Dr Matt Hibbert recently published a systematic review of sexualised drug use and chemsex among LGBT people. The SSA caught up with Dr Hibbert to find out more.
“We found the most common measurement was global, so although studies said that they were measuring sexualised drug use, really they were looking at drug use generally and sexual behaviour or HIV and STIs generally as opposed to asking that specific question in a specific context”
SSA: How do you define chemsex?
Dr Hibbert: “In this article we looked at two things. We looked at chemsex and at sexualised drug use more generally. In the article we defined chemsex as the specific use of GHB, GBL, crystal methamphetamine, ketamine and mephedrone immediately before or during sex to facilitate the sexual experience. That’s been a rising phenomenon among men who have sex with men in recent years. We also looked at broader sexualised drug use as well, so drugs that haven’t received as much attention recently such as poppers, cannabis, cocaine and ecstasy.”
You found that the range of drugs included as chemsex varied across different countries, can you say a little bit more about that?
“In studies that said they measured chemsex, GHB, GBL and crystal methamphetamine were common in all, or nearly all, definitions. Beyond that, other drugs that were included in definitions of chemsex varied considerably. We hypothesised in the article that this might be due to commonality of drugs used in different countries and drug availability and drug markets, those sorts of things.”
You reviewed the literature from 2010 to 2020, was chemsex different before 2010?
“We wanted to research studies conducted in the last decade because although historically there’s always been evidence of men who have sex with men using crystal methamphetamine for sex, the development of apps such as Grindr that are used to meet sexual partners has facilitated a growth in chemsex among men who have sex with men, so we wanted to include more recent papers to really investigate this recent trend.”
You commented that the studies were too varied to make direct comparisons between papers. How did they vary? What kind of differences did you find in study design?
“There was a lot of variability in drugs, but we included a lot of different drugs in our review, so that was to be expected. Thankfully, there were enough similarities in drugs to look at that further. What stopped us from making comparisons was the methods that studies used. So, the time period for drug use, the measurements for drugs and the measurement of sexual behaviour varied from last sexual contact or the last 24 hours to lifetime. There was a lot of variability there. Even though a study classified itself as looking at sexualised drug use, there were differences in whether it asked about drug use in a specific sexual context or whether it asked ‘have you used crystal meth yes / no’.”
You differentiate between global, situation and event level associations. Can you describe the difference between those and the importance for research?
“Yes, sure. So, I’ll use the health outcome of condom use to go through them. For global associations, a survey would ask ‘have you used crystal meth in the past 12 months, have you used condoms in the past 12 months?’ and then conduct an analysis between the two.”
“For situational associations, the question around drug use would be ‘have you used crystal meth in a sexualised setting in the past 12 months, or have you used crystal meth to enhance sex in the past 12 months’ and then there would be the same question about condom use.”
“For event level associations, the question would be ‘Last time you used crystal meth for sex did you use a condom – Yes / No?’. So, it’s sort of like an increasing degree of accuracy.”
“We found the most common measurement was global, so although studies said that they were measuring sexualised drug use, really they were looking at drug use generally and sexual behaviour or HIV and STIs generally as opposed to asking that specific question in a specific context.”
So, the most useful measurement would be the event level research?
“Yeah, that’s definitely the most detailed and then, at the very least you would sort of expect situational associations to be used, so at least you’re asking whether the drug was used for sex.”
“..there should be greater engagement of care for those engaging with chemsex and more health advice around regular screening, access to pre-exposure prophylaxis if they’re HIV negative.”
What kind of associations were there between sexualised drug use and health outcomes?
“We looked at whether someone was living with HIV, whether they’d been diagnosed with STIs and condom use. For the most part we found that studies looking at drug use and HIV found that people living with HIV were more likely to engage in drug use.”
“It is unclear whether sexualised drug use was leading to HIV transmission and it maybe that men who have sex with men living with HIV were diagnosed pre-engagement, but sexualised drug use is a common behaviour among men who have sex with men living with HIV.”
“We found an association between drug use and STI diagnoses and an association between drug use and condomless sex. We also found that studies that investigated chemsex were also more likely to find that association. So, highlighting that chemsex may involve more sexual risk taking than other types of sexualised drug use.”
What are the implications for policy and practice?
“For practice, because there’s been a more recent shift to chemsex, maybe these other drugs and the sexual risk associated with these other drugs has been somewhat neglected, so maybe just highlighting that this sexual risk still exists for these other drugs. In terms of practice, there should be greater engagement of care for those engaging with chemsex and more health advice around regular screening, access to pre-exposure prophylaxis if they’re HIV negative.”
“I think it’s important to highlight that most people engaging in sexualised drug use and chemsex are content with their behaviour, so providing a judgement free environment, but highlighting support services if they are ever needed should be routine practice.”
The majority of the studies that you included focused on men who have sex, and you found no studies that included women who have sex with women, trans men or non-binary people. Why is there such a focus on men who have sex with men?
“That can be partly explained by our search criteria. When we looked for these health outcomes, we specifically focused on the sexual health outcomes which typically occur for men who have sex with men. There were studies that focused on women who have sex with women, but they didn’t necessarily measure STIs in relation to sexualised drug use, or condoms in relation to sexualised drug use.”
“On paper, this makes sense, but then again, at the same time that’s neglecting sexual risk that bisexual women might experience. Research has found that bisexual women, or women who have sex with women but who didn’t identify as lesbian were more likely to engage in sexualised drug and with having heterosexual partners which increases risks of STIs and other sexual risks.”
“We didn’t find any research through the entire systematic review for non-binary people. With trans men, some studies that looked at men who have sex with men actually excluded trans men despite the level of sexual risk being similar if they were having sex with other men, so that was a problem.”
“The focus on men who have sex with men makes sense from a sexual risk perspective, but then maybe if you’re exploring other factors such as psychological associations or sexual risk among trans people or women who have sex with women, there needs to be more research.”
Dr Matt Hibbert is from Liverpool John Moores University. The original article was published in the International journal of Drug Policy and can be found here: A narrative systematic review of sexualised drug use and sexual health outcomes among LGBT people
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