Can needle exchange services deliver chemsex harm reduction?
Chemsex isn’t a new phenomenon, but it is something that substance use treatment providers and policymakers are newly grappling with. Natalie Davies examines research recently published in Drugs: Education, Prevention and Policy about whether mainstream needle exchange services are apt to deliver chemsex harm reduction.
‘Chemsex’ is the use of drugs before or during sex – typically to enhance or change the experience. For policymakers and practitioners, chemsex poses risks from (1) the drug use, (2) the sexual activity, and (3) the unique context of sexualised drug use. Of course, for people who engage in chemsex, those three factors – drug use, sex, and the unique context of sexualised drug use – are also potential sources of pleasure.
The UK Government’s 2017 Drug Strategy talked about chemsex as an ‘evolving or emerging threat’ – referring to the threat of new psychoactive substances with lesser known harms, particularly to subcultures that most frequently engage in chemsex. The most recent Drug Strategy, published in 2021, also made reference to the phenomenon, saying that additional funding was needed for treatment and support around the issue of chemsex.
There are several different definitions of chemsex, most of which zero in on the groups of people, circumstances, and types of drugs that tend to be associated with the practice, for example:
“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).” Matthew Peter Hibbert and colleagues in “A narrative systematic review of sexualised drug use and sexual health outcomes among LGBT people”
“[Chemsex involves] engaging in sexual activities while under the influence of drugs. [It] often involves group sex or a high number of partners in one session.” Adam Bourne and colleagues for The Chemsex Study
“The term chemsex refers to group sexual encounters between gay and bisexual men in which the recreational drugs GHB/GBL, mephedrone and crystallized methamphetamine are consumed.” Jamie Hakim in “The rise of chemsex: queering collective intimacy in neoliberal London”
“‘Chemsex’ is the use of drugs before or during planned sexual events to facilitate, enhance, prolong and sustain the experience.” Steven Maxwell and colleagues in “Chemsex behaviours among men who have sex with men: A systematic review of the literature”
“Chemsex is a term for the use of drugs before or during planned sexual activity to sustain, enhance, disinhibit or facilitate the experience.” UK Government’s 2017 Drug Strategy
There are currently no best practice toolkits or ‘gold standard’ interventions for chemsex; however, needle and syringe programmes – which exist in cities across the UK – may be convenient sites for delivering harm reduction advice and resources. A 2022 study by Claire Smiles and colleagues involved talking to 17 needle exchange workers in two UK cities about what they knew and thought about chemsex, and their capacity to reduce harm among this group of people who use drugs.
Generalities and specifics
Practitioners in the study did not have a comprehensive knowledge of chemsex. As might be expected, many were experts in harm reduction, but the study found that this did not always translate into an understanding of the harms of, and suitable responses to, chemsex. For example:
Original article: Needle exchange practitioners accounts of delivering harm reduction advice for chemsex: implications for policy and practice. By Claire Smiles and colleagues. Published in Drugs: Education, Prevention and Policy (2022).
- most could give a general definition of chemsex but were not familiar with the types of drugs commonly used in chemsex and did not have much experience working with populations most associated with chemsex (i.e. men who have sex with men)
- most knew that discussing pleasure in the context of sexualised drug use could be an opportunity to reduce harm but said they felt more comfortable talking about risks than pleasure
One of the challenges is that the ‘chemsex scene’ has been subject to changes, particularly with the advent of new psychoactive substances. For example, earlier research from Manchester (England) between January and June 2016 found that there had been a shift from the use of substances such as ecstasy and cocaine, to higher-risk practices such as ‘slamming’ (a term used to describe intravenous injection) crystal methamphetamine or mephedrone.
Working in ‘mainstream’ services
Practitioners from services in London and the North of England suggested that there was an unmet need for harm reduction among men who have sex with men; very few men from this population attended needle exchange services.
An interesting finding in the study was that some practitioners were certain that gay men had attended needle exchange services but had not been explicit about the context of their drug use. If true, this could mean that men who would benefit from chemsex harm reduction were walking through the doors of treatment services, but were not able to access the full range of information and advice that they needed.
“…It’s absolutely guaranteed that people have come through service, who might have at some point or still be engaged in chemsex and will never have disclosed it.”
Practitioners said that many of the ‘mainstream’ or ‘general’ services in the study had been designed to deliver interventions to people dependent on opioids, stimulants, and alcohol, which could be read as both an explanation and a ‘mea culpa’ for the gaps in service provision for people engaged in chemsex:
How could practitioners develop expertise in chemsex when few people attended their needle exchange for this type of support?
Why would people attend their needle exchange for advice about chemsex when there was a perception on both sides that the service was not for them?
We can add to this prior research which suggested that men who engage in chemsex may see themselves outside the traditional ‘clientele’ of drug and alcohol services. Compared with traditional populations of people who inject drugs, many men who engage in chemsex are in full-time employment and require more flexible and extended opening times in order to access harm reduction services.
Some practitioners in the featured study indicated that they relied heavily on LGBTQ specialist services, who were “better positioned to offer needle exchange and harm reduction advice for MSM who engage in chemsex”. Others said that they had put strategies in place to be more visibly inclusive to the LGBTQ community – for example, through staff wearing rainbow lanyards, and placing flags and posters in the waiting area.
Research from Manchester recommended that harm reduction services should consider a mixture of strategies to engage marginalised communities of people who use drugs with treatment and support. This could include targeted outreach, locating services within communities or contexts where drug use is prevalent (e.g. siting a needle exchange service at the heart of an LGBTQ community), and trying new marketing strategies.
Understanding why marginalised populations may have poor health outcomes
Public Health England identified three distinct but overlapping areas in which men who have sex with men bear a disproportionate burden of ill-health: (1) sexual health and HIV status; (2) mental health; and (3) the use of alcohol, drugs, and tobacco. Chemsex is an example of this overlap, and has the potential to increase harms to men who have sex with men, for example by contributing to the spread of sexually transmitted infections and blood-borne viruses.
The featured research examined whether needle exchange services could offer appropriate or specific harm reduction to people engaged in chemsex, and it did so from the perspective of a small group of practitioners. This is just one important perspective and needs to be combined with research into the thoughts, needs and contexts of people who engage in chemsex.
Drawing on resources designed by and for men who have sex with men
Among men who have sex with men, reasons for engaging in chemsex may include wanting to reduce inhibitions, increase pleasure, facilitate sustained arousal, induce a feeling of instant rapport with sexual partners, as well as manage negative feelings such as a lack of confidence, self-esteem, internalised homophobia, and stigma about HIV status.
Information resources designed by, with, and for men who have sex with men may help address harms associated with chemsex, while acknowledging the complex reasons gay and bisexual men practice chemsex and will probably continue to do so. This includes:
- “Chemsex First Aid”, which “joins a harm reduction ecosystem of both institutional resources and the ‘word-of-mouth amongst guys that engage in chemsex’”, and is “part of queer men’s ‘long history of activism…of sharing information and stories, and of looking out for each other’”.
- “Slamming”, which is adapted from a groundbreaking Dutch publication, and based on ethnographic research exploring injecting drug use at slamming parties, and effective harm reduction strategies.
The research from Claire Smiles and colleagues indicated that addiction treatment services remain designed for people who use more traditional types of drugs (opiates, cocaine etc). Whilst this may still accurately describe the main population of people with substance use problems, there should be more acknowledgement of marginalised and minority communities, as well as the impact of new psychoactive substances on the treatment needs of different groups. This research, which focused on a small number of needle exchange services, highlights some of the potential limitations of addiction treatment services, which new government investment might be able to help address.
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