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Abstract

Introduction: Chemsex is a specific form of sexualised drug use (SDU) that is an emerging public health issue among men who have sex with men (MSM). Although the recent focus on chemsex is a reflection of the associated harms it is important to understand SDU more broadly and its associations with risk behaviours. Additionally, some of the reasons suggested for MSM engagement in SDU are also likely to apply to women who have sex with women (WSW) and trans people. The aim of this review was to investigate SDU, including chemsex, among lesbian, gay, bisexual and trans (LGBT) people internationally in relation to sexual health outcomes (HIV status, STI diagnosis, condom use). Methods: Papers that were published between January 2010 and June 2020 reporting SDU in MSM, WSW, or trans people were identified through Medline, PsycINFO, CINAHL Plus and Web of Science. Results were synthesised using a narrative approach. Results: The search identified 2,710 publications, of which 75 were included in the final synthesis. The majority of studies measured SDU among MSM (n = 71), and four studies measured SDU among trans people. Research into SDU had been conducted in 55 countries and 32 countries had recorded the use of a chemsex drug among MSM, although the drugs used to define chemsex varied. Among studies that researched MSM, SDU was most commonly investigated in relation to condomless anal intercourse (n = 42), followed by HIV prevalence (n = 35), and then STI diagnoses (n = 27). Drug use was generally associated with sexual health outcomes, but particularly in chemsex studies. Conclusions: SDU research is lacking among WSW and trans people, despite trans women having a high HIV prevalence. Among MSM, most drugs were associated with sexual health outcomes, and therefore it is important to include both chemsex drugs and other drugs in SDU research.
A narrative systematic review of sexualised drug use and sexual health outcomes among
LGBT people
Abstract
Introduction: Chemsex is a specific form of sexualised drug use (SDU) that is an emerging
public health issue among men who have sex with men (MSM). Although the recent focus on
chemsex is a reflection of the associated harms it is important to understand SDU more
broadly and its associations with risk behaviours. Additionally, some of the reasons suggested
for MSM engagement in SDU are also likely to apply to women who have sex with women
(WSW) and trans people. The aim of this review was to investigate SDU, including chemsex,
among lesbian, gay, bisexual and trans (LGBT) people internationally in relation to sexual
health outcomes (HIV status, STI diagnosis, condom use).
Methods: Papers that were published between January 2010 and June 2020 reporting SDU in
MSM, WSW, or trans people were identified through Medline, PsycINFO, CINAHL Plus and
Web of Science. Results were synthesised using a narrative approach.
Results: The search identified 2,710 publications, of which 75 were included in the final
synthesis. The majority of studies measured SDU among MSM (n=71), and four studies
measured SDU among trans people. Research into SDU had been conducted in 55 countries
and 32 countries had recorded the use of a chemsex drug among MSM, although the drugs
used to define chemsex varied. Among studies that researched MSM, SDU was most
commonly investigated in relation to condomless anal intercourse (n=42), followed by HIV
prevalence (n=35), and then STI diagnoses (n=27). Drug use was generally associated with
sexual health outcomes, but particularly in chemsex studies.
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Conclusions: SDU research is lacking among WSW and trans people, despite trans women
having a high HIV prevalence. Among MSM, most drugs were associated with sexual health
outcomes, and therefore it is important to include both chemsex drugs and other drugs in
SDU research.
Keywords: LGBT people; sexualised drug use; chemsex; systematic review; sexual health
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Introduction
Sexualised drug use (SDU) is a term used to refer to sexual activities whilst under the
influence of a wide range of drugs and substances, such as cannabis, amyl nitrates (poppers),
and crystal methamphetamine and has been a topic of research among men who have sex
with men (MSM) for some time (Bourne, 2012; Leigh & Stall, 1993). Chemsex (sometimes
referred to as ‘party and play’) is a particular form of SDU whereby men engage in sex with
other men for long periods of time with multiple sexual partners, typically taking one or more
of crystal methamphetamine, γ@hydroxybutyrate/ γ@butyrolactone (GHB/GBL), methedrone,
cocaine and/or ketamine immediately before or during sex to facilitate and enhance the
sexual experience (Bourne, Reid, Hickson, Torres Rueda, & Weatherburn, 2014). Chemsex
has become a public health issue over the last decade. Clinicians (Stuart, 2013) and men who
engage in chemsex (Ahmed et al., 2016) report that this may be due to an increase in the
number of people engaging in this behaviour, with geospatial networking apps and online
sites used to meet sexual partners likely to have enabled this increase (Ahmed et al., 2016;
Stuart, 2013).
Chemsex has been associated with injecting drug use and sexual risk behaviours such
as condomless anal intercourse (CAI) and a greater number of CAI partners (Bourne et al.,
2014; Glynn et al., 2018; Hegazi et al., 2017), as well as with a greater likelihood of sexually
transmitted infection (STI) diagnoses and human immunodeficiency virus (HIV) (Gilbart et
al., 2015; Glynn et al., 2018; Hegazi et al., 2017; Hibbert, Brett, Porcellato, & Hope, 2019a).
The broader sexualised use of drugs among MSM has been a topic of research for much
longer, due to the potential for HIV acquisition from both injecting drug use and CAI
sometimes facilitated by drug use (Halkitis, Parsons, & Stirratt, 2001; Mattison, Ross,
Wolfson, Franklin, & HNRC Group, 2001; Stall & Purcell, 2000). Although there is no
agreed definition of chemsex or even of drugs associated with chemsex, people may engage
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in a variety of forms of SDU that encompasses what may be categorised as chemsex as well
as other forms of SDU. However, due to the recent focus on chemsex, SDU more broadly has
received less attention, even though it incorporates a much wider range of drug use
behaviours and therefore may be more common.
A narrative systematic review of international quantitative and qualitative chemsex
literature found that chemsex among MSM (defined as taking methamphetamine,
mephedrone, GHB/GBL, cocaine or ketamine before or during sex) was associated with high
sexual risk and HIV prevalence (Maxwell, Shahmanesh, & Gafos, 2019). Additionally, a
systematic review investigating international prevalence of SDU among MSM found the
most commonly reported sexualised drugs were methamphetamines, GHB/GBL and amyl
nitrates (poppers), and that SDU was associated with increased sexual risk (Tomkins, George,
& Kliner, 2019). A literature review investigating prevalence of both chemsex (defined as
taking methamphetamine, GHB/GBL and mephedrone before or during sex) and SDU
(defined as use of illicit drugs before or during sexual activity) in the United Kingdom (UK)
found the prevalence of both varied across studies (Edmundson et al., 2018). The reviews
identify that both SDU and chemsex are associated with sexual risk, and that the definitions
of chemsex and SDU vary between studies. A recent UK study found that those MSM who
engaged in SDU have a greater likelihood of a STI diagnosis and more anal intercourse
partners than those who had not engaged in SDU, and among those who had engaged in
SDU, those who engaged in chemsex (defined as the use of crystal methamphetamine, GHB/
GBL, ketamine, mephedrone) had a greater likelihood of an STI diagnosis and more anal
intercourse partners (Hibbert, Brett, Porcellato, & Hope, 2019b). Therefore, those engaging
in chemsex may be engaging in greater sexual risk behaviours than those who engage in other
forms of SDU.
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Research investigating SDU among MSM has mostly been conducted in Western
countries, and the term chemsex is typically used in a Western context (Bourne &
Weatherburn, 2017), but SDU, including the sexualised use of drugs associated with
chemsex, has also been observed internationally (Bourne, 2012; Maxwell et al., 2019;
Tomkins et al., 2019). Due to the nature of researching SDU, studies tend to be cross@
sectional, making causation hard to infer. Causation is also hard to infer when researching
SDU due to the large number of potentially confounding factors that could also impact on
sexual health outcomes (e.g. relationship status, number of sexual partners). Despite this,
Leigh and Stall (1993) categorised the possible ways of measuring and analysing SDU into
global associations, situational associations, and event@level associations. Global association
is where general drug use is measured over a specific period (e.g. in the past 12 months), and
sexual behaviour is also measured over a specific period, and an analysis between the two is
conducted. Situational association is where the drug use is measured in relation to sex over a
specific period, and sexual behaviour is also measured over a specific period, and an analysis
between the two is conducted. Event@level associations are where drug use and sexual
behaviour are asked about for a specific sexual event (e.g. the last time you had sex whilst
using a drug, did you use a condom?). This is particularly important when investigating SDU,
including chemsex, as drug use and sex are both linked, so a valid measurement needs to
account for this (by using situational or event@level associations) rather than to explore global
associations.
Some of the factors that have been suggested as motivations for MSM engaging in
SDU, including chemsex, such as internalised homophobia and HIV stigma (Weatherburn,
Hickson, Reid, Torres@Rueda, & Bourne, 2017), may apply to SDU among other lesbian, gay,
bisexual and transgender (LGBT) people. This is particularly pertinent for trans women who
have a high global estimate of HIV prevalence (Baral et al., 2013). However, less is known
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about SDU among trans women and if it is associated with the same sexual risk as MSM.
Additionally, SDU has been observed among women who have sex with women (WSW)
(Hibbert, Porcellato, Brett, & Hope, 2019), but comparatively little research has been
conducted in this group.
Therefore, the primary aim of this review was to:
Investigate the associations between SDU and specific health outcomes (HIV status,
STI diagnoses and CAI) among LGBT people.
Secondary aims of this review were to:
Investigate how representative research into SDU in relation to health outcomes is of
the whole LGBT population.
Analyse what methods are used to explore the relationship between SDU and health
outcomes (global association, situational association or event@level association).
Assess which countries have reported SDU among LGBT people, and in particular,
which countries have reported the sexualised use of a drug associated with chemsex.
Method
The systematic review was designed and reported following the PRISMA guidelines
(Moher, Liberati, Tetzlaff, & Altman, 2010), with the protocol registered at PROSPERO
International Register of Systematic Reviews prior to commencing the review (ID
CRD42018084366). The PECO framework (Population, Exposure, Comparison, Outcome)
(Methley, Campbell, Chew@Graham, McNally, & Cheraghi@Sohi, 2014) was used to form the
search strategy where the population was LGBT people (MSM, WSW, and trans people);
exposure was SDU; comparison was between those engaging in SDU and those who were
not; and the outcome was HIV, STI diagnoses, or CAI. These outcomes were decided upon
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due to preliminary searches identifying these outcomes as commonly measured in relation to
SDU and chemsex. The analysis between SDU and HIV, STI diagnoses, or CAI was
classified as global, situational, or event level associations. Due to the difficult nature of
attributing HIV and STI transmission to specific sexual events, only the measurement of CAI
could be classified as an event@level association. Studies that measured HIV and STIs by self@
report and/or laboratory tests were included in the review.
Suitable search terms were obtained from systematic reviews on similar topics (Choi,
Wong, & Fong, 2017; Vosburgh, Mansergh, Sullivan, & Purcell, 2012). A preliminary search
was then conducted using these terms on MEDLINE, with relevant articles retrieved to
identify additional search terms. Search terms were grouped into three concepts: “LGBT
terms”, “Drug terms”, and “Sex terms” (Table 1),so that searches used the string: “LGBT
terms” AND “Drug terms” AND “Sex terms”. The search string was used to search
MEDLINE, PsycINFO, CINAHL Plus, and Web of Science (EBSCO MEDLINE from 1879
to 30th June 2020, ProQuest PsycINFO from 1806 to 30th June 2020, EBSCO CINAHL Plus
from 1981 to 30th June 2020, Web of Science Core Collection from 1900 to 30th June 2020).
Where studies were not published in English, an attempt to find a translation was made. A
period limit of 1st January 2010 to 30th June 2020 (inclusive) was imposed due to the end
date of a previous systematic review on a similar topic (Vosburgh et al., 2012), although that
systematic review was specific to MSM engaging in SDU and event@level condom use. A
limit was also set on the period of data collection (January 2010@June 2020) to ensure that the
review represented recent patterns of SDU. An attempt to find grey literature from relevant
community organisations and public health organisations was made, but no reports provided
sufficient detail to be included.
Chemsex drugs were defined as the ‘4 chems’ (crystal methamphetamine, GHB/GBL,
ketamine and mephedrone) as in Schmidt et al. (2016), and are commonly accepted as drugs
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associated with chemsex (Bourne et al., 2014). SDU and their health related outcomes were
grouped into three categories: global association, situational association, and event@level
associations (Leigh & Stall, 1993).
Four stages were used to identify studies: identification, screening, eligibility and
inclusion (Moher et al., 2010). A data extraction form with quality assessment was adapted
from The Cochrane Public Health Group Data Extraction and Assessment Template, The
Effective Public Health Practice Project (EPHPP) Quality Assessment Tool for Quantitative
Studies, and the Center for Evidence@Based Management (CEMa) critical appraisal checklist
for surveys. This form was created using online survey software Qualtrics
(www.qualtrics.com). Cross@tabulated data on drug use and outcomes (HIV status, STI
diagnoses, condom use) were extracted, and where underlying data were not available, the
unadjusted odds ratios were extracted. There was not enough homogeneity in the data in
terms of time duration of drug use or sexual risk factor (i.e. ever, the last 12 months, the last
three months), as well as in terms of the populations studied (i.e. MSM living with HIV only,
sex workers, young MSM, Black MSM only) for meta@analyses to be conducted.
Additionally, it was not possible to control for confounding variables (e.g. age, number of
sexual partners, sexuality, relationship status) due to the variability in the confounding
variables reported in the studies. Screening and eligibility was conducted by two researchers
independently (MH and AH) and a third researcher (VD) was used for any disagreements.
Data extraction was completed by one researcher (MH), and then checked by a second
researcher (AH). Quality assessment was conducted by two researchers independently (MH
and AH), and a third researcher was used for any disagreements (VD).
*Table 1 about here*
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Inclusion criteria:
1. A measure of drug use and sexual health risk (HIV status, STI diagnoses, CAI) within
the same population.
2. An association analysis conducted between the drug behaviour and the sexual
behaviour and/or health risk.
3. Population studied included a sexual and/or gender minority population.
4. Studies published and data collected in the date range January 2010 to June 2020
(inclusive).
Exclusion criteria:
1. Articles not published in English and no translation available.
2. Studies including children (aged equal to or less than 15 years).
3. Studies that are not relevant to the research question (e.g. heterosexual populations
only, comparisons with heterosexual people, medical drug trial studies).
4. Qualitative research.
Results
The search yielded 2,710 unique citations, of which 1,658 were excluded during title
and abstract screening and 977 during full@text review, leaving 75 studies eligible for data
extraction (Figure 1). The majority of studies were cross@sectional (n=67), six studies were
cohort studies, and two were case@control studies. A list of included studies can be found in
Supplementary Material 1.
*Figure 1 about here*
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The 75 included studies spanned across 55 countries, of which 71 researched MSM and 4
researched trans women (Supplementary Material 2). No studies examining SDU among
WSW or trans men/non@binary people met the inclusion/exclusion criteria. The countries of
included studies in which SDU had been studied among MSM or trans women or both are
shown in Figure 2, as well as the countries where a study had examined the use of one or
more chemsex associated drugs (crystal methamphetamine, GHB/GBL, ketamine, or
mephedrone) among MSM.
*Figure 2 about here*
Men who have sex with men
Over one quarter of studies among MSM were conducted in the United States of
America (USA) (n=20), and around a quarter were conducted in the UK (n=16). The most
commonly studied drug among MSM was cannabis (n=34), followed by amyl
nitrates/poppers (n=29), crystal methamphetamine (n=18), erectile dysfunction drugs (EDD)
(n=15), cocaine (n=13), ecstasy (n=10), GHB/GBL (n=11), and ketamine (n=8). Less
common drugs were mephedrone (n=3), heroin (n=2), amphetamine (n=1), and crack cocaine
(n=1). The time period for measuring drug use ranged from the last anal sex event (n=6) to
lifetime use (n=3), with the most common recall period being six months (n=20).
Around one third of studies (n=23) grouped drugs into chemsex/party drugs. The
specific drugs grouped as chemsex/party drugs varied considerably, but GHB/GBL were
included in all chemsex groups, and crystal methamphetamine was included in 21 out of 23
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chemsex groups (Table 2). Fourteen of the studies used situational association analyses to
investigate the sexual health outcome and the remaining nine used global association
analyses. At least one of the drugs associated with chemsex had been investigated in the
majority of countries (n=32/54, Figure 2).
*Table 2 about here*
HIV prevalence was the outcome examined in 35 studies, 27 studies examined STI
incidence, and CAI was the most common health outcome examined (n=42). . Table 3
displays the breakdown of outcomes studied in relation to specific drugs and how many
studies found a significant bivariate association between drug use and the outcome
investigated.
*Table 3 about here*
HIV prevalence
Among the 35 studies that investigated HIV prevalence, ten measured HIV status
using a laboratory test, the remaining 25 asked participants to self@report their HIV status.
The majority of studies conducted global association analyses (n=26) and nine conducted
situational association analyses. The most common drug category investigated in relation to
HIV prevalence was poppers use (n=14) with around 70% of studies finding a bivariate
association between poppers use and HIV prevalence. Chemsex drugs grouped were
investigated in relation to HIV prevalence in thirteen studies and 77% of studies found
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bivariate associations between chemsex drug use and HIV prevalence. For chemsex drugs
that were investigated independently, four out of the seven studies investigating crystal
methamphetamine use and HIV prevalence found a bivariate association. Four studies were
found that investigated either GHB/GBL or ketamine and two found bivariate associations
with HIV prevalence (50%). Two studies investigated mephedrone and HIV prevalence and
both found a bivariate association, although both studies investigated among MSM who use
drugs only and three out of the four studies that investigated EDDs found a bivariate
association with HIV prevalence.
STI diagnoses
Among the 27 studies investigating STI diagnoses in relation to drug use, 16
conducted global association analyses, 10 conducted situational association analyses and one
study conducted both global and situational association analyses. Most studies grouped STIs
for their investigations (n=17). Seven of these groups investigated associations between drug
use and bacterial STIs only (chlamydia, gonorrhoea, lymphogranuloma venereum (LGV),
syphilis), whilst others included herpes, genital warts, and blood borne viruses such as
hepatitis A, B, and C as well as newly acquired HIV (See Supplementary Material 2). Over
half (n=15) of the studies measured STI diagnoses using laboratory tests, whilst the
remaining 12 studies used self@report methods. The recall period for self@reported STI
diagnoses was most commonly 12 months (n=8), whilst two studies had a recall period of
three months, one study had a recall period of six months, and one study did not report the
recall period.
The most commonly researched drug in relation to STI diagnoses were chemsex drugs
grouped (n=14), and in the majority of studies (n=11) this was in relation to grouped STI
diagnoses. One study each investigated chemsex drugs in relation to shigella, hepatitis C and
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gonorrhoea, and all bivariate associations between chemsex drugs and STI diagnoses were
significant. Poppers were the second most commonly researched in relation to STI diagnoses
(n=11). Six studies investigated poppers use in relation to syphilis diagnoses, all of which
were conducted in China, with two of these studies finding bivariate associations. All four
studies that conducted bivariate association analyses between poppers use and grouped STI
diagnoses found associations, and one study investigated poppers use in relation to Shigella
diagnoses and found a bivariate association.
Condomless anal intercourse (CAI)
Among the 42 studies investigating CAI, 22 studies conducted global association
analyses, 14 conducted situational association analyses, five conducted event@level
association analyses, and one study conducted both global and situational association
analyses depending on the drug of interest. The recall period for CAI ranged from event@
based (n=6) to 12 months (n=7), with the most common recall period being three months
(n=13). The most commonly researched drug in relation to global and situational analyses for
CAI was cannabis (n=19), with around 40% of studies (n=8) finding a bivariate association
between cannabis use and CAI. All 11 studies that investigated chemsex drugs grouped found
bivariate associations when analysing CAI and over three quarters of studies (n=13/16) that
investigated poppers use and CAI found a bivariate association.
Among the five studies that used event@level associations, all three studies
investigating crystal methamphetamine, EDDs, GHB/GBL, and poppers found bivariate
associations between drug use and CAI. One study found bivariate associations between
cannabis use, ecstasy use and CAI among HIV positive partners only, whilst the remaining
three studies that investigated event@level associations between cannabis use, ecstasy use and
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CAI found no association. One study investigated each cocaine and ketamine use in relation
to CAI and both found no association.
Trans women
Among the four studies that researched trans women, a range of drugs were
investigated (cocaine, crack cocaine, crystal methamphetamine, heroin, and poppers). Three
studies conducted global association analyses and one study conducted a combination of
global and situational analyses. Two studies were conducted in the USA, one in Brazil, and
one in Vietnam. A bivariate association was found between crystal methamphetamine (n=1)
and condomless sex. One study investigated a possible association between poppers use and
condomless sex, but found no association. One study found a situational association between
cocaine and HIV status, although two studies did not find this association when conducting
global association analyses. One study found an association between methamphetamine use
and HIV status. No association was found between heroin use (n=1) and HIV status or
syphilis diagnosis.
Quality assessment of the included studies
The majority of studies had an overall rating of moderate (n=31/75, 41%), 28 studies
(33%) were rated as weak, and 16 (21%) were rated as strong. The weakest sections tended to
be the reporting of withdrawals and dropouts, where 34 studies (45%) were rated as weak,
and confounders, where 20 studies (27%) were rated as weak.
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Discussion
This systematic review firstly assessed the extent to which SDU has been studied
among LGBT people in relation to sexual health outcomes, and it found that the vast majority
of research has been conducted among MSM. A smaller number of studies had been
conducted among trans women; however, no studies were found that reported on SDU in
relation to sexual health outcomes among trans men or WSW. Whilst a few studies were
found among trans women, due to the potentially high risk of HIV among trans women
(Baral et al., 2013), further studies are needed to explore SDU and its related sexual and
health implications among trans women.
It should be noted that some studies among WSW were found, but they were not
included in this review because they compared WSW with heterosexual women, and
therefore data were not available for health outcomes exclusively for WSW. These few
studies identified that WSW may be more likely to use ketamine (Heinsbroek, Glass,
Edmundson, Hope, & Desai, 2018), as well as cannabis and cocaine (Bauer, Jairam, &
Baidoobonso, 2010) compared to heterosexual women, but drug use was not measured in a
sexual context. One study did find that lesbian and bisexual women were more likely to
engage in SDU (Estrich, Gratzer, & Hotton, 2014), but data were not available exclusively
for WSW with regards to sexual risk and SDU. Recent research has indicated an association
between SDU among WSW and greater sexual risk (Hibbert, Porcellato, et al., 2019), but
further event@level research among WSW is warranted. Narrowing the search criteria to
sexual health outcomes may have limited the number of possible studies found in relation to
WSW, as the reasons for engagement and effects on sexual health may be different for WSW
(Hibbert, Porcellato, et al., 2019). However, due to bisexual women possibly being more
likely to engage in SDU (Estrich et al., 2014; Hibbert, Porcellato, et al., 2019), research
regarding sexual health behaviours like condom use and STI diagnoses may be warranted.
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





Whilst there was some research regarding SDU among trans women, further research is
needed due to the suspected high@risk of HIV transmission. Additionally, no studies indicated
they included trans men and non@binary people. Where trans men do identify as MSM, they
are most often not included in analyses among men. Therefore, further research is needed
among trans people in general, to understand if SDU exists, and if so, whether it is associated
with sexual risk.
Associations between SDU among MSM and/or trans women have been studied in 55
countries, but due to the inclusion and exclusion criteria used in this review, not all countries
which have examined SDU among LGBT people may have been identified. Additionally, the
use of at least one of the drugs associated with chemsex among MSM has been observed in
32 of these countries spanning North America, Europe, Asia, and Australasia. Although
chemsex was first documented within the UK and has been researched in other Western
countries (Bourne & Weatherburn, 2017), this behaviour has been observed internationally,
and therefore more international research is needed, particularly in countries with high
prevalence of HIV among MSM. Similar to a literature review of SDU and chemsex in the
UK (Edmundson et al., 2018), it was found that the definition of chemsex varied greatly, but
GHB/GBL was included in all chemsex definitions. This may be because the drugs used for
chemsex differ internationally, or that research had been conducted before a definition which
drugs used specifically for sex, constituted as chemsex. A consensus of what drugs constitute
as chemsex may be hard to reach due to emerging new drugs, local availability of specific
drugs, or personal preferences for the type of drugs used for chemsex. Therefore, an
international definition of what drugs constitute as chemsex may not be appropriate and
instead more local definitions may be more suitable. Although the lack of an international
definition may limit cross@cultural comparisons, because of the sexual risk associated with
chemsex, defining chemsex with regards to sexual behaviour may be equally or if not more
16
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













important, and trying to commonly define chemsex as a particular use of drugs may be too
simplistic. However, it is useful to see which drugs are common internationally, so harm
reduction and drug safety information can be shared across countries.
It is of note that nearly all drugs were associated with greater sexual risk, regardless of
the drug or outcome in question, similar to previous systematic reviews regarding chemsex,
SDU and MSM (Maxwell et al., 2019; Tomkins et al., 2019), but causation cannot be inferred
from these analyses. For some of the more commonly used, and more socially accepted
substances, such as poppers and cannabis, the associations found may in part be due to people
taking these substances also being more likely to use other substances (which they may not
always disclose). It is unclear the influence that polydrug use may have on these findings. For
example, whether individuals who use multiple drugs during the same sexual encounter are
considered to engage in greater risk taking. When considering global associations, individuals
may use multiple drugs in a variety of different contexts, some of which are specific to a
sexual context. However, in these situations, drug use outside a sexual context could be
associated with a sexual health outcome via proxy. Therefore, there is a need to move away
from global associations when investigating SDU and sexual health associations.
Certain patterns of drug use, such as chemsex, may be associated with HIV
prevalence, STI diagnoses and CAI more than other patterns of drug use, which has been
suggested by previous research (Hibbert, Brett, et al., 2019a). The variation found in this
review regarding the definition of what drugs constitute as chemsex may be because sex
under the influence of the drugs used in chemsex may lower inhibitions and therefore impact
on behaviour to a greater extent than other types of SDU, or social norms associated with
chemsex may influence risk taking. Additionally, it could be that grouping drugs creates a
more powerful analysis due to a greater number of observations included, and therefore this
is why chemsex appears to be associated with greater risk.
17
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












There were similar associations between event@level analyses and global and
situational associations for condom use, but a large number of studies relied on global
associations of drug use and health outcomes, even when aiming to research chemsex, which
is by definition use in a sexual context. Therefore, if future research is aiming to investigate
SDU, situational and event@level analyses should be used for a potentially more accurate
measurement. Another limitation identified in the research was the variability in the recall
period for reporting drug use and sexual health behaviours. Whilst lifetime use of drugs may
be important for drugs that are typically injected when investigating blood borne viruses, for
more recent sexual behaviours, the usefulness of lifetime drug use is questionable. Therefore,
studies should aim to have more recent recall periods for both drug use and sexual
behaviours. Due to the nature of researching SDU being mostly cross@sectional, causation
cannot be inferred, regardless of the measurement method chosen. It is possible that other
factors influence associations between drug use and sexual risk behaviours, for example,
those who take drugs and have CAI may just be less risk averse.
Strengths and limitations
A limitation of this review is that there may be a publication bias in the data,
suggested by most studies finding an association with the health outcome researched. An
attempt was made to find grey literature on the topic, however no reports or publications were
found where information had not already been published in peer@review journals, or that met
the inclusion/exclusion criteria. Additionally, it was not possible to control for confounding
variables that may influence drug use and HIV, STI diagnoses and condom use, such as age
and sexual identity, due to the heterogeneity among control variables in multivariable
analyses. Collating data is also difficult due to different window periods of measurement (e.g.
three months/six months/twelve months), and variability in the grouping of drugs associated
with sex. In terms of quality, one third of studies were given an overall quality assessment
18
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












rating of weak. Due to the various sub@categories in this review, it was deemed inappropriate
to exclude studies rated as weak, which may have impacted the findings.
This review focused specifically on HIV, STI diagnoses, and CAI due to these
outcomes being commonly researched in relation to SDU. However, this does ignore other
sexual health factors that may be related to SDU such as pre@ and post@exposure prophylaxis
(PrEP/PEP) use, as well as possible psychological associations. Despite this, the finding that
SDU among MSM was associated with HIV prevalence, STI diagnoses and CAI is still
important when considering service delivery, as well as harm reduction services, due to
potentially confounding factors a person may experience (i.e. drug harms, living with HIV,
greater sexual risk taking).
Conclusion
For the majority of drugs examined, drug use appears to be associated with living
with HIV, STI diagnoses, and CAI among MSM. However, the measurement of SDU often
relied on global associations between drug use and risk, so may be subject to
misclassification bias. Therefore, more accurate measurements of SDU, such as situational or
event@level analyses, should be used. Definitions of what constitutes chemsex drugs varied
across studies, making conclusions with regards to associated risks with chemsex difficult.
The definition of what constitutes chemsex drugs may be even more difficult when
considering the behaviour internationally, as the availability of certain drugs will differ across
countries, depending upon legal categorisation and common illicit drug markets. Further
research is needed regarding SDU among WSW and trans people to assess the occurrence of
SDU and any possible impact on sexual risk.
19
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







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
References
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(""5#55- >#"2C(";#"" ?:"::#
?".:(#":'(--L.8(--"
++,&
7-0*0DEM''-09#A89-!'+,9".
"!?#"".--0"G; >#"#(:#?".:
-<-/-&
-!>"D"#"@%)'>GA@+,#-5 2 0"-5
("->##<="""##((0.10+,
&
(61A@G!7''"9G"!A+,
9". 02".-""" "(0".-#:#?".
:G(".-- - ".2,-+,&
#23
"#!87-""8"#9#5=)"A+,G"#;4 >(#&
4 >(("0".-?#5#5-:#4 ("G("? "
8(--"D#<-&".
#234(5#
20
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A*G98# --#1)#5=+,"0 #"# -".-
 "> """# :".-"(" ".#(:#?".
:+A'A,B+/+,&
#23"."&&
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:+A'A,B+/+,&#23"."&&
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".-"("#(:#:#?".::#+',B2$("
;#17*%'.1;"0-"'?0 0&
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1(*9)'--+,'" ""!0".-?#;#.5#"#<=<"""
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A.:--''"A)7;#"A+,9".?#"#(:#?".
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21






































Table 1. Results generated from each search term used for each database, June 2020.
Database Keywords Articles retrieved
LGBT terms Drug terms Sex terms
Medline
Homosexuality (MH) Substance@related disorders (MH) "Sexual health"
1,858
Homosexuality, female (MH) "Substance use" Reproductive health (MH)
Homosexuality, male (MH) Alcohol drinking (MH) "Sexual behavior"
Homosexual* Alcohol "Sexual behaviour"
Gay "Drug use" Sexual behavior (MH)
Lesbian* Chemsex "Sexual risk"
Bisexual* "Party and play" Risk@taking (MH)
Transexual* Marijuana Unsafe sex (MH)
Transsexual* GBL "Unsafe sex"
Transgender* GHB
Trans Ecstasy
Transgender persons (MH) Cocaine
Genderqueer Crack
"Non binary" Methamphetamine
"Men who have sex with men" Methadone
"Sexual minorit*" Poppers
Sexual minorities (MH) "Amyl nitrate*"
LGBT* Ketamine
Viagra
"Erectile dysfunction drug*"
"Sildenafil Citrate" (MH)
PsycINFO Homosexuality (SH) Substance@related disorders (SH) "Sexual health" 1,445
Homosexuality, female (SH) "Substance use" Reproductive health (SH)
Homosexuality, male (SH) Alcohol drinking (SH) "Sexual behavior"
Homosexual* Alcohol "Sexual behaviour"
Gay "Drug use" Sexual behavior (SH)
Lesbian* Chemsex "Sexual risk"
Bisexual* "Party and play" Risk@taking (SH)
Transexual* Marijuana Unsafe sex (SH)
Transsexual* GBL "Unsafe sex"
Transgender* GHB
Trans Ecstasy
Transgender persons (SH) Cocaine
Genderqueer Crack
"Non binary" Methamphetamine
"Men who have sex with men" Methadone
"Sexual minorit*" Poppers
Sexual minorities (SH) "Amyl nitrate*"
LGBT* Ketamine
Viagra
22
"Erectile dysfunction drug*"
"Sildenafil Citrate" (SH)
CINAHL Plus
Homosexuality (MH) Substance@related disorders (MH) "Sexual health"
727
Homosexuality, female (MH) "Substance use" Reproductive health (MH)
Homosexuality, male (MH) Alcohol drinking (MH) "Sexual behavior"
Homosexual* Alcohol "Sexual behaviour"
Gay "Drug use" Sexual behavior (MH)
Lesbian* Chemsex "Sexual risk"
Bisexual* "Party and play" Risk@taking (MH)
Transexual* Marijuana Unsafe sex (MH)
Transsexual* GBL "Unsafe sex"
Transgender* GHB
Trans Ecstasy
Transgender persons (MH) Cocaine
Genderqueer Crack
"Non binary" Methamphetamine
"Men who have sex with men" Methadone
"Sexual minorit*" Poppers
Sexual minorities (MH) "Amyl nitrate*"
LGBT* Ketamine
Viagra
"Erectile dysfunction drug*"
"Sildenafil Citrate" (MH)
Web of Science
Homosexual* Substance@related disorders "Sexual health"
1,357
Gay "Substance use" "Sexual behavior"
Lesbian* Alcohol "Sexual behaviour"
Bisexual* "Drug use" "Sexual risk"
Transexual* Chemsex "Risk@taking"
Transsexual* "Party and play" "Unsafe sex"
Transgender* Marijuana
Trans GBL
Genderqueer GHB
"Non binary" Ecstasy
"Men who have sex with men" Cocaine
"Sexual minorit*" Crack
LGBT* Methamphetamine
Methadone
Poppers
"amyl nitrate*"
Ketamine
Viagra
"Erectile dysfunction drug*"
"Sildenafil Citrate"
MH – Medical Subject Heading (MeSH). SH – Subject Heading
23
Table 2. Summary of drugs included in chemsex definitions
Drug or drugs included in chemsex definitions N (n=23)
Crystal methamphetamine 21
GHB/GBL 23
Ketamine 12
Mephedrone 20
Grouped
Crystal methamphetamine, GHB/GBL, mephedrone 20
Crystal methamphetamine, GHB/GBL, ketamine, mephedrone 11
24
Table 3. Bivariate associations found in studies investigating drug use in relation to HIV prevalence, STI diagnoses, and condom use among MSM.
Drugs investigated
HIV prevalence (n=35) STI diagnoses (n=27)* Condomless anal intercourse (n=42)*
Global (n=26) Situational (n=9) Global (n=17) Situational (n=11) Global (n=23) Situational (n=15) Event (n=5)
N sig. (%) N total
N sig.
(%)
N
total N sig. (%)
N
total N sig. (%)
N
total N sig. (%)
N
total
N sig.
(%) N total N sig. (%)
N
total
Amphetamine @ @ @ @ @ @ 0 (0%) 1 @ @ 0 (0%) 2 @ @
Cannabis 4 (57%) 7 1 (50%) 2 1 (20%) 5 1 (50%) 2 4 (25%) 12 4 (57%) 7 1 (25%) 4
Cocaine 1 (25%) 4 @ @ 0 (0%) 2 1 (100%) 1 4 (80%) 5 0 (0%) 3 0 (0%) 1
Crack cocaine @ @ @ @ @ @ @ @ 1 (50%) 2 @ @ @ @
Crystal methamphetamine 4 (57%) 7 @ @ 5 (83%) 6 @ @ 4 (67%) 6 2 (100%) 2 3 (100%) 3
Ecstasy 1 (25%) 4 @ @ 0 (0%) 1 1 (100%) 1 @ @ 1 (33%) 3 1 (25%) 4
Erectile Dysfunction Drugs
(EDDs) 2 (67%) 3 1 (100%) 1 2 (100%) 2 1 (100%) 1 3 (60%) 5 1 (50%) 2 3 (100%) 3
GHB/GBL 2 (50%) 4 @ @ 2 (67%) 3 1 (100%) 1 1 (100%) 1 @ @ 3 (100%) 3
Heroin 1 (100%) 1 @ @ @ @ @ @ @ @ 0 (0%) 1 @ @
Ketamine 2 (50%) 4 @ @ 0 (0%) 2 1 (100%) 1 @ @ @ @ 0 (0%) 1
Mephedrone 2 (100%) 2 @ @ 0 (0%) 1 @ @ @ @ @ @ @ @
Poppers 9 (69%) 13 1 (100%) 1 5 (56%) 9 2 (100%) 2 11 (92%) 12 2 (50%) 4 3 (100%) 3
Chemsex grouped 4 (67%) 6 6 (86%) 7 5 (100%) 5 9 (100%) 9 3 (100%) 3 8 (100%) 8 @ @
Note: Studies measured multiple drugs for the same outcomes, therefore column totals do not add up to the total number of studies
*One study included both global and situational associations so is counted in both sub@total
25
Figure 1. Flow diagram of the identification process.
26
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Figure 2. Map of countries with studies on sexualised drug use among men who have sex
with men (MSM), trans women, or both, and those that have reported chemsex drug use
included in the review.
27
... In the last decade, much research has been published on Sexualized Drug Use (SDU) by men who have sex with men (MSM) (1)(2)(3)(4) which involves drug use just before or during sex. Most of these studies have focused on what in the UK is known as "chemsex, " which involves sexual encounters between MSM (usually group-sex) under the effects of certain drugs. ...
... Although the chemsex phenomenon was first described in the United Kingdom and has been investigated mainly in Western countries, it is a behavior that has been observed internationally (1)(2)(3)(4). Many studies only consider three or four chemsex drugs (5,14,17 used, when in reality, studies should use the term SDU, as they include substances other than chemsex drugs (18)(19)(20)(21). ...
Article
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This original study compares the prevalences of drug use for any purpose and for sexualized drug use (SDU) among MSM. It also describes relevant characteristics of first SDU, analyzes to what extent SDU has been the first experience (the gateway) with different drugs by age and explores the correlates of SDU. Study participants included 2,919 HIV-negative MSM attending four HIV/STI diagnosis services in Madrid and Barcelona. They answered an online, self-administered questionnaire. Poisson regression models with robust variance were used. About 81.4% had ever used any drug, and 71.9% had done so in the last-12-months, while 56% had ever engaged in SDU, and 50% had done so in the last-12-months. Participants under 25 years old had the lowest prevalences of SDU, and the 25–39 age group the highest, except for Viagra, which was higher among those over age 40. The most frequently used drugs for first SDU were poppers (53.6%), cannabis (19.6%) and Viagra (12.2%). These drugs were also the most ever consumed for SDU. Among sexualized users, methamphetamine (78.3%) and Mephedrone (75.4%) were used always/most of the times for sex in the last-12-months. Around 72.2% of Mephedrone sexualized users and 69.6% of Methamphetamine vs 23.1% of ecstasy users' first consumption of these drugs involved use for sex. These drugs were provided to them free where they have sex for 66.8, 79.1, and 31.9%, respectively. On that occasion, 8.1% of Mephedrone, 6.8% of Methamphetamine and 18.4% of ecstasy users had sex only with steady partner; with 50.2, 56.2, and 26.2% respectively using a condom with any partner. SDU in the first use was associated with similar variables for recreational and chemsex drugs. The highest prevalence ratios were for having ever been penetrated by >20 men and having ever injected drugs. It can be concluded that the prevalence of SDU was more than half of the prevalence for any purpose. Thus SDU was the gateway to use for many drugs in an important proportion of users, who frequently consumed drugs that were free and had condomless anal sex with occasional and multiple partners. These circumstances were much more common for chemsex than for recreational drugs.
... 11 However, to our knowledge, no study has investigated the prevalence of this practice among heterosexual people. This practice has globally increased in recent years, 1 and it is therefore essential to study its causes and consequences. The socio demographic profile of people practicing chemsex seems to be heterogenous, and not reserved to sexual minorities. ...
... Compared to GBMSM not engaged in Chemsex, users are more likely to have unprotected anal sex (a practice called barebacking) as well as intercourse group sex. 1,2,12,16 In addition, people practicing chemsex are more prone to perform risky practices, such as fisting, 5 which can lead, for example, to lesions in the rectum. Finally, in terms of risk-taking, GBMSMs practicing chemsex are more at risk of experiencing non-consensual acts during sex and abuse, 3 in particular because of the altered consciousness caused by substances like GHB/GBL ...
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Chemsex, a specific form of sexualized drug use (SDU), has rapidly increased in the last decade. This phenomenon could result in a complex public health issue because of the heterogeneity amongst socio-psychological profiles of the practitioners, leading to the difficulty to target specific populations. Healthcare professionals need to be aware of this practice and its related risks to provide care adapted to the individual who consults. Here, we suggest that better knowledge of this field can help to improve prevention measures and provide information with a non-judgmental and respectful approach to those who practice chemsex. Bolmont M, Tshikung ON, Trellu LT. Chemsex, a Contemporary Challenge for Public Health. J Sex Med 2022;XX:XXX–XXX.
... The implications of inconsistent quantitative measurements of SDU for determining the prevalence and correlates have been previously stated [108]. While the difference in SDU prevalence between studies that asked about specific drug types versus generalized questions of any drug use fell short of statistical significance, SDU prevalence in the former was, on average, 50% greater and there has been a call for a need to adopt consistent terminology related to SDU to better understand this practice [27,109,110]. The lack of clarity in defining the construct of SDU was also recognized in a qualitative review of SDU practice among MSM and transgender women in Asia [106]. ...
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Abstract Introduction Sexualized drug use (SDU), the use of psychoactive drugs in the context of sexual intercourse, has been identified as a risk factor for HIV among men who have sex with men (MSM) in Asia. Given the distinct social and cultural context of same‐sex relationships and drug‐using practice in Asia, we aimed to describe the prevalence of SDU in East and South Asian countries and its associations with condomless anal sex (CAI) and HIV status. Synthesizing SDU research in this region, including SDU definitions, prevalence and outcomes, provides insights to inform future research and improved programme planning, resourcing and advocacy. Methods We systematically searched OVID Medline, OVID EMBASE, OVID Global Health, CINAHL, PsycINFO and SCOPUS publication databases for scientific articles published from 1990 to 2022 measuring SDU among MSM in East and South Asian countries. A narrative synthesis was utilized to describe key study attributes and findings, and meta‐analyses using random pooled effect models were used to estimate SDU prevalence and its associations with CAI and HIV status. Subgroup meta‐analyses, sensitivity analysis and assessment of publication bias examined potential sources of heterogeneity for the pooled SDU prevalence estimates. Results and discussion Of the 1788 publications screened, 49 publications met the selection criteria and 18 were suitable for meta‐analyses. Findings highlight SDU definitions distinct from other regions but inconsistencies in the definition of SDU between studies that have been highlighted in research elsewhere. The pooled prevalence of recent SDU (past 12 months) was 13% (95% CI = 10–16%; I2 = 97.6) but higher when studies utilized self‐administered surveys (15%; 95% CI = 12–19%; p
... Of those who were HIV-negative, 26.1% (7,210/27,585) among those who provided information reported using pre-exposure prophylaxis (PrEP) for HIV in the last 3 months. Almost a quarter of respondents (18.7%; n = 6,156) were diagnosed with a sexually transmitted infection (STI) in the last 12 months and 8.8% (n = 2,892) had engaged in chemsex (defined as having used mephedrone, GHB/GBL, ketamine or crystal methamphetamine during sex with other sexual partners) [4] in the last 3 months. IQR: interquartile range. ...
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We assess monkeypox vaccination acceptance among male adults in the European Region. We conducted an online survey through two dating apps targeting men who have sex with men, from 30 July to 12 August 2022. We developed Bayesian hierarchical logistic regression models to investigate monkeypox vaccination acceptance. Overall crude vaccination acceptance was 82% and higher in north-western compared to south-eastern European regions. Acceptance strongly rose with perception of increased disease severity and transmission risk, and in individuals linked to healthcare.
... In recent years, many empirical studies of chemsex participation have been conducted in many countries, for example, [7,58,70]. Epidemiological and sexual health research tends to examine the correlates of engagement in chemsex, with a view to understanding the (sexual) health risks associated with the practice as well as to develop a "profile" of the average chemsex participant [71]. This research is valuable as it enables practitioners to appraise the relevant risks in an evidence-based manner and potentially to intervene proactively before the hazard materializes. ...
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This article focuses on some of the social, cultural and psychological aspects of drug use in sexualized settings in gay and bisexual men (referred to as "chemsex"). Using a narrative review approach, the article examines previous empirical research in this area and presents a novel theoretical approach for understanding and predicting chemsex behavior. Tenets of identity process theory from social psychology are drawn upon to offer an integrative theoretical framework within which the social, cultural and psychological underpinnings of chemsex can be collectively examined. Existing empirical research suggests that gay and bisexual men may experience sexuality-related stressors that can undermine feelings of self-esteem, self-efficacy, continuity and positive distinctiveness. Identity process theory examines how individuals react to threats to identity brought about by these stressors. In response to identity threat, gay and bisexual men may engage in chemsex as a coping response that encompasses and facilitates various, largely maladaptive, coping strategies and tactics. The more chemsex is perceived as enhancing identity processes and as averting identity threat, the more central it is likely to be to the identities of participants. The centrality of chemsex to one's identity may preclude self-withdrawal from the practice. Several directions for future research are presented based on existing work on chemsex viewed through the lens of identity process theory. These should form the basis of future empirical research in the sphere of sexual health among gay and bisexual men and the outcomes of this research should inform policy and practice in this area.
... Drug use was generally associated with sexual health outcomes, but particularly in chemsex studies." (Hibbert et. al, 2021). Additional findings have supported that SDU is associated with sexual risk-taking, condomless sex, HIV, and other STIs due to lowered inhibitions, reduced access to condoms, social norms, perceptions of sexual freedom, reduced sensitivity, and erections when using methamphetamine (Lin, 2018;Tan, 2018). Emergent trends are showing that ...
Article
Sexualized drug use (SDU), also known as ‘chemsex’ or ‘chem-fun,’ is an emerging public health concern. This HIV risk behavior is a major issue and marginalized communities such as men who have sex with men (MSM) may be overlooked for prevention efforts or struggle to access adequate treatment. This study aims to determine the correlates of SDU to inform interventions, policy, and prevention of SDU. A convenience sample of Malaysian MSM were recruited through advertisements on geosocial networking apps (GSN) for gay men (e.g., Grindr, Hornet) and on popular social media platforms (i.e. Facebook). From June-July 2020, participants completed an anonymous online survey that took an average of 10-12 minutes. Participants answered questions about demographics, sexual health, HIV testing practices, and preference for future HIV prevention programs. Bivariate and multivariable logistic regression were used to assess associations between SDU and participants' characteristics and other variables. Of a sample of 355 participants, the mean age was 33.1 (±8.9) years, about half (53.3%) were Malay, and 84.5% had above a tertiary level of education. Forty-two participants (11.8)% reported engaging in SDU in the past six months. The results of the multivariable logistic regression revealed that the most highly associated factors of participating in SDU in the past 6 months at a 95% CI and an alpha level of 0.05 were age, participation in group sex, and recent injection drug use, and PrEP use in a lifetime. Opportunities for SDU reduction among MSM in Malaysia, exist in prevention efforts that focus on associated factors of SDU. Accessible harm reduction focused on mitigating the associated factors of SDU may result in an overall reduction of SDU prevalence.
... Research on GHB among LGBTQ populations largely focuses on sexualised drug use among GBM, with few studies documenting sexualised drug use among LBQ women or trans and gender diverse people ( Hibbert et al., 2021 ). Counter to dominant accounts of sexualised drug use that centre GBM, our study found that GHB was used for the purpose of enhancing sex across all sexuality and gender identities. ...
Article
Background GHB is used among some sexuality and gender diverse populations at elevated rates, however little qualitative research has explored GHB use among these populations with regards to diverse contexts, settings, practices, and experiences of use. Internationally, harms relating to GHB overdose appear to be increasing. Research outlining consumers’ experiences of GHB-related pleasures and their strategies to reduce harms may inform GHB education and intervention responses. Methods N = 31 participants reporting three or more occasions of GHB use within the previous 12 months were recruited via digital advertising and snowball methods. Semi-structured interviews were conducted, data were transcribed and analysed in NVivo using a thematic framework analysis. Emergent themes were charted, and divergences and convergences were considered with regards to the sexuality and gender identities of participants. Results Pleasures associated with GHB were described in relation to the sensation of the GHB high and experiences of intimacy, and connection. GHB was used to enhance socialising and sex in domestic, private, and commercial venues. Participants prioritised terminology of ‘control’ when describing their practices associated with GHB dosing, measuring, timing and peer moderation. Most participants reported personal experience of GHB overdose with loss of consciousness. Conclusion Participants’ near-ubiquitous experience of GHB overdose highlights ongoing education needs around overdose prevention. Efforts must target people new to GHB use who appeared particularly susceptible to overdose. Inconsistencies in understandings around GHB overdose, the perceived severity of overdose and the differences between GHB and its precursors GBL and 1,4-BD, highlight potential focus areas of future education responses. Further research is required to better understand consumers’ experiences of sexual violence in the context of GHB use.
Article
Background: The prevalence of chemsex has been reported by multiple systematic reviews among men who have sex with men (MSM) focussing predominantly on the Global North. An Asian perspective with meta-analytical evidence is missing. This meta-analysis summarised the prevalence of substance use associated with chemsex, and chemsex activity among MSM and MSM sub-populations in Asia, as well as the likelihood for chemsex among MSM living with or without HIV. Methods: We utilized PubMed, Web of Science and medRxiv to search for literature describing chemsex and its associated substance use among MSM and MSM sub-populations in Asia from January 1, 2010 to November 1, 2021 to conduct three meta-analyses with both frequentist and Bayesian approaches. Results: We identified 219 studies and included 23 in the meta-analysis. Based on the frequentist models, methamphetamine was the default substance associated with chemsex among MSM in Asia (prevalence = 0.16, 95 %CI:0.09-0.22), followed by GHB/GBL (prevalence = 0.15, 95 %CI:0.03-0.27) and ketamine (prevalence = 0.08, 95 %CI:0.04-0.12), but hardly any cocaine (prevalence = 0.01, 95 %CI:0.00-0.03). Compared to a general MSM population (prevalence = 0.19, 95 %CI:0.15-0.23), MSM engaging in transactional sex showed a higher prevalence of chemsex (MSM sex work clients [prevalence = 0.28, 95 %CI:0.11-0.45]; MSM sex worker [prevalence = 0.28, 95 %CI:0.17-0.26]). MSM living with HIV also showed higher odds of chemsex activity (OR = 3.35, 95 %CI:1.57-7.10), compared to MSM living without HIV. Both meta-analytic models converged, indicating robust evidence. Conclusions: Our meta-analyses showed that chemsex is not uncommon among MSM, and MSM engaging in transactional sex in Asia. We confirmed that MSM living with HIV have a higher likelihood of engaging in chemsex, too. Chemsex prevention and management strategies in Asia should be adjusted accordingly.
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Amid incremental progress in establishing an enabling legal and policy environment for lesbian, gay, bisexual, transgender and queer-identified people, and people with intersex variations (LGBTQI+) in India, evidence gaps on LGBTQI+ health are of increasing concern. To that end, we conducted a scoping review to map and synthesize the current evidence base, identify research gaps, and provide recommendations for future research. We conducted a scoping review using the Joanna Briggs Institute methodology. We systematically searched 14 databases to identify peer-reviewed journal articles published in English language between January 1, 2010 and November 20, 2021, that reported empirical qualitative, quantitative or mixed methods data on LGBTQI+ people's health in India. Out of 3,003 results in total, we identified 177 eligible articles; 62% used quantitative, 31% qualitative, and 7% mixed methods. The majority (55%) focused on gay and other men who have sex with men (MSM), 16% transgender women, and 14% both of these populations; 4% focused on lesbian and bisexual women, and 2% on transmasculine people. Overall, studies reported high HIV and sexually transmitted infection prevalence; multilevel risk factors for HIV; high levels of mental health burden linked to stigma, discrimination and violence victimization; and non-availability of gender-affirmative medical services in government hospitals. Few longitudinal studies and intervention studies were identified. Overall, LGBTQI+ health research in India needs to move beyond the predominant focus on HIV, and gay men/MSM and transgender women, to include mental health and non-communicable diseases, and individuals across the LGBTQI+ spectrum. Future research should build on largely descriptive studies to include explanatory and intervention studies, beyond urban to rural sites, and examine healthcare and service needs among LGBTQI+ people across the life course. Dedicated funding and training for junior investigators conducting LGBTQI+ health research is crucial to building a comprehensive evidence base to inform health policies and programs.
Article
Background Research addressing sexualised use of GHB to date has largely focussed on gay and bisexual men's GHB use in the context of chemsex, this research has highlighted risks and experiences associated with sexual violence. No studies have included people of diverse sexualities and genders and documented reported practices to ensure mutually gratifying and consensual sex in the context of sexualised drug use (SDU). Methods Semi-structured interviews were conducted with 31 people from sexuality and gender diverse communities living in Australia who reported three or more occasions of GHB use in the previous 12 months. Participants were asked about their use of GHB for sex, their experiences of GHB sex and their approaches to negotiating sexual boundaries. Data were analysed thematically. Results Most participants valued the sexual possibilities enabled by disinhibitory components of GHB and were cognisant of respecting other's sexual boundaries in the context of GHB sex. Participants reported strategies to ensure communication prior to and throughout GHB sex. However, several participants narrated experiences of GHB sex that they felt were distressing and, in some circumstances, sexually violent. In most instances participant's resisted terminology of sexual violence or non-consent as descriptors of their experience and none reported accessing sexual violence services. Conclusion Positive strategies to facilitate sexual communication prior to and throughout GHB sex should be reflected in health promotion and service level responses to promote affirmative and continuous consent among people who use GHB for sex. Education initiatives to help people engaged in SDU to recognise and respond to sexual violence if it occurs ought to be prioritised.
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Introduction: Studies indicate that women who have sex with women (WSW) report greater levels of drug use than heterosexual women, but globally few studies have looked at sexualised drug use among WSW. This study investigated the factors associated with drug use and sexualised drug use (SDU) among WSW. Methods: Potential participants across the UK were invited to take part in a cross-sectional anonymous online survey between April-June 2018. The LGBT Sex and Lifestyles Survey recruited participants through Facebook advertising and social media posts from community organisations. Multivariate logistic regression was used to compare WSW who had engaged in any drug use in the past 12 months with those who had not, and those who engaged in sexualised drug use in the past 12 months with those who engaged in other drug use. Results: 1501 WSW could be included in the analyses (mean age = 28.9, 97% white ethnicity). Any drug use was reported by 39% of WSW (n = 583), 44% of which (17% of total, n = 258) reported SDU. Factors associated with drug use were identifying as queer (aOR = 1.86, 95%CI 1.08, 3.23), younger age (aOR = 0.96, 95%CI 0.95, 0.98), being born outside the UK (aOR = 1.75, 95%CI 1.15, 2.66), recent sexual assault (aOR = 2.35, 95%CI 1.43, 3.86), > = 5 female sexual partners (aOR = 3.81, 95%CI 1.81, 8.01), and psychological distress (aOR = 1.75, 95%CI 1.15, 2.67). SDU was associated with identifying as bisexual (aOR = 2.55, 95%CI 1.69, 3.86), > = 5 female sexual partners (aOR = 4.50, 95%CI 1.91, 10.59), and highest education achieved at 16 or lower (aOR = 2.46, 95%CI 1.24, 4.90). Conclusions: Some WSW may have negative experiences in relation to drug use and SDU. Harm reduction and health services that provide services for WSW should be aware of potentially compounding factors related to drug use, such as sexual assault and psychological distress, providing a safe and LGBT-friendly environment to discuss these issues.
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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).
Article
Background ‘Chemsex’ is the use of drugs before or during planned sexual events to facilitate, enhance, prolong and sustain the experience. Drugs associated with chemsex are methamphetamine, GHB/GBL, mephedrone, cocaine and ketamine. This review syntheses published research on the antecedents, behaviours and consequences associated with chemsex behaviours among men who have sex with men (MSM). Methods Papers from high income countries which were published between January 2000 and September 2018 reporting the use of chemsex drugs before or during sex were identified through Medline, Web of Science, CINAHL and Central. Results were synthesised using a narrative approach and conceptualised using a behavioural analysis framework. Results The search identified 2492 publications, of which 38 were included in the final synthesis. There were wide variations in chemsex prevalence estimates due to the heterogeneous sampling in the studies. Chemsex participants have expectations that the drugs will positively affect their sexual encounters and HIV positive MSM are more likely to engage in the behaviour than HIV negative MSM. There were wide ranging prevalence estimates on injecting drugs for sexual purposes and the sharing of injecting equipment with some evidence of unsafe injecting practices. Participants were more likely to engage in condomless anal intercourse than men who do not engage in chemsex. This may increase the risk of transmission for HIV and other sexually transmitted infections. Conclusion A minority of MSM appear to engage in chemsex behaviours but they are at risk of this negatively impacting on their health and well-being. Further research is required to examine high risk chemsex behaviours, impact of chemsex on psycho-social well-being and if chemsex influences uptake of PrEP, PEP and sexual health screening. Share link: https://authors.elsevier.com/a/1Y9Bg3PEroL8yA
Article
Aims: Sexualised drug taking is increasingly reported on national and international levels. We aim to review existing evidence of the relationship between recreational drug use (RDU) and sexual intercourse among men who have sex with men (MSM). Methods: We reviewed published abstracts and full articles identified from Cochrane, MEDLINE and Embase databases from November 2010 to 2017. We included any existing studies investigating RDU in MSM and at least one of the following: high-risk sexual practices, sexually transmitted infections (STIs) or barriers to accessing specialist support. Results: In total, 112 studies were included. Of them, 38 studies specifically reported the prevalence of chemsex-related drug use. Links with sexualised drug taking and high-risk sexual practices including condomless sex and group sex were reported by several studies. Recreational drug use in the sexual setting appears linked to the acquisition of STIs, including hepatitis C, syphilis and gonorrhoea. Reports of adverse mental health outcomes are increasingly described, with several studies documenting chemsex-related inpatient admission. A paucity of research addressing barriers to those accessing specialist drug support services was identified. Conclusion: This review demonstrates the complex interplay between recreational drug use, high-risk sexual practices and STIs. It identifies the description of adverse mental health outcomes in the chemsex setting, thus highlighting the need for a multidisciplinary approach across specialties in the management of those adversely affected. Finally, it illuminates the need for future research into perceived barriers of those who require access to support services to ensure timely and comprehensive support provision.
Article
Background: Sexualised drug use (SDU) refers to the use of drugs in a sexual context. This includes 'Chemsex'- the use of drugs (specifically crystal methamphetamine, GHB/GBL and mephedrone) before or during planned sexual activity to sustain, enhance, disinhibit or facilitate the experience. Here we aimed to synthesise available UK prevalence data for Chemsex, SDU and the use of Chemsex drugs in an undefined context (CDU) in men who have sex with men (MSM). Methods: Papers published between January 2007 and August 2017 reporting Chemsex, SDU and/or Chemsex drug use (CDU) prevalence in MSM were identified through PubMed. Citations were searched for further eligible publications. We also conducted a review of national surveillance data, extracting prevalence data for Chemsex, SDU or CDU. Synthesized data were then assessed to determine the time at which these drugs were taken, in this case just prior to or during sexual activity (event-level). Results: Our search identified 136 publications, of which 28 were included in the final data synthesis. Three of the four surveillance systems assessed provided SDU or CDU data in MSM. Few publications included event-level data for Chemsex (n = 4), with prevalence estimates ranging from 17% among MSM attending sexual health clinics (SHC) to 31% in HIV-positive MSM inpatients. Prevalence estimates for SDU (n = 7 publications) also varied considerably between 4% in MSM receiving HIV care to 41% among MSM attending SHC for HIV post-exposure prophylaxis (PEP). Eighteen publications provided data for CDU. Conclusion: Prevalence estimates varied considerably due to differences in the definition used and population assessed. Standardised definitions and studies with representative national samples of MSM are required to improve our understanding of the extent of Chemsex and its associated risks. Longitudinal event-level data for SDU and Chemsex are needed to monitor impact of interventions.
Article
Background: Higher levels of drug use have been reported in lesbian, gay, bisexual and transgender (LGBT) communities, some of which can be explained by sexualised drug use, including 'chemsex'; the use of drugs before or during planned sexual activity to sustain, enhance, disinhibit or facilitate sex. We explored injecting and non-injecting drug use by sexual behaviour among people who inject drugs (PWID) in England, Wales and Northern Ireland. Methods: Data were used from an unlinked-anonymous survey of PWID (2013-2016), where participants recruited through services self-completed a questionnaire. We included sexually active participants who had injected in the previous year, and compared injecting and non-injecting drug use between men reporting sex with men (MSM) and heterosexual men, and between women reporting sex with women (WSW) and heterosexual women. The questionnaire did not include GHB/GBL and methamphetamine use. Results: There were 299 MSM, 3215 heterosexual male, 122 WSW and 1336 heterosexual female participants. MSM were more likely than heterosexual men to use drugs associated with chemsex: injected or non-injected mephedrone (adjusted OR (AOR) 2.22, 95%CI 1.54-3.22; AOR 2.15, 95%CI 1.48-3.11) and injected or non-injected ketamine (AOR 1.98, 95%CI 1.29-3.05; AOR 2.57, 95%CI 1.59-4.15). MSM were also more likely to inject methadone, inhale solvents, take ecstasy, cocaine or speed. WSW were more likely than heterosexual women to use non-injected mephedrone (AOR 2.19, 95%CI 1.20-3.99) and use injected or non-injected ketamine (AOR 5.58, 95%CI 2.74-11.4; AOR 3.05, 95%CI 1.30-7.19). WSW were also more likely to inject methadone, inject cocaine, use non-injected cocaine, crack, benzodiazepines or ecstasy, inhale solvents, or smoke cannabis. Conclusion: Injecting and non-injecting drug use differed between MSM/WSW and heterosexual men and women. The use of drugs that have been associated with chemsex and sexualised drug use is more common among both MSM and WSW than heterosexual men and women.
Article
Background: Drug use for or during sex ('chemsex') among MSM has caused concern, because of the direct effects of the drugs themselves, and because of an increased risk of transmission of sexually transmitted infections (STIs). This study aimed to assess the prevalence of chemsex, associated behaviours and STIs among attendees at Ireland's only MSM-specific sexual health clinic in Dublin over a six week period in 2016. Methods: The questionnaire collected demographic data, information on sexuality and sexual practice, self-reported history of treatment for STIs, and chemsex use. Key variables independently associated with treatment for STIs over the previous 12 months were identified using multivariable logistic regression. Results: The response rate was 90% (510/568). One in four (27%) reported engaging in chemsex within the previous 12 months. Half had taken ≥2 drugs on his last chemsex occasion. One in five (23%) reported that they/their partners had lost consciousness as a result of chemsex. Those engaging in chemsex were more likely to have had more sexual partners(p<0.001), more partners for anal intercourse (p<0.001) and to have had condomless anal intercourse(p=0.041). They were also more likely to report having been treated for gonorrhoea over the previous 12 months (adjusted OR 2.03, 95% CI 1.19-3.46, p=0.009). One in four (25%) reported that chemsex was impacting negatively on their lives and almost one third (31%) reported that they would like help or advice about chemsex. Conclusion: These results support international evidence of a chemsex culture among a subset of MSM. They will be used to develop an effective response which simultaneously addresses addiction and sexual ill-health among MSM who experience harm/seek help as a consequence of engagement in chemsex.
Article
: In this narrative review we illustrate the patterns of substance use among gay, bisexual and other men who have sex with men (MSM), including comparisons with heterosexual populations, subgroup analyses and settings of substance use. We also consider explanations and motivations for substance use and the impact of use on sexual health as well as wider health and well-being. Finally, we consider the implications for the provision of MSM-tailored substance use and harm reduction services. : We undertook a narrative review of diverse literature across the fields of public health, psychology and sociology to synthesise complex findings relating to the use and impacts of illicit drugs and alcohol among MSM. Attempts were made to draw on literature from across the globe, including all income settings. : Global evidence relating to the use of substances among MSM is limited due to the lack of disaggregation of data by sexual orientation. While complicated by methodological diversity, most research indicates a higher prevalence of illicit drug use among MSM compared with their heterosexual counterparts, although the same is not necessarily true of alcohol. A sense of belonging, coping with everyday problems and the enhancement of pleasure, all feature in motivations for alcohol and drug use. Global association studies document a link between substance use and sexual risk behaviours, and event-level analyses suggest an especially strong association with respect to alcohol. While there is some evidence that generic harm reduction interventions can be effective among sexual minorities, these need to be tailored to the social and cultural circumstances of MSM. : Associations between substance use and sexual risk behaviour among MSM have been well documented, but the nature and pathway of these are poorly understood. A focus largely on substance use and sexual risk may have served to mask the impact of alcohol and drug use on the broader health and well-being of MSM.<br/
Article
Background: 'Chemsex' refers to the combining of sex and illicit drugs, typically mephedrone, GHB/GBL, and crystal methamphetamine. While numerous studies have examined the role of illicit drugs in sexual risk taking, less attention has been paid to the broader social context and structures of their use among gay men. Given their established role in influencing health related behaviour, this study sought to examine the nature and operation of social norms relating to chemsex among gay men residing in South London. Methods: In-depth interviews were conducted with thirty self-identifying gay men (age range 21-53) who lived in three South London boroughs, and who had used either crystal methamphetamine, mephedrone or GHB/GBL either immediately before or during sex with another man during the previous 12 months. Data were subjected to a thematic analysis. In addition, two focus groups (n=12) were conducted with gay men from the community to explore group-level perceptions of drug use and chemsex. Results: Chemsex was perceived as ubiquitous amongst gay men by a majority of participants, who additionally described a variety of ways it is arranged (including mobile apps) and a variety of settings in which it occurs (including commercial and private settings). Chemsex was associated with unique sexual permissions and expectations, although participants also described having personal boundaries with respect to certain drug and sex practices, suggesting within-group stigmatisation. Conclusion: This study clearly documents exaggerated beliefs about the ubiquity of chemsex, shifts in the perceived normativity of certain settings and means to facilitate chemsex, and attitudes revealing stigma against certain types of chemsex and men who engage in it. There is a need for health promotion interventions to challenge social norms relating to drug use generally, and chemsex specifically, and for such interventions to make use of the online settings in which chemsex is often facilitated.
Article
Background: Anecdotal evidence suggests that men who have sex with men (MSM) are increasingly combining sex and illicit drugs (an activity referred to as 'chemsex'), in particular GHB/GBL, ketamine, crystal meth, or mephedrone (here called 4-chems). Use of such drugs has been associated with mental health and sexual health harms. We aim to compare patterns of illicit drug use among MSM in 44 European urban centres. Methods: In 2010, EMIS recruited 174,209 men from 38 countries to an anonymous online questionnaire in 25 languages. As harm reduction services for drugs and sex are organised at a local level, we chose to compare cities rather than countries. We defined 44 cities based on region/postal code and settlement size. For multivariable regression analyses, three comparison groups of MSM not living in these cities were applied: MSM living in Germany, the UK, and elsewhere in Europe. Results: Data from 55,446 MSM living in 44 urban centres were included. Use of 4-chems (past 4 weeks) was highest in Brighton (16.3%), Manchester (15.5%), London (13.2%), Amsterdam (11.2%), Barcelona (7.9%), Zurich (7.0%) and Berlin (5.3%). It was lowest in Sofia (0.4%). The rank order was largely consistent when controlling for age, HIV diagnosis, and number of sexual partners. City of residence was the strongest demographic predictor of chemsex-drug use. Conclusion: Use of drugs associated with chemsex among MSM varies substantially across European cities. As city is the strongest predictor of chemsex-drug use, effective harm reduction programmes must include structural as well as individual interventions.