervous system by crystal methamphetamine has been
known to cause anxiety, depression, confusion, insomnia,
psychosis and suicidal ideation,53 and long-term use may also
result in a loss of motor control or memory.54
GHB/GBL (Gamma-butyrolactone) is a party drug that brings a
sense of euphoria. It is usually sold diluted in water, although
just an extra millilitre of GBL over a moderate dose can result in
an overdose, the eﬀects of which are often unconsciousness,
coma or death by respiratory depression. GBL can be addictive
(although this usually only develops over longer periods
of time) and, therefore, can result in signiﬁcant withdrawal
After-eﬀects of inhaling poppers can include headaches, skin
rashes, sinus pains and burns, but only if the liquid comes
into contact with the skin. They have also been known to
cause nausea and vomiting. Inhaling poppers after taking
anti-impotence drugs, such as Viagra or Cialis, can result in a
dangerous drop in blood pressure.55 This may be more likely
to occur if also taking a protease inhibitor as part of HIV anti-
retroviral therapy (ART).
There is evidence to suggest that the use of a range of drugs,
particularly methamphetamines, GBL and ecstasy, might have
a detrimental impact on adherence to ART.56, 57
Harms to sexual health and well-being
The association between drug use (particularly
methamphetamine, ecstasy and cocaine) and sexual risk
behaviours is complex, and a comprehensive analysis of this
literature is beyond the scope of this chapter (for a review,
see Corsi et al.58 or Romanelli et al.59). It is possible to say that
there is a clear association between certain drug use and sex
that carries a risk of HIV transmission. However, it is not clear
whether this is causal or simply co-relational.
Signiﬁcant attention has been paid to the role of
methamphetamine in HIV transmission risk behaviours,
particularly in the USA. This drug can cause feelings of
hypersexualisation and is commonly utilised as part of
sexual marathons (protracted periods of sexual activity)
and group sex activities.60-62 Ensuing rectal trauma facilitates
the transmission of HIV. Numerous studies have suggested
that the use of methamphetamine causes high-risk sexual
behaviour,63-65 perhaps via a myopic mechanism or the
removal of sexual inhibitions. However, other studies have
challenged this causal pathway.66, 67
Other associations with high-risk sexual behaviour have been
identiﬁed in relation to ecstasy,68 GHB/GBL69 and ketamine.70
Men who reported polydrug use in the recent past (up to
three months) are more likely to report HIV risk behaviours
than men who took only one drug.44, 47
Poppers cause blood vessels to dilate and also relax the
anal sphincter muscle. This can make receptive anal
intercourse more comfortable for some men. The process of
vasodilatation, and the fact that sex may be rougher or last for
longer while using poppers, means that their use during sero-
discordant anal intercourse can increase the probability of HIV
transmission by a factor of three.71, 72
Motivations for drug use
There has been relatively little research exploring the reasons
or motivations for drug use among MSM or the personal and
social context within which drug use occurs, particularly
outside North America, Western Europe and Australia.
Numerous authors52, 73 have highlighted that in most settings
the majority of venues to meet other men for social and/
or sexual interaction are those where alcohol is served and
drug use is common. Clubs and bars are the centre of most
‘gay scenes’, and drug use itself is normalised within this
environment. Drugs often serve a very deliberate purpose
in helping individuals to relax, to socialise, to mitigate social
unease and to gain conﬁdence in seeking sexual partners.74
The value of these actions and activities should not be
underestimated by those seeking to support MSM to reduce
any harm that may be associated with their drug use.
Further to this, a signiﬁcant body of research indicates that
(crystal) methamphetamines are often used by MSM to
psychologically enhance sexual experience, to maintain
sexual activity over long periods of time and to facilitate
sexual desires by dissipating sexual inhibitions.75-77 Drugs may
also help MSM with diagnosed HIV, in particular, to ‘cognitively
escape’ from fear of rejection and negative self-perception
and to cope with broader emotional and physical demands of
living with HIV on a daily basis.78
The best indicator of whether drug use is problematic, or
is in danger of becoming so, is if the individual concerned
considers their use in this way. As already discussed, drug use
among MSM in general tends to be episodic in nature, but
dependency can still develop and signiﬁcant harm can result.
For many men, drug use becomes problematic when the costs
or side-eﬀects associated with usage impinge on their ability
to live the life they are comfortable or content with.
Harm reduction interventions to meet
the needs of MSM
Drug use interventions for MSM need to empower men with
honest information about what the possible eﬀects (both
positive and negative) might be of taking a range of drugs.
They should seek to support men, and those around them,
to control or limit their use, or to limit the harms associated
with such use, at times when they consider their drug
use is causing harm to themselves or others. This can be
accomplished in a number of ways, ranging from provision
of educational information to psychotherapeutic support
and pharmacological interventions. Whatever the setting,
interventions should take into account each man’s personal
circumstances, acknowledging that drugs can serve a useful
purpose in their lives, particularly in terms of mitigating
psychological unease or by facilitating social or sexual
contact. Health professionals should take account of these
motivations and work with men to identify what level or type
of drug use they are comfortable with, and help to reduce
harms associated with this use.
Numerous civil society organisations in Australia, Canada,
Germany, Poland, the UK and USA have developed websites or
printed information booklets that explain the eﬀects of drugs
commonly used by MSM, and describe ways in which any
associated harms might be mitigated. They often also include
information about the legal status of each drug, and provide
referral information for direct contact services if readers
consider their use problematic.
Provision of psycho-therapeutic services or counselling
speciﬁcally designed to address problematic drug use
among MSM varies considerably across the world and
within individual countries. They are known to currently
exist in Australia, Canada, Germany, New Zealand, Norway,
South Africa,79 Spain, Sweden, the UK and USA. A service
in Hong Kong ran between 2007 and 2009. Such therapy
includes drop-in advice, motivational interviewing, support
groups and cognitive behavioural therapy. Many of these
interventions appear grounded in evidence from evaluations
of the general population (for review, see Shearer80), although
there have been a number of evaluations of behaviour change
interventions related to methamphetamine use speciﬁcally
among MSM.81-83 In many instances, such evaluated
programmes focus on reducing harms to sexual health and
the likelihood of contracting or transmitting HIV, with mixed
success (for review, see Rajasingham et al.57). In a very small
number of settings, primarily the UK and USA, pharmacologic
interventions exist to address methamphetamine use, but
their eﬀectiveness is still uncertain.84, 85
In Australia, and in many parts of Europe and North America,
harm reduction services are situated within the HIV prevention
sector, largely because of the association with sexual risk
behaviours and because this sector is well established with
strong links to the gay communities they serve. There is
currently no provision of any harm reduction interventions
speciﬁcally targeting MSM in Africa (except the Republic of
South Africa), Asia, the Caribbean or South America. While
MSM could access services for the general population (where
they exist), previous research has reported that they often
feel uncomfortable or unwelcome in such environments.52
Drug use among MSM is frequently associated with ‘gay scene’
social activity or with sex, and many services for the general
population may not be suﬃciently knowledgeable, skilled or,
indeed, accepting to help address drug use that occurs within
antidote @ London friend
This organisation works exclusively with lesbian, gay,
bisexual and transgender (LGBT) people who use drugs,
the majority being gay men in their 20 and 30s, mostly
employed and ﬁnancially self-supporting. In the past
three to four years the drug use proﬁle of their clients
has shifted towards crystal meth and GHB/GBL, with
many people using them in sexual contexts. There
has been a trend to inject crystal, and for GBL use to
rapidly escalate to dependence levels (dosing around
every two hours), so the type of intervention has had to
extend to medical (mainly prescribing for GBL detox),
having been mainly psychosocial. This typically involves
administering benzodiazepines in high doses (often
> 100mg/24hrs),6 which they oﬀer in partnership with
the NHS Club Drug Clinic, to help clients deal with
withdrawal symptoms. Dependence on GBL is an entirely
new phenomenon for members of the community, who
have used other drugs, often without major problems,
for many years.
Most service users do not ﬁt the typical proﬁle of
mainstream UK drug services or the typical drug
patterns presenting there. By oﬀering a targeted service
they are able to remove many of the barriers of users not
identifying with generic support. Being an LGBT service
means that people feel less judged and more able to talk
about their full range of associated problems, which they
may feel inhibited to do in generic services, particularly
as it may involve talking about sexual behaviours they
feel ashamed of.
They work around reasons for using, dealing with
cravings and trigger situations, negotiating safer
boundaries and improving well-being overall; these are
all typical substance misuse interventions, but it is their
provision in a safe and understanding LGBT environment
which sets the service apart. c
This review has highlighted the extent of drug use among
MSM and summarised the range of harms that can be
associated with their use. Drug use is common among MSM
and is well established in gay social and sexual environments.
Given the signiﬁcant harms associated with many of the drugs
that MSM use, harm reduction interventions that meet the
speciﬁc needs of MSM should be prioritised in all parts of the
c See http://www.londonfriend.org.uk
Establishing the prevalence of drug use among MSM living
in Central Asian Republics, South America, the Caribbean
and Africa is a research priority. Systematic population and
local-level estimations for MSM populations are a necessary
precursor to this. There is a need for more qualitative research
in many parts of the world that explores the reasons why MSM
use drugs and the personal and social context of this use.
Harm reduction practitioners should seek to understand
variations in drug use among MSM in their local area and
tailor interventions accordingly. They should attend to
changes in such use over time, and be accepting of the social
and sexual environments in which drug use often occurs.
Harm reduction practitioners should also attend to ethnic or
sexuality variation within MSM communities, acknowledging
that further marginalised sections of the population are more
likely to use drugs and for such use to be problematic. As the
evidence base for prevalence, motivations, context and harms
associated with drug use among MSM evolves, so it would be
beneﬁcial to develop toolkits for eﬀective interventions for
rollout in various settings.
As long as homosexuality – or acts of sex between men – is
criminalised, and as long as MSM face stigma and persecution,
it will remain a signiﬁcant challenge to develop and deliver
eﬀective interventions to meet the complex needs that this
review identiﬁes. Legal and policy reforms relating to MSM are
required in a large number of countries if prevention of HIV
transmission and a reduction in other harms associated with
drug use is to be realised.
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