“Chemsex is a term for the use of drugs before or during planned sexual activity to sustain, enhance, disinhibit or facilitate the experience. Chemsex commonly involves crystal amphetamine, GHB/GBL and mephedrone, and sometimes injecting these drugs (also known as slamming). These practices can have an adverse impact of the health and wellbeing of MSM (Men who have Sex with Men).” (Public Health England, 2015)

While the above PHE definition provides a useful introduction, it is insufficient for those unfamiliar with the sociocultural arena around which Chemsex is centred. Mobile applications (e.g. Grindr, Scruff) among other social changes have facilitated rapid access to drugs and a plethora of sexual partners using similar substances. The obvious primary health concern here is of acquiring infections during disinhibited sex. However, the risks are multifaceted and may include drug induced psychosis, GHB overdose and death. Furthermore, Chemsex behaviour was used to disguise the actions of a serial killer in Barking, demonstrating that Chemsex participants may also be at risk from those they engage with.

As such, the article by Edmundson et al., ‘Sexualised drug use in the United Kingdom (UK): A review of the literature’, is a necessary addition to our understanding of this behaviour and its prevalence.

Finally, it is important to note that the purpose of this article is not to stigmatise any form of consensual sexual behaviour, but rather to help improve the care of the small but significant group of individuals who suffer consequences of Chemsex behaviour.

Definitions

Sexualised Drug Use (SDU): The use of illicit drugs just before or during sexual activity.

Chemsex Drug Use (CDU): The use of any Chemsex drugs (mephedrone, methamphetamine, GHB/GBL) in an undefined context.

Methods

The authors used a two-part strategy to collate available prevalence data for Chemsex, SDU and CDU:

1. The authors used the PubMed database to search for papers published between 2007 and 2017, excluding results that were not written in English, did not contain UK data or were reporting non-human evidence. Their search utilised a combination of terms associated with; Chemsex, sexualised drug use, men who have sex with men, mephedrone, GHB/GBL, crystal methamphetamine and ketamine. An additional review of citations of included papers was conducted
2. PHE national surveillance systems were extracted and data included in the synthesis if they reported prevalence data for Chemsex, SDU or CDU specific to MSM in England.

Results

The literature search provided 28 eligible publications:

• 7 of these reported prevalence data for SDU
• 4 for Chemsex
• 28 for CDU.

SDU prevalence

• 4 publications and the Genitourinary Medicine Clinic Activity Dataset (GUMCAD) reported the prevalence of SDU among a sample of HIV+ and HIV- MSM attending routine sexual health clinic (SHC) appointments. The median prevalence was 23%
• SDU prevalence appears to rise in individuals with an STI diagnosis
• GUMCAD reported that 43% of MSM reporting any illicit substance misuse in the last three months, reported SDU in their last sexual encounter.

‘Chemsex’ prevalence

• Only 4 publications and none of the national surveillance systems provided event-level data for Chemsex among MSM
• Estimates of prevalence were from 17% among MSM attending SHC to 31% in HIV positive MSM admissions
• Results revealed a lack of consensus on the definition of Chemsex. Two studies included secondary drugs, cocaine and ketamine in their definition.

CDU prevalence

• 23 studies and 3 national data sources reported on CDU as a proxy of Chemsex behaviour
• Mephedrone was found to be the most commonly used Chemsex drug
• GHB/GBL use only exceeded mephedrone use when HIV- subjects were excluded
• The prevalence of ketamine use reported varied greatly between studies
• Past four-week CDU was highest in Brighton (16%), Manchester (16%) and London (13%) when compared with 41 other large European cities
• Regional disparity was seen with CDU, such that methamphetamine use among MSM in London was found to be 5 times greater than outside London (Gay Men’s Sex Survey).

One study captured event-level data for injection of Chemsex drugs and found methamphetamine to be the most commonly injected Chemsex drug when compared with mephedrone.

Conclusions

The authors conclude that:

the extent of sexualised drug use and Chemsex among MSM in the UK remained poorly understood… SDU and Chemsex seem to vary considerably both by HIV status, risk behaviour and region.

Furthermore, they highlight the need for a standardised definition of Chemsex to gain a better understanding of the extent of this behaviour, the risks it carries and the efficacy of any interventions.

Strengths and limitations

The review by Edmundson et al. is a very welcome addition to a much-needed dialogue surrounding Chemsex and health. However, there are several methodological limitations acknowledged by the author that should be considered when using this evidence:

• Only one database (PubMed) was used for the literature search
• The search results were only reviewed by one researcher
• A formal quality assessment was not conducted on individual papers included in the review.

Further limitations were identified in the Chemsex literature, including:

• The use of CDU as a proxy for MSM Chemsex behaviour is problematic, as it ignores the non-sexualised use of these substances that may occur in the first instance or with increasing dependence
• Individual studies largely reported on small samples that were at times biased by opportunistic sampling in crises
• The data was predominantly concerned with Chemsex in UK urban settings.

Implications for practice

The findings of this study are inconclusive in so far that they are not able to offer a definitive estimate of prevalence. However, it is clear that Chemsex prevalence is significant, as are the aforementioned risks. As such, whilst the majority of MSM do not have unhealthy substance use, there may be scope for conducting a thorough alcohol and substance-use history periodically among MSM attending general practice and those reporting high risk sexual behaviour in the genitourinary medicine setting. A list of resources is detailed below which can help both the clinician and the service user to understand Chemsex.

In addition, it was apparent throughout the review by Edmundson et al. that a consensus definition is required in the academic community regarding which substances fall under the Chemsex umbrella and which recall periods should be used in order for standardised research to be compared.

Conflicts of interest

The author has no conflict of interest to declare.

Links

Primary paper

Edmundson C, Heinsbroek E, Glass R, Hope V, Mohammed H, White M, Desai M. (2018) Sexualised drug use in the United Kingdom (UK): A review of the literature. International Journal of Drug Policy, 2018 https://doi.org/10.1016/j.drugpo.2018.02.002

Other references

PHE Public Health England. (2015). Substance misuse services for men who have sex with men involved in chemsex, 1–11.

Public Health England. (2015a). Genitourinary medicine clinic activity dataset (GUMCADv3) pilot. Retrieved 21 September 2017, from Public Health England

Additional resources:

Bourne A, Reid D, Hickson F, Torres Rueda S, W. P. (2014). The Chemsex study: drug use in sexual settings among gay & bisexual men in Lambeth, Southwark & Lewisham. 2014. https://doi.org/978-1-906673-18-5

Something For The Weekend: Life In The Chemsex Underworld, James Wharton

An excellent resource by David Stuart to help individuals make changes with CDU. http://www.davidstuart.org/care-plan

Sexual health clinics with Chemsex support:

• http://dean.st/chemsex-support/
• https://www.burrellstreet.co.uk/chemsex/

Grindr and general online safety tips:

• https://www.pinknews.co.uk/2016/11/23/15-ways-you-can-stay-safe-on-grindr-and-other-dating-apps/
• https://help.grindr.com/hc/en-us/articles/217955357-Safety-Tips

Narcotics anonymous: http://ukna.org/

Photo credits

• By See-ming Lee from Hong Kong SAR, China [CC BY-SA 2.0], via Wikimedia Commons
• By GreenZeb – Own work, CC BY-SA 3.0, Link
• See Ming Lee CC BY 2.0
• Photo by Caitlyn Wilson on Unsplash
• Photo by Kevin Grieve on Unsplash