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HibbertMP, etal. Sex Transm Infect 2019;0:1–9. doi:10.1136/sextrans-2018-053933
Behaviour
ORIGINAL ARTICLE
Psychosocial and sexual characteristics associated
with sexualised drug use and chemsex among men
who have sex with men (MSM) in theUK
Matthew Peter Hibbert, 1 Caroline E Brett,2 Lorna A Porcellato,1 Vivian D Hope1
To cite: HibbertMP,
BrettCE, PorcellatoLA, etal.
Sex Transm Infect Epub ahead
of print: [please include Day
Month Year]. doi:10.1136/
sextrans-2018-053933
1Public Health Institute,
Liverpool John Moores
University, Liverpool, UK
2Department of Psychology,
Liverpool John Moores
University, Liverpool, UK
Correspondence to
Mr Matthew Peter Hibbert,
Public Health Institute, Liverpool
John Moores University,
Liverpool L2 2QP, UK; m. p.
hibbert@ 2017. ljmu. ac. uk
Received 11 December 2018
Revised 25 February 2019
Accepted 24 March 2019
© Author(s) (or their
employer(s)) 2019. No
commercial re-use. See rights
and permissions. Published
by BMJ.
ABSTRACT
Objective To understand how the emerging public
health issue of chemsex relates to broader patterns of
sexualised drug use (SDU) among men who have sex
with men (MSM), which has been understudied.
Methods Potential participants were invited to
take part in an anonymous, cross-sectional online
survey through Facebook advertising and community
organisations’ social media posts (April–June 2018).
Multivariable logistic regression was used to compare
MSM who engaged in recent SDU (past 12 months)
with those who did not, and those who engaged in
chemsex (γ-hydroxybutyrate/γ-butyrolactone, crystal
methamphetamine, mephedrone, ketamine) with those
who engaged in other SDU (eg, poppers, cocaine,
cannabis).
Results Of the 1648 MSM included, 41% reported
recent SDU; 15% of these (6% of total, n=99) reported
chemsex. Factors associated with SDU were recent STI
diagnosis (aOR=2.44, 95% CI 1.58 to 3.76), sexual
health clinic attendance (aOR=2.46, 95% CI 1.90 to
3.20), image and performance-enhancing drug use
(aOR=3.82, 95% CI 1.87 to 7.82), greater number of
condomless anal male partners, lower satisfaction with
life and greater sexual satisfaction. Predictors of chemsex
compared with other SDU were not being UK-born
(aOR=2.02, 95% CI 1.05 to 3.86), living in a densely
populated area (aOR=2.69, 95% CI 1.26 to 5.74), low
sexual self-efficacy (aOR=4.52, 95% CI 2.18 to 9.40)
and greater number of condomless anal male partners.
Living with HIV, taking pre-exposure prophylaxis (PrEP),
and experiencing or being unsure of experiencing sexual
contact without consent were significantly associated
with SDU and chemsex in bivariate analyses but not in
the multivariable.
Conclusion Health and behavioural differences were
observed between MSM engaging in chemsex, those
engaging in SDU and those engaging in neither. While
some MSM engaging in chemsex and SDU appeared
content with these behaviours, the association with
life satisfaction and sexual self-efficacy indicates
psychosocial support is needed for some. The association
with sexual risk and sexual consent also indicates the
importance of promoting harm reduction among this
population (eg, condoms, PrEP, drug knowledge).
INTRODUCTION
The use of drugs among men who have sex with
men (MSM) has historically been researched in the
context of the HIV epidemic, due to the increased
sexual risk as well as the increased risk of blood-
borne viruses associated with needle sharing when
injecting drugs.1 2 Sexualised drug use (SDU) refers
to the use of drugs before or during sex to facili-
tate or enhance sexual activity, pleasure or intimacy.
Estimates of the prevalence of SDU among MSM
vary greatly depending on definition, measurement
and recruitment methods used.3 Chemsex (some-
times referred to as ‘party and play’) is a partic-
ular form of SDU among MSM where men engage
in sex for long periods of time, with multiple
sexual partners, with crystal methamphetamine,
γ-hydroxybutyrate/γ-butyrolactone (GHB/GBL),
mephedrone, cocaine and/or ketamine taken imme-
diately before or during sex.4 The rise of chemsex
as a public health issue may be due to an increase
in the number of people engaging in this behaviour
and its associated sexual risk-taking, which has
been reported by sexual health services and men
who engage in chemsex,5 6 both suggesting geospa-
tial networking applications and online sites to
meet sexual partners have enabled this increase.
Quantitative research has also found a higher use
of ‘barebacking’ (condomless sex) geospatial sexual
networking applications among MSM engaging in
chemsex.7
The European MSM Internet Survey found that
the three European cities with the highest preva-
lence of use of chemsex-associated drugs were
Brighton (16.3%), Manchester (15.5%) and London
(13.2%).8 Behaviourally, engaging in chemsex has
been associated with more sexual partners, group
sex, condomless anal intercourse, fisting, sharing
sex toys, injecting drug use and higher alcohol
consumption.4 7 9 While MSM reporting chemsex
are more likely to be living with HIV, MSM who
do not have HIV and report engaging in chemsex
are more likely to have accessed postexposure
prophylaxis.7 10 In Amsterdam, a higher proportion
of MSM engaging in chemsex were taking pre-ex-
posure prophylaxis (PrEP) compared with MSM
not engaging in chemsex.11 Among MSM living
with HIV, illicit drug use has been associated with
reduced antiretroviral therapy adherence and a
detectable viral load, making transmission of HIV
possible, and polydrug use was associated with
increased condomless anal intercourse with a sero-
discordant partner.12 13 When MSM have specified
particular drug use, GHB, crystal methamphetamine
on 13 April 2019 by guest. Protected by copyright.http://sti.bmj.com/Sex Transm Infect: first published as 10.1136/sextrans-2018-053933 on 12 April 2019. Downloaded from
2HibbertMP, etal. Sex Transm Infect 2019;0:1–9. doi:10.1136/sextrans-2018-053933
Behaviour
and non-chemsex-related drugs (eg, erectile dysfunction drugs,
poppers) have been associated with condomless anal intercourse
among MSM in England.14
Reasons for engagement in chemsex that have been suggested
in qualitative interviews are the stigma around HIV, internalised
homophobia and the intense sexual experience of chemsex.15
However, quantitative research recruiting MSM through Face-
book advertising did not find an association between inter-
nalised homophobia, experiences of discrimination and sex
under the influence of drugs in the UK.16 Research to date into
understanding SDU and its associated implications for sexual
health has had a focus on health protection and health promo-
tion, whereas the impact on mental health and psychological
well-being has been somewhat neglected. During qualitative
interviews with MSM engaging in chemsex in London, it was
reported that chemsex was having an impact on some men’s
personal relationships and professional conduct.17 In Australia,
being dependent on methamphetamine was associated with
depression and anxiety compared with non-dependent users, but
this was not measured in a sexual context.18 In Dublin, a quarter
of MSM attending a sexual health clinic reported that chemsex
was having a negative impact on their lives, 17% reported losing
consciousness while engaging in chemsex, and 6% reported their
partners had lost consciousness,19 and MSM have reported in
qualitative interviews feeling uncomfortable in these situations,
due to issues regarding a person’s ability to consent to sex.17
Research into chemsex and other forms of SDU among
MSM in the UK to date has mostly focused on sexual health
outcomes.3 To inform public health responses, this study exam-
ines both chemsex and SDU across the UK, comparing differ-
ences in sexual and psychosocial characteristics between MSM
who do not engage in any form of SDU, those who engage in
SDU and those who engage in chemsex.
METHODS
Design
This analysis uses data from a sample of MSM recruited via a
national, cross-sectional online questionnaire aimed at lesbian,
gay, bisexual and transgender (LGBT) people aged 18 or over
in the UK. A convenience sample was obtained using spon-
sored Facebook advertising and promotion on social media via
relevant LGBT organisations. Four LGBT organisations across
the UK promoted the survey on their social media accounts
(COAST, London Friend, Gay Men’s Health Collective and
National LGB&T Partnership). A sample size calculation using
the Public Health England estimate that 2.5% of the population
in England are lesbian, gay or bisexual,20 a margin of error of
5% and 95% CI indicated that a minimum target sample size for
MSM was 384.
Participants
Four sponsored adverts were run on Facebook for 6 weeks
between April and June 2018, targeting MSM, women who
have sex with women, trans people or LGBT people generally.
Facebook users were shown the sponsored advert for the ‘Sex
and Lifestyles survey’ if they engaged with one or more MSM
or LGBT topics on Facebook. Participants were invited to take
part in the survey if they had ever had a sexual partner of the
same gender and/or they identified as trans. Participants would
then be directed to the online survey and asked two screening
questions, ensuring that participants were aged 18 or over and
currently lived in the UK. To aid recruitment participants had
the option to enter a prize draw for a £50 or one of two £25
Amazon vouchers.
Measures
The questionnaire was divided into three areas: demographics,
sexual health and drug use, and psychological well-being. MSM
participants were those who identified as male and who gave
their sexual orientation as gay or bisexual, or who stated they
had sex with men. Sexual health questions were adapted from
research on similar topics.21 Aligned with previous research,
questions about drug use and SDU were asked with regard to
specific drugs.22 Participants were first asked if they had taken
any of the 14 listed drugs (including alcohol) in the past 12
months. SDU was grouped as participants who had stated they
had been under the influence of cannabis during sex in the past
12 months, or stated having taken amphetamine, cocaine, crack
cocaine, ecstasy, heroin, GHB/GBL, ketamine, mephedrone,
methamphetamine, Viagra or other erectile dysfunction drug,
poppers, or another unspecified drug just before or during sex in
the past 12 months. The chemsex group was defined as having
taken GHB/GBL, ketamine, mephedrone and/or methamphet-
amine just before or during sex.
Sexual satisfaction was measured using an adapted version
of the New Sexual Satisfaction Scale,23 and sexual self-efficacy
(participants’ confidence in practising safer sex consistently) was
measured using a previously validated tool for use with MSM.24
Questions regarding motivations for engaging in SDU and sex
under the influence of alcohol were adapted from motivations
and attitudes towards chemsex questions.9 Psychological well-
being was measured using a variety of previously validated
scales: the Internalised Homophobia Scale,25 the Objectified
Body Consciousness Scale to measure body image satisfaction,26
a Three-Item Loneliness Scale,27 the Satisfaction With Life
Scale,28 and the Kessler Psychological Distress Scale.29
Analysis
All analyses were conducted using SPSS V.25. Forward step-
wise multivariable logistic regression analyses were used to
explore factors associated with engaging in SDU compared with
not engaging in SDU, and factors associated with engaging in
chemsex as opposed to SDU (entry p<0.05, removal p>0.10).
Factors significant at the univariate level (p<0.05) were included
in the multivariable model. Descriptive χ2 analyses were used to
compare motivations for and effects of engaging in, chemsex,
other types of SDU and sex under the influence of alcohol.
RESULTS
Of the 4690 surveys started, 96 participants did not meet the
eligibility criteria, and 1014 did not complete the survey suffi-
ciently to be included in analyses (completion rate of 78%).
Overall, the median time taken to complete the survey was 12
min. Of the 3676 participants included, 1663 were identified
as MSM, and 1649 of these MSM (99%) had completed the
drug use and sex questions to be included in the analysis. MSM
who completed the survey were more likely to be university-ed-
ucated (53% vs 61%, p<0.05), but did not differ on any other
demographic variables where data were available. One MSM
identified as heterosexual and was therefore not included in the
analysis. The majority of MSM identified as gay/homosexual
(86%), were of white ethnicity (95%), with a mean age of 30.7
(SD=10.4, range 18–76), and 43% stated they were single/not in
a relationship. Half of participants had attended a genitourinary
medicine (GUM) clinic in the past 12 months, 4% were living
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HibbertMP, etal. Sex Transm Infect 2019;0:1–9. doi:10.1136/sextrans-2018-053933
Behaviour
Table 1 Univariate and multivariable analyses for factors associated with sexualised drug use in the past 12 months
Univariate Adjusted model
MSM not engaged in sexualised
drug use (n=978) MSM engaged in sexualised drug use (n=670)
OddsRatio (95% CI)
adjusted Odds Ratio
(95% CI) n or mean % or SD n or mean % or SD Row %
Sexuality
Homosexual 824 84% 587 88% 42 Ref
Bisexual 108 11% 44 7% 29 0.57 (0.40 to 0.83)**
Queer 24 2% 26 4% 52 1.52 (0.86 to 2.68)
Age group
18–24 359 37% 174 26% 33 Ref Ref
25–34 403 41% 240 36% 37 1.23 (0.97 to 1.56) 1.08 (0.81 to 1.44)
35–49 171 17% 186 28% 52 2.24 (1.70 to 2.96)*** 2.51 (1.81 to 3.50)***
≥50 44 4% 68 10% 61 3.19 (2.10 to 4.85)*** 4.00 (2.43 to 6.59)***
Ethnicity
White 934 96% 637 95% 41 Ref
Person of colour 42 4% 32 5% 43 1.12 (0.70 to 1.79)
Country of birth
UK 855 87% 577 86% 40 Ref
Not UK 106 11% 76 11% 42 1.06 (0.78 to 1.45)
Education
University or higher 578 59% 401 60% 41 Ref
Qualifications at 18 290 30% 176 26% 38 0.88 (0.70 to 1.10)
Qualifications at 16
or lower
87 9% 75 11% 46 1.24 (0.89 to 1.74)
Work status
Full time 615 63% 426 64% 41 Ref
Part-time 69 7% 44 7% 39 0.92 (0.62 to 1.37)
Student 185 19% 79 12% 30 0.62 (0.46 to 0.83)**
Unemployed 35 4% 24 4% 41 0.99 (0.58 to 1.69)
Other (sick leave,
retired, carer)
70 7% 91 14% 57 1.88 (1.34 to 2.62)***
Relationship status
Living with partner 355 36% 232 35% 40 Ref
Relationship not
living with partner
197 20% 120 18% 38 0.93 (0.70 to 1.23)
Relationship with
multiple
17 2% 18 3% 51 1.62 (0.82 to 3.21)
Single 408 42% 299 45% 42 1.12 (0.90 to 1.40)
Population density per hectare
<5 225 23% 136 20% 38 Ref
5–20 219 22% 127 19% 37 0.96 (0.71 to 1.30)
20–41 233 24% 166 25% 42 1.18 (0.88 to 1.58)
>41 287 29% 236 35% 45 1.36 (1.04 to 1.79)*
Internalised homophobia
Low 616 63% 444 66% 42 Ref
High 354 36% 213 32% 38 0.84 (0.68 to 1.03)
Discrimination
sexuality
None 534 55% 340 51% 39 Ref
Any setting 414 42% 297 44% 42 1.13 (0.92 to 1.38)
Perceived health
Fair/good/very good 877 90% 580 87% 40 Ref
Very poor/poor 101 10% 90 13% 47 1.35 (1.00 to 1.82)
Psychological
distress
Normal 206 21% 153 23% 43 Ref
Moderate 220 22% 154 23% 41 0.94 (0.70 to 1.26)
High 267 27% 152 23% 36 0.77 (0.57 to 1.02)
Continued
on 13 April 2019 by guest. Protected by copyright.http://sti.bmj.com/Sex Transm Infect: first published as 10.1136/sextrans-2018-053933 on 12 April 2019. Downloaded from
4HibbertMP, etal. Sex Transm Infect 2019;0:1–9. doi:10.1136/sextrans-2018-053933
Behaviour
Univariate Adjusted model
MSM not engaged in sexualised
drug use (n=978) MSM engaged in sexualised drug use (n=670)
OddsRatio (95% CI)
adjusted Odds Ratio
(95% CI) n or mean % or SD n or mean % or SD Row %
Very high 275 28% 203 30% 42 0.99 (0.75 to 1.31)
Diagnosed STI in the past 12 months
None 903 92% 511 76% 36 Ref Ref
STI diagnosis 42 4% 135 20% 76 5.68 (3.95 to 8.17)*** 2.44 (1.58 to 3.76)***
Not stated 33 3% 24 4% 42 1.29 (0.75 to 2.20) 1.45 (0.77 to 2.71)
Attended genitourinary medicine in the past 12 months
No 594 61% 199 30% 25 Ref Ref
Yes 368 38% 457 68% 55 3.71 (3.00 to 4.58)*** 2.46 (1.90 to 3.20)***
Not sure 9 1% 9 1% 50 2.99 (1.17 to 7.62)* 3.61 (1.15 to 11.34)*
Number of men anal intercourse in the past 12 months
0–1 622 63% 182 27% 23 Ref
2–5 261 27% 190 28% 42 2.49 (1.94 to 3.19)***
6–10 52 5% 126 19% 71 8.28 (5.76 to 11.90)***
>10 40 4% 171 26% 81 14.61 (9.97 to 21.40)***
Number of men without condom anal intercourse in the past 12 months
0–1 811 83% 362 54% 31 Ref Ref
2–5 137 14% 170 25% 55 2.79 (2.16 to 3.60)*** 1.77 (1.31 to 2.40)***
6–10 17 2% 63 9% 79 8.33 (4.80 to 14.43)*** 4.31 (2.38 to 7.80)***
>10 7 1% 74 11% 91 23.75 (10.83 to 52.06)*** 8.42 (3.67 to 19.29)***
Sexual contact without consent in the past 12 months
No 925 95% 595 89% 39 Ref
Yes 37 4% 41 6% 53 1.72 (1.09 to 2.72)*
Unsure 12 1% 24 4% 67 3.11 (1.54 to 6.26)**
HIV status
Negative 807 83% 496 74% 38 Ref
Negative, on PrEP 28 3% 71 11% 72 4.12 (2.63 to 6.48)***
Positive 19 2% 55 8% 74 4.71 (2.76 to 8.03)***
Don’t know 124 13% 48 7% 28 0.63 (0.44 to 0.90)*
Sexual self-efficacy
High 934 96% 615 92% 40 Ref
Low 34 3% 44 7% 56 2.03 (1.28 to 3.22)**
Taken image or performance-enhancing
drugs in the past 12 months?
No 959 98% 629 94% 40 Ref Ref
Yes 19 2% 36 5% 65 2.89 (1.64 to 5.08)*** 3.82 (1.87 to 7.82)***
Body satisfaction 42.0 11.8 41.3 12.7 1.00 (0.99 to 1.00)
Loneliness score 5.5 1.8 5.5 1.8 1.01 (0.96 to 1.07)
Satisfaction with life 20.6 7.1 19.6 7.6 0.98 (0.97 to 1.00)** 0.97 (0.95 to 0.99)***
Sexual satisfaction 40.6 9.2 42.5 8.7 1.02 (1.01 to 1.04)*** 1.03 (1.01 to 1.04)***
*P<0.05, **p<0.01, ***p<0.001.
MSM, men who have sex with men; PrEP, pre-exposure prophylaxis; Ref, reference.
Table 1 Continued
with HIV, 6% were taking PrEP, and 5% reported having had
sexual contact without consent in the past 12 months. There
was no statistical difference between London (45%, n=121/264)
and outside of London (39%, n=545/1375) for SDU, and no
statistical difference between MSM reporting recent chemsex
between London (11%, n=30/263) and other densely populated
areas (9%, n=25/287).
SDU was reported by 41% of MSM: 28% of MSM had taken
amyl nitrates (poppers) immediately before/during sex; 13%
had been under the influence of cannabis during sex; 12% had
taken Viagra before or during sex; and 10% had taken cocaine
before or during sex. Less prevalent drugs taken before or during
sex were ecstasy (4%), GHB/GBL (3%), mephedrone (3%),
methamphetamine (2%), ketamine (2%), amphetamines (1%)
and other drug not specified (1%). GHB/GBL, ketamine, meth-
amphetamine and mephedrone were grouped as chemsex drugs,
and 99 (6%) MSM had engaged in chemsex drug use just before
or during sex.
Table 1 displays the multivariable analysis describing the
sexual and psychosocial characteristics of MSM who had
engaged in any SDU in the past 12 months, compared with
MSM who did not report any SDU. Due to the strong associ-
ation between the number of male anal intercourse partners
and number of condomless male anal intercourse partners in
the past 12 months, only the latter was included in the multi-
variable analysis, due to greater sexual risk. Factors associated
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HibbertMP, etal. Sex Transm Infect 2019;0:1–9. doi:10.1136/sextrans-2018-053933
Behaviour
Table 2 Univariate and multivariable analyses for factors associated with engaging in chemsex in the past 12 months compared with other
sexualised drug use
Univariate Adjusted model
MSM engaged in other sexualised
drug use (n=570) MSM engaged in chemsex (n=99) Odds Ratio (95% CI)
adjusted Odds Ratio (95%
CI)
n or mean % or SD n or mean % or SD Row %
Sexuality
Homosexual 497 87% 90 91% 15 Ref
Bisexual 40 7% 4 4% 9 0.55 (0.19 to 1.58)
Queer 23 4% 3 3% 12 0.72 (0.21 to 2.45)
Age group
18–24 154 27% 20 20% 11 Ref
25–34 198 35% 42 42% 18 1.63 (0.92 to 2.90)
35–49 152 27% 34 34% 18 1.72 (0.95 to 3.13)
≥50 65 11% 3 3% 4 0.36 (0.10 to 1.24)
Ethnicity
White 548 96% 89 90% 14 Ref
Person of colour 22 4% 10 10% 31 2.80 (1.28 to 6.11)*
Country of birth
UK 497 87% 80 81% 14 Ref Ref
Not UK 57 10% 19 19% 25 2.07 (1.17 to 3.66)* 2.02 (1.05 to 3.86)*
Education
University or higher 337 59% 64 65% 16 Ref
Qualifications at 18 154 27% 22 22% 13 0.75 (0.45 to 1.27)
Qualifications at 16
or lower
63 11% 12 11% 16 1.00 (0.51 to 1.97)
Work status
Full time 356 62% 70 71% 16 Ref
Part-time 38 7% 6 6% 14 0.80 (0.33 to 1.97)
Student 73 13% 6 6% 8 0.42 (0.18 to 1.00)
Unemployed 20 4% 4 4% 17 1.02 (0.34 to 3.07)
Other (sick leave,
retired, carer)
78 14% 13 13% 14 0.85 (0.45 to 1.61)
Relationship status
Living with partner 202 35% 31 31% 13 Ref
Relationship not living
with partner
105 18% 15 15% 13 0.93 (0.48 to 1.80)
Relationship with
multiple
14 2% 4 4% 22 1.85 (0.57 to 6.00)
Single 250 44% 49 49% 16 1.27 (0.78 to 2.07)
Population density per hectare
<5 126 22% 10 10% 7 Ref Ref
5–20 120 21% 7 7% 6 0.74 (0.27 to 1.99) 0.59 (0.21 to 1.69)
20–41 139 24% 27 27% 16 2.45 (1.14 to 5.26)* 1.86 (0.82 to 4.21)
>41 181 32% 55 56% 23 3.83 (1.88 to 7.80)*** 2.69 (1.26 to 5.74)*
Internalised
homophobia
Low 373 65% 71 72% 16 Ref
High 189 33% 24 24% 11 0.67 (0.41 to 1.09)
Discrimination
sexuality
None 294 52% 46 46% 14 Ref
Any setting 248 44% 49 49% 16 1.26 (0.82 to 1.95)
Perceived health
Fair/good/very good 499 88% 81 82% 14 Ref
Very poor/poor 72 13% 18 18% 20 1.54 (0.87 to 2.72)
Psychological distress
Normal 130 23% 23 23% 15 Ref
Moderate 131 23% 23 23% 15 0.99 (0.53 to 1.86)
Continued
on 13 April 2019 by guest. Protected by copyright.http://sti.bmj.com/Sex Transm Infect: first published as 10.1136/sextrans-2018-053933 on 12 April 2019. Downloaded from
6HibbertMP, etal. Sex Transm Infect 2019;0:1–9. doi:10.1136/sextrans-2018-053933
Behaviour
Univariate Adjusted model
MSM engaged in other sexualised
drug use (n=570) MSM engaged in chemsex (n=99) Odds Ratio (95% CI)
adjusted Odds Ratio (95%
CI)
n or mean % or SD n or mean % or SD Row %
Sexuality
High 133 23% 19 19% 13 0.81 (0.42 to 1.55)
Very high 172 30% 31 31% 15 1.02 (0.57 to 1.83)
Diagnosed STI
None 448 79% 63 64% 12 Ref
STI diagnosis 99 17% 36 36% 27 2.59 (1.63 to 4.12)***
Not stated 24 4% 0 0% 0 –
Attended
genitourinary medicine
No 186 33% 13 13% 7 Ref
Yes 374 65% 83 84% 18 3.18 (1.72 to 5.85)***
Not sure 7 1% 2 2% 22 4.09 (0.77 to 21.70)
Number of men anal intercourse in the past 12 months
0–1 175 31% 7 7% 4 Ref
2–5 171 30% 19 19% 10 2.78 (1.14 to 6.78)
6–10 105 18% 21 21% 17 5.00 (2.06 to 12.16)***
>10 119 21% 52 53% 30 10.92 (4.80 to 24.87)
Number of men without condom anal intercourse in the past 12 months
0–1 338 59% 23 23% 6 Ref Ref
2–5 143 25% 27 27% 16 2.78 (1.54 to 5.00)** 2.15 (0.85 to 5.41)
6–10 49 9% 14 14% 22 4.20 (2.03 to 8.70)*** 4.02 (1.60 to 10.12)**
>10 39 7% 35 35% 47 13.19 (7.08 to 24.56)*** 7.86 (3.38 to 18.30)***
Sexual contact without consent in the past 12 months
No 512 90% 83 84% 14 Ref
Yes 34 6% 7 7% 17 1.27 (0.55 to 2.96)
Unsure 15 3% 9 9% 38 3.70 (1.57 to 8.73)**
HIV status
Negative 443 78% 53 54% 11 Ref
Negative, on PrEP 50 9% 21 21% 30 3.51 (1.96 to 6.29)***
Positive 35 6% 20 20% 36 4.78 (2.57 to 8.87)***
Don’t know 43 8% 5 5% 10 0.97 (0.37 to 2.56)
Sexual self-efficacy
High 538 94% 77 78% 13 Ref Ref
Low 25 4% 19 19% 43 5.31 (2.79 to 10.10)*** 4.52 (2.18 to 9.40)***
Taken image or performance-enhancing drugs
in the past 12 months?
No 538 94% 91 92% 14 Ref
Yes 30 5% 6 6% 17 1.18 (0.48 to 2.92)
Body satisfaction 41.0 12.6 42.9 13.1 1.01 (1.00 to 1.03)
Loneliness score 5.5 1.8 5.5 1.7 1.00 (0.89 to 1.13)
Satisfaction with life 19.7 7.7 19 7.1 0.99 (0.96 to 1.02)
Sexual satisfaction 42.3 8.9 43.6 7.5 1.02 (0.99 to 1.04)
*P<0.05, **p<0.01, ***p<0.001.
MSM, men who have sex with men; PrEP, pre-exposure prophylaxis; Ref, reference.
Table 2 Continued
with SDU in the multivariable analysis were being aged 35 years
and over, having a recent STI diagnosis, recently attending a
GUM clinic, having a greater number of condomless male anal
intercourse partners, recent image and performance-enhancing
drug use, having a lower satisfaction with life and greater sexual
satisfaction.
This analysis was then repeated for factors associated with
chemsex compared with other SDU in the past 12 months
(table 2). Factors associated with chemsex in the multivariable
analysis were being a person of colour, living in a more densely
populated area, having six or more condomless male anal inter-
course partners and having low sexual self-efficacy.
Three-quarters (74%) of the sample had engaged in any type
of SDU or sex under the influence of alcohol. Figure 1 compares
the motivations for and effects of engaging in chemsex, other
SDU and sex under the influence of alcohol in the past 12
months. χ2 analyses showed MSM engaging in chemsex were
more likely to do so because it gave them an intense sexual expe-
rience, allowed them to have sex for longer, were more likely
to have sex without a condom and do things they would not do
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Figure 1 Comparing reasons for engagement and effect of chemsex, other sexualised drug use, and sex under the influence of alcohol. *P<0.05,
**p<0.01, ***p<0.001.
sober, compared with other SDU and those having sex under
the influence of alcohol. MSM engaging in chemsex were also
more likely to report engagement was having a negative impact
on their life, and were doing so because of pressure from friends.
DISCUSSION
This study investigated the sexual and psychosocial character-
istics associated with engaging in SDU and chemsex among an
internet sample of UK MSM, and provides novel insights into
how the relationships with well-being and self-efficacy vary
between these groups. Engaging in SDU was associated with
more condomless anal intercourse with male partners than those
who did not engage in SDU, and engaging in chemsex was asso-
ciated with more condomless anal intercourse than other types
of SDU. Engaging in SDU was also associated with the use of
image and performance-enhancing drugs in the past 12 months,
but this difference was not observed when comparing those who
engage in chemsex with engaging in other SDU.
This cross-sectional study obtained a large sample of MSM
from across the UK to investigate chemsex and SDU. Previous
research into SDU and chemsex has mostly been based in densely
populated areas, usually recruiting from sexual health clinics.3
It was observed that broad SDU did not differ by population
density, but chemsex was reported more often in densely popu-
lated areas, highlighting geographical differences in the type of
SDU MSM engage in. This is of significance to sexual health
clinics nationally, as both SDU and chemsex were associated with
sexual risks and issues around sexual consent.
While using Facebook as a method of recruitment enabled the
large sample size, the sample was slightly young and the sample
is biased to participants with social media accounts. Due to the
large proportion of MSM identifying as white, the results may
not be representative of MSM of colour, which has been noted as
an issue in other UK-based LGBT research.30 A possible way for
future research to overcome this is to use organisations specific
to LGBT people of colour. Being born outside the UK was a
predictor of engaging in chemsex; therefore, future research in
this area should aim to recruit MSM of colour, as well as those
being born outside of the UK, to investigate the possible intersec-
tionality between sexuality, ethnicity and country of birth.
Similar to previous research, MSM engaging in SDU were
more likely to have engaged in condomless anal intercourse.4 7 9 14
MSM engaging in SDU were also more likely to have attended
a GUM clinic in the past 12 months and received an STI diag-
nosis.7 10 11 However, when comparing MSM engaging in
chemsex with MSM engaging in other types of SDU, this differ-
ence did not hold at the multivariable level, possibly due to the
overlap with the number of condomless anal intercourse part-
ners. MSM engaging in chemsex were more likely to be taking
PrEP compared with MSM engaging in other SDU, which is
similar to the findings in Amsterdam,11 but possibly due to the
overlap between taking PrEP and number of condomless anal
intercourse partners; this was not significant at the multivariable
level.
Although the stigma of living with HIV has been suggested as
motivation for engaging in chemsex,15 living with HIV was not
significantly associated with SDU or chemsex once other factors
were controlled for, similar to other UK research.7 However,
this could be due to an overlap with confounding variables, and
due to the higher proportion of MSM living with HIV engaging
in chemsex, support services for MSM living with HIV need to
be aware of the possible impact of this behaviour. A previous
qualitative study had suggested internalised homophobia and
experiences of discrimination as possible reasons for engaging in
chemsex,15 but these were not observed here.
Engaging in SDU was associated with lower life satisfac-
tion, but there was no significant difference in life satisfaction
between those engaging in chemsex and those engaging in other
types of SDU. Previous research has mostly focused on the phys-
ical health effects of SDU and neglected possible psychological
associations. Additionally, MSM engaging in chemsex were more
likely to report their SDU having a negative impact on their life.
The proportion of MSM engaging in chemsex reporting a nega-
tive impact is similar to research in Ireland9; however, this is
the first study to investigate how this differs between chemsex,
other forms of SDU and sex under the influence of alcohol.
Those engaging in SDU reported greater sexual satisfaction,
compared with those not engaging in SDU, but no difference
was observed between engaging in chemsex and in other SDU,
although MSM engaging in chemsex were more likely to report
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Behaviour
doing so because of the intense sexual experience and being able
to have sex for longer. This suggests the perceived benefits, risks
and possible negative impact from engaging in SDU and chemsex
are complex.
In the bivariate analyses, MSM engaging in SDU were more
likely to report having experienced or being unsure of having
sexual contact without consent in the past 12 months, and when
comparing chemsex with other SDU, MSM engaging in chemsex
were more likely to report being unsure of sexual contact without
consent. These associations did not remain in the multivariable
analyses, possibly due to small numbers reporting recent sexual
contact without consent, and this being associated with other
factors. Despite this, these findings still highlight a possible issue
of how consent is affected during SDU and chemsex.
These results highlighted how SDU and chemsex can impact
the health and well-being of MSM, and differences in motiva-
tions for engaging in these behaviours. While it is encouraging to
find a higher percentage of MSM engaging in SDU and chemsex
were more likely to take PrEP, further research is needed to
understand possible interactions between PrEP adherence, drug
interactions and possible barriers for MSM engaging in SDU and
chemsex to taking PrEP, due to the elevated sexual risk associ-
ated with these behaviours. Furthermore, these results should
promote awareness among clinicians around the issue of consent
and SDU, and ensure referral pathways and patient safeguarding
strategies are in place.
In conclusion, this research highlights a complex interaction
between motivations, perceived benefits and negative impact
for engaging in SDU and chemsex. Despite the vast majority of
participants stating they were content and in control of their sex
life, engaging in SDU was associated with a lower life satisfac-
tion and engaging in chemsex was associated with lower sexual
self-efficacy. Due to the associated sexual risk-taking, issues
around sexual consent and possible harms from drug use, it is
important to promote harm reduction among this population
(eg, condoms, PrEP, drug knowledge and safer drug use), while
having support services in place for anyone wanting to stop
or who are experiencing negative effects of engaging in these
behaviours.
Key messages
►Motivations for and associated benefits and risks of
engagement in sexualised drug use and chemsex among men
who have sex with men (MSM) are complex.
►Sexual assault was associated with sexualised drug use and
chemsex; therefore, greater awareness of this risk should be
promoted among MSM and support services.
►Harm reduction should be promoted among MSM engaging
in sexualised drug use and chemsex, as well as referral
pathways for those experiencing negative effects.
Handling editor Dr Adam Huw Bourne
Acknowledgements The researchers would like to thank everyone who
participated in the survey, as well as CliniQ, COAST, GALOP, Gay Men’s Health
Collective and the National LGB&T Partnership for their contribution to the design
and recruitment for the survey.
Contributors MPH conducted the literature review and drafted the manuscript.
Design of the survey, data collection and statistical analysis were conducted by MPH,
with input and supervision from CEB, LAP and VDH. All authors contributed to and
approved the final draft.
Funding This study was funded as a PhD project by Liverpool John Moores
University.
Competing interests None declared.
Patient consent for publication Not required.
Ethics approval Ethical approval for this study was obtained from the Liverpool
John Moores University Research Ethics Committee (approval reference: 18/PHI/011).
Provenance and peer review Not commissioned; externally peer reviewed.
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