The future of drugs: recreational drug use and sexual health among gay and other men who have sex with men

For millennia, humans have used psychoactive drugs to produce transformations and create new possibilities of feeling, acting and relating that are difficult to achieve by other means.¹ In simple terms, Alcohol and Other Drugs (AOD) have served as one of several means through which people have tried to change their situation. Sex is no exception: In Macbeth, Shakespeare wrote of alcohol, ‘it provokes the desire, but it takes away the performance’.² But for sexual minorities, this relation is reversible. Psychologists have found that drug use can be motivated by ‘a desire to escape very rigorous norms and standards’, because it can enable cognitive disengagement from normative pressures.³ From this perspective, intoxication may provide the incentive, licence and fortitude to act on same-sex desires that have been severely socially stigmatised historically – and still are in many contexts.

Drugs emerge here as one way of acting upon sexual desires and activities whose performance is otherwise foreclosed by the normative pressures of heterosexual culture and/or HIV prevention. The drivers of this process are cultural as much as biological (though the point is rarely acknowledged by health scientists). ‘Because they are commonly believed to be disinhibitive, [alcohol and drugs] may provide socially acceptable excuses for engaging in sexual behaviours in which people may want to engage but perhaps know they should not.’⁴ In other words, disinhibition circulates as a cultural narrative that has become available to explain the occasional transgression of norms around sex and other behaviours. The sociocultural licence that drugs supply for engaging in disapproved activities is evident in cultural representations of gay sex in as early as 1970, well before the onset of HIV/AIDS. For example, the gay characters of the film The Boys in the Band discuss the ‘Christ-I-was-drunk-last-night syndrome’ as a prevalent ‘excuse’ for homosexual encounters, and simply observe ‘a lot of guys have to get loaded to have sex’.⁵ From this perspective, the entanglement of sex with substance use is an upshot of the historical pressures of sexual stigma. But these histories do not exhaust the possible ways in which these activities come together; indeed, such histories are still being written and experimented with. Nor is sexuality the only significant context of AOD use among all gay and MSM; AOD use may be bound up in the performance of gendered and cultural identities, and associated problems are often mediated by factors such as class, employment status and affective conditions.

It is often said that drug abuse and addiction ‘decimate communities’, and no doubt this is true in certain contexts. But it is also a matter of historical record that certain communities and social relations have been brought into being through drug practices; the use of MDMA (3,4-methylenedioxy-methamphetamine ) or ecstasy within queer culture is a key example.⁶ Drug experiences have sometimes served to multiply and enrich affective bonds between participants in these subcultures, notwithstanding the risks associated.⁷ Since the 1970s, psychoactive drugs have been significant within urban gay communities for the social pleasures they afford as much as the cultural licence they supply to act upon stigmatised desires.⁸ From the disco era,⁹ through 1990s dance culture,¹⁰ to the more recent emergence of ‘chemsex’,¹¹ stimulant drugs have participated in the formation of significant social bonds among men who have sex with men (MSM), producing a provisional sense of belonging and community for some participants in these sexual subcultures. Over the 1990s, the sense of community generated within urban gay scenes became a significant element in ‘community responses to HIV/AIDS’ in some locations,¹² giving rise to innovations in care, community education, HIV prevention and harm reduction.^8,13 However, commercial gay scenes have their own social hierarchies and dynamics that do not cater to the needs and desires of all participants. Indeed, some men’s AOD use may be complicated by the feeling of not belonging to prevailing forms of sexual community.^14,15 In this sense, connections between AOD use and the experience of urban gay scenes are highly variable. And while certain problems may be associated with the use of illicit substances, it is also evident that the policing, criminalisation, harassment and incarceration of users conducted under the auspices of the War on Drugs has played an equally significant part in the decimation of minoritised communities over the last half century, as numerous studies have demonstrated.^16–19

The use of illicit drugs for specific social and personal functions finds a mirror in contemporary developments in biomedicine, in particular the emergence of so-called ‘lifestyle drugs’, such as Viagra and other medications.^12,20 Contemporary pharmaceutical markets are increasingly characterised by proximities between bodily desires, personal enhancement and chemical practices.^21–23 Since the mid-20th century, sex and sexuality have functioned as key domains for the technical and pharmaceutical modification of the body.^24,25 Preciado describes postwar pharmaceuticals as ‘a new set of technologies for producing sexual subjectivity’ and situates the invention of the category ‘gender’ as bound up in the ‘exciting possibility of using technology to modify the deviant body’.²⁶ From the clinical use of hormones for sex-reassignment surgery and body modification to the development of blockbuster drugs such as Viagra, the desire to enhance sexual experience and alter sexual functioning have been major factors in the emergence of lucrative pharmaceutical markets (the use of antiretroviral drugs for HIV prevention, which will be discussed below in further detail, can be considered a further instance of such proximities).^20,23 Many of these products appeal to a sense of non-normative embodiment.^12,24,27,28 From this perspective, it is not surprising that illicit drug use is also found to be higher among lesbian, gay, bisexual, transgender and queer (LGBTQ) populations.²⁹ Medical and social authorities have long classed the gender and sexual preferences of LGBTQ populations as problematic, pathological and in need of correction.^30–32 Chemical practices have presented one set of possibilities for changing this situation, though not always in terms that conform with medical or social prescription.^12,33

Alongside their perceived benefits, drugs are known to be associated with a range of dangers, including drug interactions and resistance, iatrogenic effects, accident, dependence, overdose, mental illness, hospitalisation and death (these dangers are associated equally with the misuse of certain medications, and are not the exclusive province of prohibited substances).^34–36 Aware of these dangers, international agencies and experts are increasingly inclined to call on governments to end the criminalisation of illicit drug use and possession^37–39 – though not without encountering local resistance. Promising health outcomes have been achieved in jurisdictions where less punitive policies are implemented,^40,41 and a range of programs have emerged locally and internationally that seek to provide non-judgmental care and resources to users, including pill testing, syringe provision, peer outreach services and supervised injecting. These services are frequently controversial and precarious, however, and vulnerable to political agendas. The effectiveness of peer-driven education and support (among other harm-reduction measures) is substantially compromised by the criminalisation of drug use.⁴²

Given their historical associations with HIV prevention, LGBT community health organisations have long been informed by harm-reduction principles and are among the leading proponents of some of these innovations. However, public funding for health education and service provision within LGBT populations tends to prioritise HIV prevention and sexual health. As a result, AOD programs tend to be poorly resourced and are difficult to maintain as prominent programs within these organisations. Meanwhile, mainstream AOD services typically presume a heterosexual clientele, and often lack the specialised skills and expertise to handle problems associated with sexuality-related drug use, with some exceptions.^43,44

Given the connections between sexual minoritisation and desires to chemically alter bodily experience, a key argument of our contribution is that public funding of LGBTQ health should not remain restricted to questions of HIV prevention and sexual health exclusively. As a matter of priority, it should be expanded to support AOD services and harm-reduction initiatives within LGBT community health agencies, as well as programs that aim to equip mainstream AOD services with the requisite forms of cultural and sexual literacy that will enable them to work effectively with LGBTQ clients.²⁹ For sexual and gender minorities, drug and alcohol use can be a creative or experimental response to social marginalisation – and not necessarily a problematic one in every instance. Rather than seeking to eliminate drug use, or confine themselves narrowly to questions of sexual risk-taking, sexual health programs should therefore seek to counter the material effects of sexual normalisation and sexual stigmatisation in general. These processes constitute the conditions in which LGBT drug use emerges as significant for many participants and have a material effect on whether the consequences are destructive or constructive.⁴⁵

A growing body of work in the AOD field investigates the sociomaterial arrangements in which different drug effects and practices emerge.^46–48 This literature challenges commonplace understandings of drugs as stable entities with fixed chemical properties, and instead demonstrates that the action of drugs and their purported effects is a product of their relations with various other actors, contexts and practices. Here, agency is not equated with the properties of chemical entities or the intentions of human subjects exclusively. Rather, drug effects are brought into being and changed in their encounters with a wide array of phenomena, including informational environments,^46,47 administration techniques,^46,49 devices and technologies,^50,51 social and affective climates,^50,51 law enforcement practices,^18,19,52 clinical and public health arrangements,⁵³ particular contexts and locations,^19,50,54 and individual bodies,⁴⁸ among other variables.

Given these contingencies, it is impossible to predict the future of drugs or their effect on sexual health with any degree of certainty. Instead, this article proceeds by outlining some of the conditions that are most likely to mediate such futures in the medium term. These conditions include contexts of drug consumption (‘Sexual Geographies’); technological developments (in digital and social media for example); the moral status of sex and drug practices (‘New Stigmas and Moralism’); legislative environments and law enforcement practices (‘Surveillance and Policing’); the availability and uptake of HIV biomedical prevention measures; and relevant developments in health and social care arrangements.

One question that is relevant to, but largely beyond the scope of our analysis, is how markets in psychoactive substances will evolve over the medium term, both locally and internationally. While it is impossible to predict drug trends linked to future market developments, it is important to note that these futures are contingent on regulatory environments and drug classification practices. For example, the last two decades have seen a rapid proliferation of new psychoactive substances and ‘legal highs’ available for purchase and sale on the Internet in Europe and elsewhere.^55,56 Specialists attribute these developments to the criminalisation of once-popular recreational drugs (such as MDMA or ecstasy).⁵⁷ In order to circumvent regulatory constraints, clandestine laboratories have pursued research and development programs into new psychoactive substances that dodge legislative classifications. But the effects, uses, and impacts of these new substances are generally unknown.⁵⁸ Some of these substances are associated with a range of risks and dangers – including transition to injecting on the part of users in some locations.^59,60 Market devices such as drug-checking technologies;^61,62 the possibility of legal, regulated psychoactive markets;⁶³ or the extension of prohibitionist practices and policies have the potential to ameliorate or exacerbate certain dangers, including the potential contamination of these substances with highly toxic compounds, known to be a feature of unregulated drug markets.⁶⁴

The association of stimulant use with sexual risk-taking has dominated concerns around gay men’s recreational drug use. A correlation between the two is well established in the scientific literature, though the exact nature of this relation is typically assumed rather than specifically investigated.^65–69 Common wisdom positions risk-taking as a biopsychological consequence of intoxication. But this explanation uncritically reproduces the cultural notion of ‘disinhibition’ to explain sexual risk-taking and neglects event-level and other analyses that find that people who engage in unprotected sex under the influence of drugs are just as likely to take sexual risks when they have not consumed these substances.^4,12,70–75 Many alternative explanations for the correlation between drug use and sexual risk-taking are possible; those who engage in the consumption of illicit drugs may simply be more likely to engage in other risky practices (such as unprotected sex); and/or drug use may itself be prompted by shame around unprotected sex. As both illicit drug use and sex without condoms represent instances of sociomedical non-compliance, those who are led to breach one of these prescriptions may well be inclined to breach the other in certain circumstances, especially when such prescriptions fail to take into account the lived realities and constraints of people’s everyday lives and desires. While men who engage in chemsex and ‘party ‘n’ play’ (‘PnP’) scenes do so for a range of reasons (including pleasure, adventure and enjoyment),^11,76 several studies have found associations between traumatic childhood incidents, such as childhood sexual abuse, the use of stimulants for sex and sexual risk-taking.^77,78 For some, sexualised drug use may operate as a form of affective experimentation that is undertaken with a view to reconfiguring prior, difficult bodily experiences.⁷⁹

Whatever the relation between recreational drug use and risk-taking (and the relation is certainly multiple), numerous studies have found that infection with HIV and other sexually transmissible infections (STIs) and blood-borne viruses (BBVs) is more likely to occur among gay and MSM who consume recreational drugs than those who do not.^80–82 Reasons for this extend beyond straightforward explanations that attribute individual sexual risk-taking to substance use⁶⁹ to include a range of contextual factors and cultural variables. For example, the sexual networks of men who use drugs for gay sex are characterised by a higher prevalence of HIV-positive participants and lower rates of condom use (often as a result of attempted serosorting).^70,73 Lower rates of condom use within this sexual milieu may affect the prevention practices of HIV-negative participants, who may wish to conform to the sexual and social norms they perceive to be operating in those contexts. Meanwhile, stimulants such as methamphetamine are commonly used for ‘sex-binges’ that involve a higher number of sexual partners and a greater likelihood of anal and other physical abrasions that increase susceptibility to HIV and BBV infection.^11,83 In general, HIV-negative men who participate in these sexual networks are likely to have a higher number of HIV-positive sexual partners.^69,70 The higher prevalence of injecting drug use within these sexual networks increases the risk of exposure to BBVs such as hepatitis C, which may occur through sharing drug and/or sex equipment and/or through specific sexual activities.⁸⁴ Precautionary measures that may be effective in other contexts become more precarious in these conditions, putting those who participate in networks of sexualised drug use at greater risk of HIV, BBV and STI infection.

Significantly, however, the risks associated with this cluster of practices are variable, contingent and context-specific. On the basis of clinical trial evidence, community agencies now promote the use of antiretroviral treatment as prevention.^85,86 Even in the context of ‘drug-fuelled’ multi-partner sex without condoms (as ‘chemsex’ is often sensationally characterised), the risk of HIV infection is reduced if the viral load of HIV-positive participants is suppressed by the use of antiretroviral therapy,⁸⁷ and/or when HIV-negative participants are using pre-exposure prophylaxis.⁸⁸ With increased rates of HIV testing, early initiation of antiretroviral therapy on the part of HIV-positive individuals, uptake of pre-exposure prophylaxis by at-risk individuals and effective adherence, the risk of HIV infection can be reduced (though the transmission of other STIs will not necessarily be mitigated). Taken together, these developments oblige us to confront what some may consider an equally scandalous but nonetheless recognisable possibility: the prospect of ‘drug-fuelled HIV prevention’.

The emergence of ‘chemsex’ in its present incarnation became possible with the growing popularity of online dating sites and hook-up apps among gay and other MSM.^11,89,90 But analyses of ‘chemsex’ often neglect to account for the simultaneous eradication of other gay social spaces in urban centres over the past decade. A variety of factors have contributed to the erasure of public spaces of gay social life. These include the gentrification of urban centres;^91,92 the attraction of wider demographics to queer nightlife precincts and associated increases in homophobic and transphobic violence;⁸ intensified policing of public disorder, drug possession, noise and ‘anti-social behaviour’ in nightlife precincts;^17,93 zoning laws and licensing restrictions that affect the commercial viability of bars, dance clubs, sex shops and other social spaces;^94,95 and the growing uptake of digital devices that provide other avenues for meeting sexual partners. As well as reducing participation in more established gay social spaces, the latter provides a mechanism for the emergence of more geographically dispersed sexual networks among gay and MSM. Gay capitals such as Sydney and New York have seen particularly intense governmental assaults on nightlife precincts that were once important scenes of LGBTQ socialisation.^8,19,96,97 For some gay men, the result has been ‘a sense of isolation and diminished expectations for queer life, as well as an attenuated capacity for political community’.⁹⁶

The decline in live scenes of urban sociability effects gay men’s experience and use of psychoactive substances in material ways. Where gay dance culture was popularly perceived to involve the dispersion of sexual energies to the more diffuse eroticism and communal affection of the dance floor,^10,12 the use of digital hook-up devices typically locates gay sexual socialising at home,¹¹ and frames sex as the exclusive modus operandi of such encounters.⁹⁸ Associations have been found between social isolation and reliance on hook-up devices for sexual and social contact with others.⁹⁹ Clinicians providing AOD services to gay men speculate that social isolation is a key factor in problematic drug use and stimulant dependence.¹⁰⁰ Conversely, those who manage to balance their participation in digitally facilitated sexual encounters with other social activities and forms of pleasure may be less likely to experience such difficulties.⁹⁸ On this argument, the availability of other social outlets that are attractive to gay men and fulfil their complex social and sexual needs may play a part in mitigating problematic patterns of substance use. Where a paucity of such social opportunities exists, gay men may be led into modes of drug dependence, in which stimulant use becomes a primary source of recreational pleasure.¹⁹

The decline in publicly accessible social spaces of LGBTQ life also comes with certain pedagogical losses because these spaces have served has key sites of LGBTQ community formation and socialisation. In the digital context, gay men are less likely to be personally exposed to a range of experiences of gay life beyond their ‘sexual type’. This reduces possibilities for experiential learning, exposure to socio-sexual difference and the maintenance of queer cultures of inclusiveness. In contrast, some see the decline of commercial gay scenes in urban centres as evidence of the growing acceptance of gays and lesbians in mainstream society. Together with online dating and other new cultural forms, this presents gay men with expanded opportunities to organise their lives outside once centripetal zones of gay life such as the bar and club scene, perhaps allowing more diverse expressions of gay life.

The past decade has seen the articulation of new desires for sexual citizenship, manifested in an intensified push for marriage equality internationally on the part of gay and lesbian activists. From the perspective of citizenship equality, the denial of same-sex marriage rights is manifestly unjust, and in fact, there is evidence of less demand for mental health services among gay and bisexual men in locations where such rights are recognised.¹⁰¹ While for many gay men, mainstream acceptance has produced a greater range of options for arranging their lives; political mobilisation around this objective has also produced new forms of moralism within gay and lesbian communities that create new challenges for public health. The desire for liberal equality has spawned ‘a homonormative desire to dissociate homosexuality from cultural undesirable practices and experiences such as AIDS, promiscuity, drag, prostitution and drug use’.¹⁰² In this context, it may become less possible to have frank discussions that acknowledge gay men’s engagement in these practices and develop appropriate forms of care, education and support for those who do. The contrast with earlier conditions that enabled the emergence of ethical and pragmatic community responses to HIV/AIDS is pertinent. The desire to present a publicly respectable image of gay life can override pragmatic, non-judgmental attention to the needs of at-risk individuals and groups in some forums, and these men may find themselves newly stigmatised within gay community discourse.¹⁰³

Vestiges of homonormative discourses are evident in the forms of moralism that characterise some public and community representations of ‘chemsex’. The high profile UK documentary, Chemsex, largely attributed gay men’s sexualised drug use to the inherently ill or historically damaged nature of gay sexuality itself.¹⁰⁴ Meanwhile, popular and self-help discourses addressing ‘chemsex’ propose normative intimacy as the most assured route to recovery and health.¹⁰⁵ These discourses reproduce moral investments in monogamy and abstinence that, at a population level, have been shown to be ineffective strategies for preventing HIV/AIDS.¹⁰⁶ Gay culture is characterised by a wide range of intimate relations and sociosexual arrangements, only some of which align with normative investments in monogamy and marriage.^{96,98,103,107} However useful some gay men may find recovery discourses that stipulate a renunciation of ‘immoral’ activities, these strategies are not realistic or practicable for many others.

The popularisation of these discourses in gay culture is likely to have a demoralising and debilitating effect on those who wish to organise their sexual and intimate lives in alternative ways, exacerbating the already stigmatised status of casual sex and recreational drug use. This in turn may create barriers to prevention and health care, because those who are shamed by moral discourses become less likely to openly discuss disapproved practices with healthcare professionals or seek support from peers or services should they need it. In this context, finding non-judgmental ways to acknowledge the validity of a range of sexual and drug using preferences in both clinical practice and community education is necessary. Rather than promoting particular ideals of intimacy, sexual health and drug treatment programs are most effective when they help gay men manage the risks of sex and drug use and maintain their social relationships without moral proselytism. The effectiveness of early community responses to HIV/AIDS was not predicated on moral compliance, but frank acknowledgement of non-normative attachments.^12,106

Part of the appeal of online hook-up devices is the veil of privacy they appear to confer on queer sexual arrangements. Stigmatising associations between HIV, casual sex, drug use and the use of online hook-up devices may incline users towards patterns of secrecy and evasiveness.^12,90 However closely users of online hook-up devices guard their personal privacy though, it is clear that this privacy is under threat from other directions. User data is of increasing interest to commercial, public health, law enforcement and security agencies,¹⁰⁸ and there have been documented cases of police using digital interactions to entrap users under HIV disclosure and/or drug enforcement provisions internationally.⁹⁰ The raid of the rentboy.com website (a New York-based gay sex work site), in which Federal officers seized personally identifying user data and other company files, reveals how activities such as sex work and drug use make gay men newly vulnerable to apprehension on the part of law enforcement agencies.¹⁰⁹

The digitalisation of clinical records makes clients of sexual health services similarly vulnerable to privacy breaches, whether on the part of law enforcement, online hackers or as a result of technical accidents.¹¹⁰ The risk of humiliating public exposure is likely to drive risk practices further underground, or lead to avoidance of care on the part of those who need it – a development all the more probable given the increasing securitisation of public health in the digital context. In this context, there is a renewed need to advocate for privacy protections, and bring law enforcement practices into line with public health objectives in this context. Advocacy for the decriminalisation of drug use and sex work, in addition to HIV-positive sex, becomes an increasingly important objective for sexual health advocates. Criminalisation of these activities is known to work against public health and creates barriers to engagement in care.^38,111,112 The digital context has only multiplied potentials for the apprehension and surveillance of those who engage in ‘illicit activities’. Redressing the moral and legal status of these activities is of utmost importance.

It is impossible to predict the future effect of gay men’s recreational drug use on sexual health with any degree of certainty. Instead, we have sought to flag some of the conditions likely to mediate possible futures. In an ideal world, the decriminalisation of drug use and widespread access to a range of HIV prevention tools will create conditions in which HIV infections decline, and individuals who use drugs will be able to access any care and support they require to live well. Better regulation of drug markets prompted by the decriminalisation of drug use will equip users with the tools they need to manage their use and keep themselves relatively safe. The convergence of sexual health services with community outreach programs will enable the timely diagnosis and treatment of HIV and STIs, leading to reductions in serious sexual infections. All of this is predicated, of course, on affordable access to treatments and services for those who need it.

In a more dystopian future, intensified stigma around drug use and casual sex will drive these practices underground. The securitisation and privatisation of public health will lead to new dangers, avoidance of care and isolation of those at risk. New HIV prevention tools will fail to reach those who most likely will benefit from them, and undiagnosed infections will proliferate, producing an escalation in HIV and STI infections. The persistence of drug prohibition will result in the emergence of new psychoactive substances that will likely generate new risk practices and unknown dangers. The social isolation of users will compound other harms, including endemic drug dependence, mental illness and incarceration of users.

Given current political climates both locally and internationally, we feel genuinely uncertain about which of these futures will eventuate and where. But in closing, we would like to signal some promising convergences between sexual politics and drug politics in recent times. A new wave of grassroots activism around drug policy is evident in various locations. In Sydney, recent mobilisations have occurred at the intersection of queer community and drug use. Groups such as Unharm have prompted collective discussions that situate the emergence of innovative care practices within cultures of drug use.¹¹³ Informed by histories of sexual community, their activities connect harm reduction to broader questions of access to public space. Their efforts to prevent dangers associated with drug use are characterised by a critique of criminalisation, an appreciation of the diversity of bodily experience and openness about the pleasures some associate with drug use.

Politically significant connections between sexuality and drug use are evident elsewhere. During the UK Psychoactive Substances Bill debate, a conservative MP came out publicly as a user of amyl nitrate, a substance that some gay men use to facilitate receptive anal sex.¹¹⁴ While the Bill was eventually passed, the implementation of the Act has been postponed indefinitely. We believe the MP’s admission was suggestive for the affinities it produces between the politics of sexuality and the politics of drugs. We take his speech to amount to a claim on the legitimacy of self-surrender, and believe the popular receptivity surrounding his admission to be a promising development.

As Keane has argued, the dominant discourse of human rights is centred on ideals of autonomy, rationality and sovereign individuality.¹¹⁵ This can reinforce a model of the ‘normal’ sovereign individual that has served to pathologise and marginalise drug users historically. While human rights can be effective tools for arguments about public health in some contexts, their prioritisation of norms of sovereign individuality is worrisome for drug politics. Hence our interest in this instance, in which self-loss itself constitutes the focus of legitimation.

Significantly, public acknowledgement of the intelligibility of human desires for self-surrender is also pertinent to the politics of HIV/AIDS. Bersani has analysed the virulent homophobia that characterised discourses surrounding the early AIDS crisis as a displacement and projection of common human desires for receptivity and self-surrender onto sexual others: gay men and women.¹¹⁶ Needless to say, such conditions were disastrous for HIV prevention.

As we argued at the outset of this paper, the need to disorganise the self might be regarded as a common human need that people turn to on occasion to produce transformations. In highlighting the proximities between sexual and drug experience, and having this claim acknowledged by many as reasonable, we believe this moment in the Psychoactive Substances Bill debate pushes both sexuality and drug use into more promising political territory.¹¹⁷ In particular, it might be taken to signal common recognition of a need (that anyone may experience on occasion) to become other than oneself: a right to self-disruption. Against dominant discourses of sovereign individuality that prescribe self-control and self-same identity as the prerequisite of human intelligibility, recognition of the occasional need – indeed, the right – to produce self-disruptions may generate more inhabitable sexual and social climates for everyone.

None declared.