Sexualised Drug Use and Other Addiction Issues

Home , Party and play

2 Sexualised Drug Use and Other Addiction Issues

Journal Club 7 Oct 2020

Loretta Healey, Senior Counsellor Yen Li Lim, Registrar RPA SHC

Sexualised Drug Use (SDU) - Definition

 Use of drug in a sexualized context  Any illicit drug just before or during sex

Alcohol and Drug Foundation (ADF) “ Drug Wheel” https://adf.org.au/drug- facts/#wheel

4 Chemsex (subset of SDU)

 Socially constructed concept

 Subject to preferences of participants, popularity and availability of specific drugs

 Chemsex behaviours are described as the use of specific drugs before or during planned sex to facilitate, initiate, prolong, sustain and intensify the encounter (Public Health England, 2015)

 Chemsex has negative connotations for many health workers

 Associated with : High risk drug/sexual behaviour & increased transmission risk of HIV, STI and BBV

 Use of crystal associated with our problematic HIV patients

6 Articles

 Associations with drug use and sexualised drug use among women who have sex with women (WSW) in the UK: Findings from the LGBT Sex and Lifestyles Survey. Hibbert M.P., Porcellato L.A., Brett C.E., Hope V.D. Int. J Drug. 2019.

 Chemsex behaviours among men who have sex with men: A systematic review of the literature. Steven Maxwell, Maryam Shahmanesh, Mitzy Gafos. Int J Drug Policy 2019 Jan;63:74-89.

 ‘Sex, drugs and social connectedness: wellbeing among HIV-positive gay and bisexual men who use party-and-play drugs.’ Jennifer Power et al, Sexual Health, 2018, 15, 135-143

 The sexualised use of cannabis among young sexual minority men: “I’m actually enjoying this for the first time” Natasha Parent et al, Culture, Health & Society May 2020 1-16.

Substance Use in Women Research Report. National Institute on Drug Abuse, Apr 2020.

M > F M = F F > M All types of illicit drugs Develop More susceptible to craving and Illicit drug use -> ED substance relapse. visits/OD deaths abuse disorder Higher rates of dependence Similar Stimulants : More sensitive to effects on illicit drugs & ETOH increases in of cocaine & reinforcing effects. aggression Taken to inc energy, dec exhaustion, with MDMA weight loss High rate of co-occuring depression Marijuana use higher. Assoc Marijuana taken for panic attacks, with other substance anxiety. use/personality disorders Alcohol binge drinking Self-medicate with prescription opioids (w/o prescription) for pain, anxiety. Misuse of CNS depressants ?sec inc prescriptions

8 9

Articles

 Chemsex behaviours among men who have sex with men: A systematic review of the literature. Steven Maxwell, Maryam Shahmanesh, Mitzy Gafos. Int J Drug Policy 2019 Jan;63:74-89.

10 Associations with drug use and sexualised drug use among WSW

 Aim : factors assoc with drug use & SDU among WSW

 Study : observational, cross-sectional. (Can’t determine causal r/p)

 Method : UK participants 6/52 Apr-Jun 2018. Survey advertised online through social media (Fb) with entry to competition for Amazon voucher.

 Univariate and multivariate analysis used

 Inclusion criteria : UK residents, >age 18, WSW, Drug use.

 Bias : self selection bias – cohort IT savvy, reward motivated, English 1st language.

Groupings

 Participants were first asked if they had taken any of the 14 listed substances in the past 12 months.  SDU : had stated they had been under the influence of cannabis during sex in the past 12 months OR stated having taken amphetamine, cocaine, crack cocaine, ecstasy, heroin, GHB/GBL, ketamine, mephedrone, methamphetamine, Viagra or other erectile dysfunction drug, poppers, OR another unspecified drug just before or during sex in the past 12 months.  Chemsex : grouping created for the drugs associated with chemsex - ie those reporting the use GHB/GBL, ketamine, mephedrone and/or methamphetamine just before or during sex.

12 Results

 Total Completed Survey Participants : 3676

 WSW : N=1501 (mean age = 28.9, 97% white ethnicity).

 Any drug use (DU): N= 583 (39% of total)

 SDU : N = 258 (17% of total)

Results - Factors associated with drug use

 identifying as queer (aOR = 1.86, 95%CI 1.08, 3.23),

 younger age (aOR = 0.96, 95%CI 0.95, 0.98)

 being born outside the UK (aOR = 1.75, 95%CI 1.15, 2.66)

 recent sexual assault (aOR = 2.35, 95%CI 1.43, 3.86)

 > = 5 female sexual partners (aOR = 3.81, 95%CI 1.81, 8.01)

 and psychological distress (aOR = 1.75, 95%CI 1.15, 2.67)

14 Results - Factors associated with SDU

 identifying as bisexual (aOR = 2.55, 95%CI 1.69, 3.86)

 > = 5 female sexual partners (aOR = 4.50, 95%CI 1.91, 10.59)

 highest education achieved at 16 yo or lower (aOR = 2.46, 95%CI 1.24, 4.90)

Discussion

 Most common drug – cannabis

 Higher levels of ecstasy & cocaine use vs Australian LBQ women (Mooney-Somers et al, 2019)

 No methamphetamine use

 Smaller proportion of WSW use drugs assoc with chemsex vs MSM

 WSW range of negative experiences in relation to DU & SDU

 Research not representative of all LBGTQI people

 Be aware of potentially compounding factors related to drug use among WSW (SA & psychological distress)

16 Chemsex behaviours among men who have sex with men: A systematic review (2019)

 1st systematic review on chemsex behaviour  Exclusively incorporates and examines research on chemsex drug use before or during sex AIM  Comprehensively analyse the behaviours involved in chemsex activities  including risks to participants.  inform the development of evidence-based risk reduction strategy  provide recommendations for further research.

PICO  Population – MSM

 Intervention – Chemsex

 Comparator – No chemsex

 Outcome – Assess ABC of chemsex behaviour

18 Topics + ABC framework to structure results

 Prevalence and type of non-injective drugs  Prevalence and type of injecting drug  Drug use settings  Sexual behaviour  Biomedical risk reduction interventions  Socio-demographics of participants  Role of HIV status  Expectations of the event  Biological impact  Psycho-social impact

Methods – Eligibility & Search  studies of chemsex behaviours that involve drug use

 before or during sex

 any one of the following drugs: methamphetamine, mephedrone, GHB/GBL, cocaine and ketamine.

 studies of primary research from high income countries

 published in peer review journals in the English language

 between 1st of January 2000 and 1st of September 2018

 4 databases : Medline, CINAHL, Web of Science and CENTRAL.

 3 researchers applied inclusion & exclusion criteria

 Study data extracted onto structured data extraction template.

20 N = 38

Qualitiative = 8 Cross section = 26 Case note = 2 Observational cohort = 1 Exploratory = 1

Positives

 Clear objectives  Defined sample being recruited  Defined exposures/outcomes  Appropriate methodology for data analysis.  Clear recruitment strategy  Justified the data collection methods  Secured ethics approval  Described a rigorous analysis methodology  Provided the findings in a clearly structured format

22 Negatives

 Quantitative cross-sectional and case note review studies  Risk of bias assessment in individual studies  Difficult to assess heterogeneity across the studies due to quantitative cross-sectional nature  Unable to determine causal relationships  Did not provide a sample size justification  Only measured the exposures once  Excluded low/middle income countries  Excluded non-English articles

Discussion  HIV is a key influencer

 Affects likelihood of engagement in chemsex

 Affects the event behaviour

 HIV transmission can be a potential consequence

 Prevalence of chemsex ~ 15%

 But this varies between & within countries

 Drugs used vary by geographical location

 Limiting our ability to generalise findings

24 Discussion 2  MSM who combine chemsex drugs with sex are engaging in high risk sexual behaviours, including CAI and esoteric acts.

 substantive evidence in this review to demonstrate that some HIV negative MSM who participate in chemsex will engage in CAI.

 correlates with the review’s findings

 MSM who combine drugs with sex are more likely to engage in high risk sexual practices when compared to MSM who do not combine drugs with sex

Discussion 3

 Studies in this review did not focus on injecting drug use.

 Evidence is that this is a small minority in SDU

 high risk chemsex behaviours puts participants at increased risk of acquiring STIs/HIV

 the majority of the evidence base regarding the risk of STIs and HIV is associative

26 Discussion 4  between 14%–25% of chemsex participants have experienced a negative impact on their psycho-social functioning.

 Wider literature provides evidence demonstrating – higher frequency of the drug use -> more detrimental the impact is on psycho-social well-being of the user (esp if poly-drug use)

 biological risk for poly-drug users who use different substances which can create highly toxic and dangerous reactions in the body.

 evidence for the impact of chemsex behaviours on psycho- social well-being is weak

Discussion 5

 V limited evidence suggests chemsex participants are more likely to access PEP and PrEP compared to MSM who do not engage in chemsex

 “The new MTV generation” (Australian study, (Hammoud, Vaccher et al., 2018) - highlighted that the concurrent use of methamphetamine, Viagara and PrEP in 2014 was 1.9% - increased to 6% in 2017

 important research question - PrEP could potentially influence how chemsex participants use other interventions and chemsex behaviours may influence the participants PrEP adherence.

28 Conclusion

 minority of MSM engage in chemsex behaviour, but there are inter-connected high-risk behaviours associated with the activity.

https://www.susi.org.au

Chemsex 101 : A Toolkit. Any Positive Change. Access 2/10/20. https://anypositivechange.org/wp- content/uploads/Toolkit-on-Chemsex.pdf 30 Articles

 ‘Sex, drugs and social connectedness: wellbeing among HIV- positive gay and bisexual men who use party-and-play drugs.’ Jennifer Power et al, Sexual Health, 2018, 15, 135-143

 The sexualised use of cannabis among young sexual minority men: “I’m actually enjoying this for the first time” Natasha Parent et al, Culture, Health & Society May 2020 1-16.

Kerryn Drysdale et al Destabilising the ‘problem; of chemsex: Diversity in settings, relations and practices revealed in Australian gay and bisexual men’s crystal methamphetamine use, International Journal of Drug Policy, 78 (2020): 1-7.

 Chemsex refers to the intentional and simultaneous use of drugs to facilitate, enhance, and/or prolong sex within an identifiable pattern of settings, relations and practices ascribed to gay male culture

 In public health research chemsex is framed as problematic.

 Authors state that in a ‘rush to risk’ all combinations of drug use and sexual practices are considered problematic and in need of intervention

32 Drysdale et al

Seek to destabilise the term ‘chemsex’ so that a greater diversity and contingency of practice is captured.

Develop a more nuanced understanding of chemsex

Aims:

Develop a deeper understanding of the ways in which crystal is used;

The pleasures its users associated with having sex on crystal;

The strategies men employed to reduce the risks associated with its use.

Methods

 Between 2017 and 2019 individual, semi-structured, in- depth interviews with 88 gay and bisexual men

 Recruited through LGBTQI+ community organisations, commercial gay premises,, paid advertisements on social media and health organisations

 1 hour interview, $40 payment

 Audio recordings, transcribed verbatim

 Thematically coded using a constructivist grounded theory approach

34 Drysdale et al

 Participants description of their initial & subsequent encounters of crystal use

 Accounts of sexual activity

 Explored the data for experiences that both conformed to, and deviated from, the common representation of chemsex.

 Age range: 21 to 74, median 45;

 34 employed, 30 unemployed, 24 students or other;

 > half not in a relationship

 80 were Caucasian

Drysdale et al

 Crystal use ranged from daily to irregular use

 Planned use with social events to spontaneous, opportunistic and ‘triggered’

 32 injected only, 14 smoked only, 15 both

 Commonly combined with GHB referred to as (G&T), ketamine, alcohol, cannabis, amyl and ED meds

 Privately organised parties, temporary play rooms, beats, saunas, SOPVs and setting involving audio visual conferencing

36 Drysdale et al

Almost 1/3 were introduced to crystal through sexual networks facilitated by use of digital technologies;

My partner and I separated that night and I went online and found some people and went over to their place, I’d never used before. I blasted. It was game on.

Themes

o curiosity,

o adventure,

o taking a break from stresses of life,

o disrupt the perceived monotony of their sex lives

Drysdale et al

 Using described as a way to spend time with friends- shared pleasures of crystal consumption were emphasised over sex

 Connection between dance party cultures and sexual adventurism

 Increased circulation of crystal in informal setting

Like, (crystal) has basically replaced alcohol, to be honest. Like I don’t go out drinking with my friends anymore to the city. Like we will catch up in someone’s house and just smoke drugs. Like, it’s almost as if it’s become what we do when we catch up with each other and socialise.

38 Drysdale et al

 The men commonly reported condomless AI and group sex

 Description of crystal leading to open discussion about risk

 Modes of administering typically informed by first experience – the ‘host’s’ preference

 Men with longer histories more able to assert preference

 Distinction between social modes- smoking and sexual modes- injecting

 Variety of experiences points to lack of single intention in using crystal for sex

 Not all report problematic use- diversity of settings, relations and practices

 Danger in limited view of chemsex

Jennifer Power et al, ‘Sex, drugs and social connectedness: wellbeing among HIV-positive gay and bisexual men who use party-and-play drugs.’ Sexual Health, 2018, 15, 135-143

 Non-prescribed drug use more prevalent among GBM and higher still among PWHIV

 Rite of passage for some GBM

 HIV positive over-represented within sexual subcultures of GBM where P&P drug use is higher

 Interventions tend to focus on reducing harms associated with drug use

 Most research focussed on sexual or injecting risks

40 Power et al Aims

 Identify the frequency of use of a wide range of drugs, including party-and-play drugs;

 Identify the main social contexts in which party-and-play drugs were used;

 Explore associations between party-and-play drug use and wellbeing;

 Explore whether social connectedness played a mediating role in associations between party-and-play drug use and wellbeing

Power et al  Part of the HIV Futures 8 study- cross-sectional survey

 Anonymous, self-complete instrument on paper or online

 ~ 250 items health, wellbeing, finances, employment, ART, drug use, sex and relationships

 Convenience sampling

Measures: - Demographic variables - Drug use - Physical and mental health - Diagnosed depression and anxiety - Resilience -Stigma - Social connectedness and support

42 Powers et al Analysis:

 Descriptive analysis

 Bivariate analysis (users vs non-users)

 Multinomial logistic (different user groups vs non-users)

 Controlled for key demographic variables

 SPSS statistics 24

 714 men (79.8% of total participants) met criteria

Sample profile of non-heterosexual Australian men living with HIV (n = 714) n (%) Age (years), mean (SD) 50.7 (12.5) Sexual orientation -Gay/homosexual 663 (92.9) -Bisexual 47 (6.6) -Other non-heteronormative 4 (0.6) Educational attainment -High school or below 166 (23.4) -Diploma/trade certificate/TAFE 199 (28.1) -University educated 344 (48.5) Employment status -Employed 394 (56.0) -Unemployed/not working/retired 200 (28.4) -Other 110 (15.6) Income (Australian dollars) -< $30 000 174 (26.0) -$30 000–$49 999 110 (16.4) -$50 000–$99 999 221(33.0) -$100 000+ 164 (24.5) Area of residence -City/suburban 522 (74.4) -Regional/rural 180 (25.6)

44 Frequency of drug use in past 12mths

Non- Once or Occasional regularly Users users twice overall % (n) crystal 78.0 9.8 (70) 7.6 (54) 4.6 (33) 22.0 (157) (557) MDMA 84.0 11.8 (84) 3.9 (28) 0.3 (2) 16.0 (114) (598) Cocaine 90.1 8.6 (61) 0.7 (5) 0.6 (4) 9.9 (70) (640) ketamine 94.2 5.8 (41) 1.1 (8) 0.1 (1) 5.8 (41) (672) GHB 97.7 1.8 (13) 0.1 (1) 0.3 (2) 11.3 (80) (690) Party and 70.3 14.6 9.8 (70) 5.3 (38) 29.7 (212) play drugs (502) (104)

Powers et al No significant differences between users and non-users – Emotional wellbeing – Diagnosed depression or anxiety – General social support

Participants who occasionally or regularly used reported – Higher levels of resilience (p=0.02) – Higher levels of physical functioning (p=0.02) – Lower levels of perceived HIV related stigma (p<0.001) – Spent more time with LGBT and HIV+ friends (p<0.001) – Reported higher levels of support from PLHIV and LGBT friends

46 Powers et al

Correlations between

o Party-and-play drug use

o Social connectedness & support

o Stigma

o Resilience

Overall higher levels of resilience and lower levels of perceived stigma were associated with party-and-play drug users spending more time with, and feeling more supported by their LGBT friends and other PLHIV.

Natasha Parent et al, The sexualised use of cannabis among young sexual minority men: “I’m actually enjoying this for the first time” Culture, Health & Society May 2020 1-16.

 Cannabis absent from analyses of chemsex

 Canadian study

 Objective is to identify how cannabis use features within the sexual lives of young sexual minority men.

 Non-medical use became legal in Canada in October 2018

 Decriminalised in 2005.

 57% of 20-24 year olds had used in 2017

48 Parent et al Methods

In-depth, semi-structured interviews through online and posters

Inclusion criteria – Identifying as a sexual minority – Aged 15 to 30 – Having used cannabis in the past year – CDN$30

 41 participants

Gender Number (41) Cisgender men 36 Genderqueer 2 Queer 4 Trans men 3 Other 1

Sexual Orientation Asexual 1 Bisexual 12 Gay 23 Pansexual 6 Queer 4 Straight 1 Unsure 1

50 Parent et al

Theme 1

 Using cannabis to increase sexual pleasure and lower inhibitions

I’ve been having anal sex for, like, probably a decade but until very, very, very recently while having an edible, I’ve never actually liked it…..it’s never been better than a six out of ten. Yeah. And, like, I’m actually enjoying this for like the first time, solidly, like a nine out of ten! And then the next time I had sex without an edible, I was enjoying it as an eight out of 10. I’m like, “Huh?!” So it changed something in me

Parent et al

 Using cannabis to reduce anxiety and foster intimacy

There’s a lot of anxiety that comes with dating on Grindr, at least for myself. Dating apps can shatter your self-esteem because we all look better in photos than we do in real life. That’s what the point of the photo is, is that you look nice, right? So there’s a lot of anxiety that comes with actually meeting the person and, you know, expectations. At least for me. I worried a lot with, like, “Oh, what if they don’t think I look like I’m the same person?” or, like- and I know my friends also have gotten really bad comments. Like, “oh, you’re bigger in person” or things like that. And it can be very anxious, right? Hearing from other people what your partner might think of you. Even if they don’t say it, the fact that they might be thinking it that’s enough to cause me anxiety

52 Parent et al

Cannabis is a strategic resource to deliberately achieve desired sexual affects – Increasing arousal – Intensifying physical sensations – Facilitating receptive anal sex – Reducing inhibitions

Parent et al

 Anxiety related to – Internalised homophobia and shame – Socio-technological ‘hook up’ culture

 Cannabis helps participants: – Satisfy their desire for connection and intimacy – Provides the confidence and disinhibition required to experience more pleasure For men who have problematic chemsex behaviours, cannabis may be a safer option.

54 References

 Destabilising the ‘problem; of chemsex: Diversity in settings, relations and practices revealed in Australian gay and bisexual men’s crystal methamphetamine use. Kerryn Drysdale et al International Journal of Drug Policy, 78 (2020): 1-7.  ‘Sex, drugs and social connectedness: wellbeing among HIV-positive gay and bisexual men who use party-and-play drugs.’ Jennifer Power et al, Sexual Health, 2018, 15, 135-143  The sexualised use of cannabis among young sexual minority men: “I’m actually enjoying this for the first time” Natasha Parent et al, Culture, Health & Society May 2020 1-16.  Associations with drug use and sexualised drug use among women who have sex with women (WSW) in the UK: Findings from the LGBT Sex and Lifestyles Survey. Hibbert M.P., Porcellato L.A., Brett C.E., Hope V.D. Int. J Drug. 2019.  Chemsex behaviours among men who have sex with men: A systematic review of the literature. Steven Maxwell, Maryam Shahmanesh, Mitzy Gafos. Int J Drug Policy 2019 Jan;63:74-89.  The new MTV generation: Using methamphetamine, Truvada™, and Viagra™ to enhance sex and stay safe. Observational Study Int J Drug Policy. 2018 May;55:197-204.  Attitude and beliefs about the social environment associated with chemsex among MSM visiting STI clinics in the Netherlands. PLOS One. June 2020. Ymke J. Evers, Jill J. H. Geraets, Geneviève A. F. S. Van Liere, Christian J. P. A. Hoebe, Nicole H. T. M. Dukers-Muijrers  Differential Risk for Drug Use by Sexual Minority Status among Electronic Dance Music Party Attendees in New York City. - Griffin M. , Callander D., et al Substance use & misuse (volume 55 issue 2 pages 230-240) 2020  Chemsex in Moscow: investigation of the phenomenon in a cohort of men who have sex with men hospitalized due to addictive disorders. International journal of STD & AIDS. Feb 2020.  Chemsex 101 : A Toolkit. Any Positive Change. Access 2/10/20. https://anypositivechange.org/wp- content/uploads/Toolkit-on-Chemsex.pdf