Chemsex questions: what are we actually asking?

Keywords: chemsex, drug use, men who have sex with men, MSM, sexual behaviour, risk factors, sexualised drug use, STI.

Sexualised drug use (SDU) is a risk factor for unsafe sexual practices among men who have sex with men (MSM), as well as the broader community.^1–3 Intervention can reduce risk behaviours and facilitate STI prevention.^4–6 Identification of drug use, and subsequent information provision and referral, is therefore an important aspect of sexual health assessment. Previous research indicates that drug use may be under-identified in sexual health centres.⁷ Recent research has placed considerable focus on Chemsex, a subset of SDU, typically involving crystal methamphetamine (CMA), gamma-hydroxybutyrate (GHB), or mephedrone. Chemsex has been shown to have a particularly high effect on STI risk.^8,9 The aim of this analysis was to describe how a new question about Chemsex was utilised by a sexual health service.

We undertook a retrospective review of MSM attending Sydney Sexual Health Centre (SSHC), a large publicly funded service in New South Wales, Australia, between 1 December 2018 and 30 November 2019. In June 2018 the service introduced a new question to a comprehensive computer assisted self-interview (CASI) used for English speaking MSM clients that they answered themselves when attending the service for the first time, to identify Chemsex (CMA, GHB, mephedrone).¹⁰ The answers to these questions were then reviewed by a clinician together with the client. It was based on a question used by 56 Dean St, a sexual health centre in London, UK, according to private correspondence from a Senior Staff Specialist in February 2017: ‘Have you used drugs during sex in the last 6 months? (e.g. Ice/Crystal Meth, G)’. It was optional for clinicians to make notes in a free text box adjacent to the CASI-collected Chemsex question, including the type of drug. Training on SDU was provided (including Chemsex) to staff, including an overview of the concepts, how to interpret the answer to the new question, and how to refer a client for treatment. The training did not specifically exclude alcohol as a drug. Participants were asked other questions about non-sexualised substance use, including alcohol, in a separate part of the initial assessment.

Retrospective data was collected from electronic medical records, and frequencies were calculated using Microsoft Excel (Microsoft). This project was assessed by the South Eastern Sydney Local Health District Research Support Office and was determined to be a quality improvement activity not requiring independent ethics review.

2246 eligible (English proficient) MSM attended the clinic for the first time during the study period. Client demographics are described in Table 1. 227 (10%; 95% CI 8–11) participants self-reported SDU. Where a specific drug used during sex was identified (33%, 74/227), 30% (22/74; 95% CI 19–40) did not use a drug commonly associated with Chemsex, while the remaining 70% (52/74; 95% CI ;60–81) did. Alcohol was never noted as a drug used during sex, though, along with other drugs, was identified by clients elsewhere in the assessment.

Table 1.  Characteristics of MSM clients answering the Chemsex question while attending SSHC.

Our study describes the introduction of a new Chemsex question to SSHC’s CASI for all new MSM attendees to the service. We identified the following: (1) there was a relatively low proportion of clients reporting SDU compared to other populations in Sydney and in Europe, where SDU culture may be different;¹¹ (2) clients appeared to interpret the question to be more broadly about SDU than Chemsex; and (3) there was low identification of specific drugs used during sex.

Although CMA was most commonly identified, the high proportion of non-Chemsex associated drugs suggests that questions identifying SDU, not just Chemsex, may be more appropriate for identifying risk behaviours in a sexual health service. The question asks about drugs used during sex, and some clients may have interpreted this to exclude drugs used immediately before, and for the purposes of, sex.

The optional box for clinicians to record the type of drug, as well as other details (treatment and referral), was poorly utilised. This may point to a training requirement for clinicians working in sexual health services to engage in discussions around SDU, or to a need for the system to specifically prompt for further information in order to provide appropriate referrals or treatment. Neither clients or clinicians appeared to consider alcohol as a drug; given the links with sexual risk behaviour, further research should explore the clinical utility of specific questions around alcohol use during sex. This result is unlikely to be explained by alcohol questions elsewhere in the assessment because the other drugs that were listed by clinicians in the SDU section were also asked there. Future training should include alcohol as a drug of concern.

Our study had the following limitations: (1) incomplete data on drug type used; (2) lack of pre- and post-Chemsex question comparison; (3) exclusion of returning clients and those who did not speak English; (4) we were unable to correlate SDU with other markers of risk behaviour; and (5) this was a single site study of individuals attending a sexual health service, which creates selection bias and limits generalisability to other populations.

Further evaluation of the utility of an SDU question in sexual health services, correlation to risk behaviours, and linkage to interventions are required.

The data that support this study cannot be publicly shared due to ethical or privacy reasons and may be shared upon reasonable request to the corresponding author if appropriate.

The authors declare no conflicts of interest.

This research did not receive any specific funding.