Chemsex and the city: Sexualised substance use in gay bisexual and other men who have sex with men (GBMSM) attending sexual health clinics.
A Hegazi 1, MJ Lee 1, W Whittaker 3, S Green 2, R Simms2, R Cutts 1, M Nagington 3, B Nathan 2, M Pakianathan 1
1The Courtyard Clinic, Wandsworth Integrated Sexual Health, St. George's University Hospital Foundation Trust , London , UK, 2Department of Sexual Health, The Wolverton Centre, Kingston Hospital NHS Foundation Trust, London, UK 3Centre for Health Economics, University of Manchester, Manchester, UK
Abstract
Objective: To analyse associations between sexualised substance use (chemsex), STI diagnoses and sexual behaviour among GBMSM accessing sexual health clinics to better inform clinical pathways.
Methods: Retrospective case notes review following the introduction of more detailed and holistic profomas for all GBMSM attending two London sexual health clinics between 1/6/14 and 31/1/15.
Results: Chemsex status was documented for 655/818. Overall, 30% disclosed recreational drug use of whom 113 (57%) disclosed chemsex and 27 (13.5%) injecting drugs. HIV positive GBMSM were more likely to disclose chemsex [AOR 6.68; 95% CI 3.91-11.42; p<0.001]. Those disclosing chemsex had a higher incidence of acute bacterial STIs [AOR 2.83 CI 1.79-4.47; P<0.001], rectal STIs [AOR 3.10 CI 1.81-5.32; P<0.001] or Hepatitis C [AOR 15.41 CI 1.50-158.17; P=0.021]. HIV incidence in the study period was 1.8% (chemsex) vs 0.9% (no chemsex) [p=0.61]. Chemsex was associated with having more sexual partners, transactional sex, group sex, fisting, sharing sex toys, injecting drug use, higher alcohol consumption and the use of ‘bareback’ sexual networking applications (p<0.004). Chemsex participants were also more likely to have accessed post-exposure prophylaxis for HIV in the study period and report sex with a discordant HIV or hepatitis C infected partner (p<0.001).
Conclusion: Chemsex disclosure is associated with higher risk-taking behaviours, acute bacterial STIs, rectal STIs and Hepatitis C incidence. HIV incidence was higher but not significantly so in the study period. Chemsex disclosure in sexual health clinics should prompt an opportunity for prevention, health promotion and wellbeing interventions.
Introduction
Sexualised substance use or ‘chemsex’ is a recently described phenomenon amongst gay, bisexual and other men who have sex with men (GBMSM) (1, 2). In the UK, chemsex refers to the use of mephedrone, crystallised methamphetamine or γ-hydroxybutyrate (GHB), γ-butyrolactone (GBL) and to a lesser extent cocaine and ketamine to facilitate sex (1). Chemsex sessions can at times last days and involve multiple partners often identified using smartphone sexual networking applications (1, 3). Prolonged sex sessions with drugs, may include mucosally traumatic sex, with increased STI acquisition, in particular HIV (4) and Hepatitis C (5). There are no UK studies specifically examining the link between chemsex and STIs, apart from one study implicating chemsex in a Shigella flexneri outbreak (6).
In qualitative interviews some chemsex participants report using drugs to overcome a lack of confidence or to ameliorate negative feelings such as low self-esteem, internalised homophobia or stigma associated with being HIV positive (3). Chemsex may escalate immediately following an HIV diagnosis, relationship breakdown or migration to London (1). Condomless anal sex with casual partners and other unintended risk behaviour such as perceived reduced capacity to say ‘no’ to unwanted sex or negotiate condom use have been attributed to drug and alcohol use during sex but specific data on chemsex is lacking (7-9).
GBMSM are more likely to use recreational drugs than the male population in general. In particular rates of, club drug use, polydrug use, substance dependency and problematic alcohol consumption are significantly higher amongst GBMSM (10-12). A 2011 survey of 254 GBMSM attending a London sexual health clinic found that GBMSM were more likely to report recent or lifetime recreational drug use than their heterosexual counterparts (13). The ASTRA study surveyed 2248 HIV-positive GBMSM attending 8 UK out-patient clinics (14). 51% reported recreational drug use in the preceding 3 months and 24% reported using club drugs. 3% reported injecting. Drug use in this cohort was independently associated with younger age, cigarette smoking, non-adherence to ART, harmful drinking, condomless sex, new STI diagnoses, having a higher number of sexual partners and group sex.
In 2014, Public Health England highlighted a ‘triad’ consisting of sexual health, mental health and drug, alcohol and tobacco use, in which health inequalities in GBMSM are most apparent (15). The three interrelated areas often form a syndemic driving much of the health inequality in this population. A holistic national wellbeing action plan was launched, in line with the national strategy of ‘making every contact count’ envisaging that all GBMSM enjoy long healthy lives whilst creating and sustaining respectful and fulfilling social and sexual relationships (16). In response, in June 2014 two South London sexual health clinics based at St George’s University Hospital and Kingston University Hospital introduced a new holistic clinical proforma for GBMSM to include routine more detailed assessments of mental health and substance use. This study presents the associations observed between chemsex and STI, Hepatitis C and HIV incidence, and sexual behaviours associated with a higher risk of HIV/STI transmission.
Methods
We carried out a retrospective case notes review of all GBMSM attending these two South London sexual health centres between 1/6/14 - 31/1/15. Cases were identified through GUMCAD sexual orientation coding. GUMCAD data on demographics (age, ethnicity, country of birth) were extracted electronically along with relevant diagnostic codes.
All GBMSM seen in clinic during this time period were routinely assessed using a standardised clinical history taking proforma (supplementary file). In addition to a standard clinical history, this proforma incorporated detailed questions about current recreational drug use, HIV risk behaviours and current chemsex. In those reporting current chemsex participation, additional questions about patient perceived negative consequences of chemsex were asked.
Clinical parameters were manually extracted from case notes onto a standardised proforma and three sets of analyses were performed. Firstly, we investigated the association between chemsex participation and patient characteristics using a logistic model taking into account age, age-squared, ethnicity (dummy for non White-British), country of birth (dummy for non UK born) and a HIV positive dummy as independent variables was estimated. Age-squared was included to account for potential non-linearity in the relationship between age and chemsex participation.
Secondly we investigated the associations between chemsex, and STI diagnoses and risk taking sexual behaviours associated with a higher risk of HIV/STI transmission. Five groups of STI diagnoses were investigated: acute bacterial, rectal, new HIV diagnosis, new Hepatitis C, and no STI. Eleven behaviours were investigated (Table 2). For each group separate multivariate logistic regressions were estimated against our main variable of interest, self-reported chemsex and potential confounding factors associated with both STI diagnoses and behavior and chemsex: being HIV positive, age, ethnicity, and being UK born. These were included to remove potential bias should either measures be correlated with chemsex and the dependent variable of interest. Our third analysis describes patterns of drug use and patient perceived negative consequences. In this analysis, denominators used referred to the number of patients for which the variable was documented. Data were analysed in MS Excel and Stata (v13). Missing or undisclosed data were assumed missing at random.
Results
Eight hundred and eighteen GBMSM clinic attendees were identified between 1/6/14 - 31/1/15. Median age was 35 years (range 14-83) and 70% were UK born. Ninety-one percent identified as homosexual and 9% as bisexual. Patients described their ethnicity as White British 63%, White other 21%, Asian 8% and 4% as Black. HIV status was documented for 752 patients and 14.2% (n=107) were known to be HIV positive. Median reported number of partners in the preceding 3 months was 2 (range 0-65). Information on recreational drug use was available for 673 men. 29.7% (200/673) reported recreational drug use of whom 13.5% (27/200) reported injecting drug use.
Chemsex participation
Chemsex participation was documented for 655 patients, of whom 113 disclosed current chemsex participation. Median age of chemsex participants was 33 compared to 32 for non-participants. In the multivariate analysis HIV positive GBMSM were significantly more likely to participate in chemsex [OR 6.68; 95% CI 3.91-11.42; p<0.001] than those who were HIV negative. Chemsex was not statistically associated with non-white British ethnicity [OR 0.90; 95% CI 0.48-1.71] or UK birth [OR 1.46; 95% CI 0.73-2.92]. Chemsex association was concave in age [age OR 1.35; 95% CI 1.14-1.60; age-squared OR 0.996; 95% CI 0.994-0.998].
STI diagnoses
Chemsex participants were more likely to be diagnosed with any STI during the study period and with the exception of HIV this association remained significant on multivariate analysis after adjusting for age, ethnicity, HIV status and UK birth (Table 1).
Table 1 STI diagnoses differences by chemsex participation
STI / No chemsex % (n) / Chemsex %(n) / Unadjusted Odds-Ratio[95%CI] / Adjusted Odds-Ratio* [95%CI] / p-value
Acute Bacterial† / 19.9 (108/542) / 48.7 (55/113) / 3.81 [2.49- 5.83] / 2.83 [1.79- 4.47] / <0.001
Rectal / 9.4 (51/542) / 31.9 (36/113) / 4.50 [2.76- 7.34] / 3.10 [1.81-5.32] / <0.001
HIV diagnosis^ / 0.9 (5/542) / 1.8 (2/113) / 1.94 [0.37-10.10] / 1.54 [0.29- 8.15] / 0.611
Hepatitis C / 0.2 (1/542) / 3.5 (4/113) / 19.85 [2.20-179.35] / 15.41 [1.50-158.17] / 0.021
No STI / 65.5 (355/542) / 38.9 (44/113) / 0.34 [0.22- 0.51] / 0.42 [0.27- 0.66] / <0.001
Estimates for the unadjusted and adjusted from a logistic regression of the behaviour variable against chemsex participation.
*Adjusted models adjust for age, non White-British ethnicity, HIV status and UK birth. ^ Model excludes HIV+ status dummy. †Chlamydia (including LGV), gonorrhea and all non-latent syphilis diagnoses.
Behaviours
Reported sexual behaviours responses varied, for this analysis we report results for the sub-sample of patients with valid behavioural responses (Table 2). Chemsex was significantly associated with the sexual behaviours: having greater than 6 sexual partners in the past 3 months, transactional sex, group sex, fisting, sharing sex toys, injecting drug use, higher alcohol consumption and the use of ‘bareback’ sexual networking applications. Chemsex participants were also more likely to have accessed PEP in the study period as well as to report sex with a discordant HIV or hepatitis C infected partner.
Chemsex patterns and negative consequences
Drugs most commonly used for chemsex were mephedrone (69.3%, 70/101), GBL/GHB (56.4%, 57/101), crystal methamphetaime (46.0%, 46/100), cocaine (15.8%, 16/101) and ketamine (5.9%, 6/101). Many (67.3%, 68/101) GBMSM reported polydrug use. Seventy-nine out of 113 chemsex participants reported a valid frequency of participation in the preceding 3 months. Responses to this question were 27/79 (34.18%) > once a month, 14/79 (17.72%) 1-3 times in the past 3 months and 38/79 (48.10%) less often.
Information on negative consequences was available for only a sub-sample of the chemsex participants. Fifty-two percent (39/75) of GBMSM perceived negative consequences as a result of chemsex. Those most commonly described were, having to take time off work (14.1%, 9/64 responses), accidental overdose (4.8%, 3/63), hospitalisation (7.7%, 5/65 responses) or an adverse impact on their mental health (15.1%, 11/73 responses).
Only a small minority of those participating in chemsex and reporting injecting drugs reported sharing injecting equipment (4.9%, 3 patients of the 61 patients with valid responses to sharing injecting equipment of the 97 reporting chemsex participation and injecting drugs) and shared snorting devices (35.1%, 20/57 responses).
Table 2 Behavioural differences by chemsex participation
Risk Behaviour / No chemsex % (n) / Chemsex% (n) / Unadjusted Odds-Ratio / Adjusted Odds-Ratio* [95%CI] / p-value
≥ 6 sexual partners in past 3 months / 10.1(54/535) / 35.6 (37/104) / 4.92 [3.01- 8.03] / 5.31 [3.07, 9.17] / <0.001
PEP use^ / 4.6 (25/542) / 14.2 (16/113) / 3.41 [1.76- 6.63] / 3.41 [1.72, 6.76] / <0.001
Group sex / 8.6 (36/421) / 51.3 (39/76) / 11.27 [6.41- 19.83] / 10.01 [5.39, 18.60] / <0.001
>21 units alcohol per week / 2.8 (13/470) / 11.8 (9/76) / 4.72 [1.94- 11.47] / 4.18 [1.63, 10.70] / 0.003
Sharing sex toys / 1.2 (5/417) / 9.9 (7/71) / 9.01 [2.78- 29.26] / 7.32 [2.01, 26.65] / 0.003
Fisting / 1.7 (7/424) / 14.9 (11/74) / 10.40 [3.89-27.82] / 8.82 [2.99, 26.01] / <0.001
Transactional Sex / 2.7 (13/483) / 9.8 (8/82) / 3.91 [1.57- 9.75] / 4.55 [1.62, 12.75] / 0.004
HIV+ partner^† / 8.3 (38/458) / 30.7 (19/62) / 4.88 [2.59- 9.21] / 4.27 [2.23, 8.16] / <0.001
HCV/HBV partner / 1.7 (7/418) / 10.5 (7/67) / 6.85 [2.32- 20.21] / 8.30 [2.36, 29.21] / 0.001
‘Bareback’ app / 1.3 (5/384) / 12.5 (8/64) / 10.83 [3.42- 34.27] / 7.40 [1.99, 27.51] / 0.003
Injecting drugs / 1.6 (1/63) / 25.8 (25/97) / 21.53 [2.83- 163.49] / 27.8 [3.13, 246.37] / 0.003
Estimates for the unadjusted and adjusted from a logistic regression of the behaviour variable against chemsex participation.
*Adjusted models adjust for age, non White-British ethnicity, HIV status, UK birth and HIV+ status dummy. ^ model excludes HIV+ status dummy † HIV negative patients only
Discussion
This is the first UK study to demonstrate that chemsex disclosure is associated with higher STI and hepatitis C incidence and the first to quantify the impact of chemsex on STI and HIV transmission and sexual behaviours associated with a higher risk of HIV/STI transmission. These findings were robust when potential confounding patient characteristics (age, ethnicity, and nationality) were controlled for. Our finding of an association between chemsex disclosure and sexual behaviours is consistent with previous studies examining sexualised crystal methamphetamine or alcohol use (4).
It is important to note however, that our findings only represent an association; and further research would be needed in order to determine whether chemsex was in any way implicated in causality. Our study has several limitations. Data were retrospectively collected in the context of routine clinical care, and as a result there were large amounts of missing data which precludes meaningful quantitative analysis of fields such as perceived adverse consequences of chemsex. It is probable that social desirability bias would have impacted the disclosure of potentially stigmatised behaviours such as transactional sex, unprotected anal sex and sharing needles. Patients were asked about current chemsex engagement and from our data we were unable to stratify by how recently this occurred.
Whilst we were able to adjust for age, ethnicity, and UK birth, there may be residual confounding from other factors that correlate with chemsex participation and STI diagnoses/behaviours. Our data comes entirely from a clinic based sample of GBMSM which is not representative of GBMSM in other settings. Finally, findings from London may not apply in other areas of the country where population profiles and social networks may differ considerably.
Many of those asked, perceived chemsex to have had a detrimental impact on their health and wellbeing, often citing employment or relationship difficulties and adverse mental health. Again, this finding is not unique (3, 15) and chemsex undoubtedly exacerbates the health inequalities experienced by GBMSM compared to heterosexuals.
Apart from community surveys, much UK research on chemsex has focussed on HIV positive populations (14) or those accessing specialised drug services (1). Our study drew participants from a largely HIV negative population attending for routine sexual health care at two south London clinics, one in an inner London Teaching hospital and the other an outer London district general hospital. Our findings therefore may be more generalisable to other GUM clinic settings in London than other studies.
Whilst chemsex is more common amongst those who are HIV positive, the vast majority of those having chemsex in our study were HIV negative. A higher HIV incidence was observed in those reporting chemsex but this was not statistically significant. This may be due to relatively small number of HIV seroconversions in the study period. Higher usage of PEP amongst chemsex participants may have also led to this difference in seroconversion rates being less marked. Recently published data describing 874 GBMSM attending a central London chemsex clinic found that of the 52% who were HIV negative at baseline, 9% had tested positive for HIV at the same clinic within a year of presentation (1). This is clearly therefore a vulnerable population that should be targeted for HIV prevention.
Generic drug services have traditionally been designed around the needs of opiate users and do not routinely collect sexual orientation data (17). More recently developed drug services tailored to GBMSM have seen an exponential rise in attendances due to chemsex harms in the past ten years (17). These specialised drug services and the evidence base for chemsex harm-reduction remain in their infancy and their evaluation and development are in progress (1, 17).
Gay men may feel more comfortable initially discussing drug use and its impact on their sexual behaviour at sexual health services and there may be a reluctance to access drug services directly due to a perceived lack of cultural competence around sexuality and chemsex (3). Depression, anxiety, suicide and self-harm are also much more common among GBMSM than in men in general (10). Unlike other clinical settings, GUM clinics are unique in routinely establishing sexual orientation information from patients. Our findings support an improved care pathway for GBMSM accessing sexual health services which include routine assessments of mental health, substance use and chemsex participation.
These holistic assessments of GBMSM in can improve the identification of opportunities for evidence based behavioural or biological interventions to help make ‘every contact count’ (18). Chemsex disclosure in these settings should prompt appropriate assessment, support, targeted health promotion and prevention interventions or referral. Clinics could also review follow-up procedures for patients disclosing chemsex, inviting them for more frequent follow-up and testing for STIs.
It is important therefore that sexual health clinics are adequately resourced to support GBMSM who are experiencing problematic drug use and closer partnership working with specialised drug services is crucial to achieving this. Holistic prevention strategies that are not narrowly focussed around condom use, PEP and PrEP will be vital in improving the health and wellbeing of the vulnerable in this population.
Funding and Conflicts of interests
There were no additional sources of funding or any conflicts of interests to declare.
1.Stuart D, Weymann J. Chemsex and Care Planning: One year in practice. HIV Nursing. 2015;15:24-8.
2.Kirby T, Thornber-Dunwell M. High-risk drug practices tighten grip on London gay scene. The Lancet. 2013;381(9861):101-2.
3.Bourne A, Reid D, Hickson F, Rueda ST, Weatherburn P. The Chemsex Study: drug use in sexual settings among gay and bisexual men in Lambeth, Southwark & Lewisham. 2014.
4.Vosburgh HW, Mansergh G, Sullivan PS, Purcell DW. A review of the literature on event-level substance use and sexual risk behavior among men who have sex with men. AIDS and Behavior. 2012;16(6):1394-410.
5.Hagan H, Jordan AE, Neurer J, Cleland CM. Incidence of sexually transmitted hepatitis C virus infection in HIV-positive MSM: a systematic review and meta-analysis. AIDS. 2015.