Submission to The Social Lens: A Social Work Action Blog by John Segui, SOWK alumnus, BC Children’s Hospital social worker
Interventions for Sexualized Drug Use, Chemsex and Methamphetamine Use Among Men Who Have Sex with Men
Background on Sexualized Drug Use and Chemsex
Sexual drug use is referred to the use of recreational drugs – such as methamphetamine, mephedrone, gamma-hydroxybutyrate (GHB) and gamma-butyrolactone (GBL) – to facilitate sex sessions (Tomkins et al., 2019). Men who have sex with men (MSM) participate in sexual drug use to have enhanced sexual arousal and pleasure (Edmundson et al., 2018). The trend began in the last decade with a shift away from ‘club drugs’ such as cocaine and ecstasy (Edmundson et al., 2018).
There is a limited body of research for the motivations of MSM to induce alcohol and drug use (Bourne & Weatherburn, 2017). One explanation is that in the 1970s, gay clubs were literally the only safe space for gay men to socialize and interact, which made drugs and other substances difficult to avoid (Bourne & Weatherburn, 2017). Another explanation for the motivation for substance use is to aid in coping with “adverse life events or perceived personal inadequacies” (Bourne & Weatherburn, 2017, p. 343).
While there is a growing body of research on positive motivations for substance use amongst MSM, the impacts of substance use continue to rise (Operario et al., 2006). For example, recent reviews indicate that sexual risk behaviours – such as condomless anal intercourse and contracting HIV and other STIs, the most common being the Hepatitis C virus (Operario et al., 2006) – have increased. Psychological impacts have also been attributed to sexualized drug use, such as acute anxiety attacks, psychosis and a dependency on drugs to have pleasurable intercourse (Bourne & Weatherburn, 2017).
The literature also discusses ‘chemsex’ – a colloquial term that is a subset of sexualized drug use and is associated with the intentional use of drugs during sex to amplify sexual arousal and pleasure (Maxwell et al., 2019). Chemsex often occurs in private residences and sex parties, which can occur over consecutive days (Maxwell et al., 2019). According to Pakianathan (2016), methamphetamine and mephedrone are the most common as they stimulate “sexual arousal, euphoria, increased heart rate and blood pressure” (p. 568). Another commonly used yet equally as dangerous substance used during chemsex is GBL (butyrolactone)/GHB (hydroxybutyrate) (Pakianathan, 2016). GBL or GHB can be diluted in a drink and if the dose is too high or is used in combination with alcohol, it can cause “life-threatening central nervous system,” “respiratory depression” and overdose (Pakianathan, 2016, p. 567).
Prevalence and Effects of Sexualized Drug Use, Chemsex and Methamphetamine Use Among MSM
Sexualized Drug Use Among MSM
Studies have identified the prevalence of sexualized drug use among MSM. The first study is a systematic review by Tomkins et al. (2019). They explored the existing evidence of a relationship between recreational drug use and sexual intercourse among MSM. In 112 amalgamated and identified studies, Tomkins et al. (2019) identified high rates of risky behaviour – such as condomless sex – among MSM who participate in sexualized drug use (STI). One study identified that “chemsex participants were significantly higher to engage in condomless anal intercourse than non-chemsex participants (84.3% vs. 61.1%; p< .001)” (Drückler et al. 2018). In another study that conducted interviews with 30 chemsex participants, the results showed that a quarter of the participants chose not to use condoms due to believing condomless sex is the norm and is the popular opinion in the chemsex scene (Tomkins et al., 2019).
Tomkins et al. (2019) also identified the prevalence of sexually transmitted infections (STI) amongst MSM. They reported a strong correlation between chemsex and increased risk of the Hepatitis C virus (HCV) (Tomkins et al., 2019). In a 2012 study in the UK, 2.4 per 1000 MSM reported having HCV, and rates of HIV infection were even higher with an estimated 45,000 HIV positive among MSM (Tomkins et al., 2019). Other prevalent STIs reported were gonorrhea (23 citations) and syphilis (16 citations) (Tomkins et al., 2019). A study in Madrid on HIV-positive MSM patients found that “cocaine, crystal methamphetamine or alcohol use and a past history of greater than one STI” were extremely common among gonorrhea culture-positive patients (Tomkins et al., 2019, p. 28). In another study, 19.2% of Californian MSM who used methamphetamine in the past year were diagnosed with primary or secondary syphilis (Chew et al., 2013).
Chemsex Among MSM
As stated in the previous section, chemsex is a sub-set of sexualized drug use and is a colloquial term for the intentional use of crystallized methamphetamine, mephedrone, hydroxybutyrate (GHB), butyrolactone (GBL), cocaine and ketamine to facilitate sex as well as to enhance sexual arousal and pleasure (Pufall et al., 2018). Chemsex drugs can be taken orally, snorted, smoked or injected (Pakianathan et al., 2018). Chemsex produces biological impact on MSM (Maxwell et al., 2019). MSM who engage in chemsex are at higher risk of condomless anal intercourse and the rate of performing condomless anal intercourse is dependent on the effect and toll the drug has on the individual (Maxwell et al., 2019). Furthermore, many of the participants in chemsex have an HIV-positive status or sexually transmitted disease (Pakianathan et al., 2016). The interconnected factors of condomless anal intercourse and HIV-positive prevalence in chemsex events demonstrate that HIV-negative participants who engage in “chemsex-related behaviours” have an increased risk of contracting HIV and other sexually transmitted infections (Maxwell et al., 2019, p. 83). There is limited evidence that fully supports how chemsex negatively affects one’s psycho-social dimension (Maxwell et al., 2019).
A study reported that chemsex lowers the physical and mental ability of MSM to fulfill their daily functioning (Pakianathan, 2018). Chemsex can also impact employment: Hegazi et al. (2017) portrayed that some MSM had lost their jobs and a study by Kurtz (2005) showed 14% of participants reported they had taken time off work.
Chemsex poses negative biological and psychological impacts, but also serves as a form of culture and liberation for many MSMs (Operario et al., 2006). Chemsex provides community and support from society’s negative attitudes towards homosexuality, trauma, stigma of the AIDS epidemic, and hegemonic sexual expectations (Giliauskas, 2019). A study in Germany found that chemsex events let men achieve cognitive freedom and freedom from care (Graf et al., 2018). Chemsex allows them to freely express their sexuality in a way free from stigma, insecurities and anxieties (Giliauskas, 2019).
Methamphetamine Use Among MSM
Methamphetamine is the most commonly injected drug among MSM (Giliauskas, 2019; Lea et al., 2017; Nerlander et al., 2018). Methamphetamine is either taken orally, snorted, smoked or injected through the bloodstream (Kahan, 2012). This manufactured drug creates several physiological effects like reducing the flow of saliva in the mouth causing “meth mouth,” deterioration of muscle fibre and tissue (Kahan, 2012; Westhaver, 2011). Methamphetamine impacts the neurochemical system and releases dopamine, serotonin and norepinephrine – which play important roles in motor function, motivation, and the experience of reward and pleasure (Giliauskas, 2019). The use of methamphetamine also increases the risk of HIV and STIs (Nerlander et al., 2018). Westhaver (2011) further states that methamphetamine has psychological effects such as increased levels of “confidence, mental clarity, energy, and libido, and decreased appetite, feelings of loneliness and boredom” (p. 161). Chronic use of the drug leads to depression, anxiety disorders, irritability, aggression, paranoia, psychosis that mimics that of schizophrenia, and increased rates of suicidality (Westhaver, 2011).
In Nerlander et al.’s 2018 study on HIV infection in MSM who inject methamphetamine, they recruited 961 MSM over the age of 18 and from across eight different cities in the United States. The results show that among 961 MSM participants, 33.7% reported methamphetamine as the most common drug they inject themselves with. Regarding the frequency of injecting methamphetamine, n=149 of participants injected once or more than once a day, n=108 reported more than once a week, n=65 reported once a week or less (Nerlander et al., 2018). Further results show that “HIV prevalence among MSM who primarily injected meth was almost 50% higher than among MSM who injected other drugs,” which indicates a high correlation between methamphetamine and HIV positive status amongst MSM (Nerlander et al., 2018, p. 216).
In a similar study, Lea et al. (2017) states that gay men report higher rates of methamphetamine use compared to heterosexual men. Community-based surveys indicate higher reports of methamphetamine use, specifically among HIV-positive men with 27.4% in the previous six months versus 9.9% among HIV-negative and untested men (Lea et al., 2017). The research further explains that a barrier to receiving treatment is due to stigmatization and discrimination from the mainstream public and the perception that services will have inadequate knowledge of the psychological distress and treatment of gay and bisexual men in the study (Lea et al., 2017).
Harm-Reduction Interventions
Specific LGBTQ2S+ Services
The first harm-reduction approach we will introduce is specific services catered to the LGBTQ2S+ population, rather than generic services that fail to meet the cultural competencies of this population (Cullen et al., 2013). LGBTQ2S+ services provide cultural competency through the appropriate use of language, LGBTQ2S+ positive physical spaces, and trained staff who are aware of discrimination and internalized oppression among LGBT2S+ and who provide unique assessment and treatment (Cullen et al., 2013). An example of using appropriate language is asking the clients their preferred pronoun(s), or simply how they would like to identify themselves because culture and geographical location heavily influence how one identifies themselves (Cullen et al., 2013). Client A may proudly self-identify as queer because their environment and culture accepts LGBTQ2S+ individuals, whereas Client B may be in an environment and a culture where inclusivity for LGBTQ2S+ is absent and even sometimes oppressed.
Motivational Interviewing
Providing motivational interviews to MSM clients is another form of harm-reduction intervention. Motivational interviewing (MI), according to Herie and Skinner (2013), is a person-centered counselling approach that emphasizes collaboration and pays particular attention to the specific language of the client to explore and elicit change. The “Spirit” of MI is a fundamental component and has elements which include partnership, acceptance, compassion, and evocation (Herie & Skinner, 2013). The spirit is derived from Carol Rogers’ egalitarian approach and recognizes that the client possesses untapped strengths within themselves to succeed. Our role as counsellors is to approach them with unconditional acceptance, compassion and empathetic understanding (Herie & Skinner 2013). The clinician fosters partnership by raising the awareness that the client is the expert in their own lives (Herie & Skinner, 2013).
Several studies provide evidence on the effectiveness of motivational interviewing, both on people who use substances and MSM (Lundahl et al., 2010; Lea et al., 2017). One study compared the effectiveness of treatment as usual to MI, and the result indicated that 75% of the participants’ conditions improved, 50% found the process meaningful, and 25% gained moderate to strong effects (Lundahl et al., 2010). In another study by Lea et al. (2017), the researchers examined the treatment outcomes among gay and bisexual men (GBM) receiving outpatient counselling at a specific LGBTI-specific, harm reduction treatment service in Australia. Eligible participants were men over the age of 18 who “identified as gay or bisexual” and were “seeking treatment for methamphetamine use” (Lea, et al., 2017, p. 3). The outpatient utilized different counselling modalities: motivational interviewing, cognitive-behavioural therapy (CBT), acceptance, and commitment therapy (Lea et al., 2017). The treatment was eight sessions long with two follow-ups (during the fourth and eighth session) (Lea et al., 2017). The results showed significant reduction in methamphetamine use between baseline (92.1%), follow-up 1 (78.3%), and follow-up 2 (71.9%, p < .001) (Lea et al., 2017). The study also exhibited a reduction in participants’ reporting of sharing ancillary injecting equipment between baseline and follow-up (Lea et al., 2016). Clients also displayed a reduction in psychological distress and improvements in their quality of life (Lea et al., 2017). The study showed a reduction in methamphetamine use and the effectiveness of MI (Lea et al., 2017).
It is also crucial to note that when MI is paired with different counselling modalities such as a strength-based approach with harm-reduction, the effectiveness of MI increases (Herie & Skinner, 2013). It is also important to be aware that MI does not utilize and emphasize procedures like CBT, but a conversational framework for counsellors to evoke change and strengthen clients’ resolve towards recovery (Herie & Skinner, 2013).
Technology-Based Intervention
Technology-based intervention is the third form of the harm-reduction approach for men who have sex with men. With the novel COVID-19 virus in 2020, technology-based interventions provided a way for clients to safely access their health care needs (Hagopian et al., 2013).
Applications, mostly known as “apps,” are digital software that help the user accomplish or meet a specific task (Hagopian et al., 2013). The apps evolved to meet and serve the healthcare needs of many clients and exhibited several advantages such as providing time- and cost-effective interventions, accessibility through the use of the Internet, and increased autonomy and control of clients over their own health care (Hagopian et al., 2013). Text-messaging, electronic therapy from counselling from peers and clinicians, and web-based psychoeducation to treat anxiety, depression or gambling are some of the interventions delivered through technology (Reback et al., 2019). Technology-based intervention is in line with the harm-reduction approach because it provides clients full autonomy and decisions over addiction (Marsh & Kuehl, 2013).
Two research studies show the use of the novel text-messaging intervention to reduce methamphetamine use and HIV sexual risk behaviours among men who have sex with men (Reback et al., 2012; Reback et al., 2019). A study by Reback et al. in 2012 recruited 52 MSM who were between the ages of 18 and 65 years, had unprotected anal intercourse with a non-primary male partner and used methamphetamine in the previous two months. Participants engaged in a two-week text-messaging intervention where they were provided with social support and health education in real time (Reback et al., 2012). After two months, participants followed up and the research results showed a significant decrease in the frequency of methamphetamine use (20.8% vs. 8.3%; p < .05) and unprotected sex between the baseline and follow-up (Reback et al., 2012).
In 2019, Reback et al. showed similar results in a similar study showing a significant reduction of methamphetamine use and condomless anal intercourse with main male partners and casual male partners. Technology-based intervention is not suitable for everyone, even with its accessibility benefits and time- and cost-effectiveness (Hagopian et al., 2013). The intervention poses barriers for people who are homeless, individuals living in remote communities with limited access to the Internet, persons with certain disabilities, or people with literacy or language barriers, such as refugees and immigrants (Hagopian et al., 2013).
References
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