Harm reduction and multidisciplinary consultations for gay, bisexual, and other men who have sex with men practising chemsex based in a French infectious disease unit: patients’ characteristics and perceptions

Introduction

Chemsex is a type of sexualised drug use that has gained attention and expanded among gay, bisexual, and other men who have sex with men (GBMSM) in the past two decades.¹ In developed countries, about 15–60% of GBMSM engage in chemsex, and it is a growing public health concern.^2,3 Chemsex is characterised by a clear and planned intent to use psychoactive drugs to facilitate or enhance sexual activity in terms, for example, of intensity or duration. Its expansion among GBMSM was facilitated by smartphones and hook-up (sexual networking) mobile applications that provide easy access to new sexual partners and ‘recreational’ drugs.^1,4 Chemsex is indeed related to Internet addiction, fear of missing out, and ‘phubbing’ behaviours (i.e. the act of ignoring companions in a social situation by checking or using one’s smartphone), which contribute to interpersonal relationship problems and diminish feeling of wellbeing.⁵

While synthetic substances such as crystal methamphetamine (or crystal meth), g-hydroxybutyrate/gamma-butyrolactone (GHB/GBL), and cathinones (including 3-methylmethcathinone/3-chloromethcathinone (3MMC/3CMC), mephedrone, etc.), and also cocaine and ketamine^6,7 are mainly used in chemsex, the term includes several practices that vary in terms of consumed substances, intensity, frequency, and nature. For instance, ‘Slam’ is a type of chemsex practice involving the injection of drugs reported among about 5% of people practising chemsex in literature reviews.^8,9 Potential harm exists, including traumas and somatic damages associated with sexual activities and substance consumption, interactions, or overdoses, and psychiatric decompensation.^1,10 Chemsex is associated with increased risks for psychiatric pathologies, and sexual health conditions, as well as sexually transmitted infections (STIs) and HIV, possibly due to the disinhibition of sexual practices and decision making, the alleviation of anxieties and concerns for sexual risks, and the potential exchange of drug injection equipment.¹

One’s experience of chemsex is often modelised into a ‘journey’ distinct from other forms of recreational consumption and potentially leading to ‘problematic chemsex’¹¹ when the physical, social, or emotional toll on people’s lives gets too heavy. An element of this model that still needs clarification is the association between chemsex and health-seeking behaviours, including engagement in sexual health, psychological and addictologic support, and STIs and HIV prevention and treatment. Risks and factors protecting people practising chemsex from transitioning into later and more problematic patterns of chemsex are not well understood, including factors associated with healthcare service attendance.¹² However, practising chemsex may reinforce and expose to certain barriers to health care. Those engaging in chemsex are more likely to have sub-optimal clinical attendance.¹³ Drug use is generally associated with disengagement from care, including poor clinic attendance,¹³ partly due to stigmatisation. Many people engaging in chemsex already presented some form or predisposition to vulnerability associated with adverse experiences or unsupportive, marginalised environment (e.g. physical or sexual abuse, stigmatisation, mental health problems) prior to it.¹² In contrast, engaging in chemsex is not associated with poor HIV pre-exposure prophylaxis (PrEP) adherence, mainly due to a heightened self-perception of risk.^14,15 People may have different motivations to engage in chemsex. Some may engage in chemsex to address or seek transcendence from issues related to sexual identity, ways of feeling and relating in the context of sex, intimacy and connection among GBMSM, and loneliness, among others.¹ Some may also do so by hedonism; i.e. for the pursuit of pleasure, which may have protective implications for problematic chemsex, and yield greater engagement in care and support-seeking or support-providing behaviour, when compared to those who practice chemsex to address sexual health issues.¹⁶

Several approaches exist to prevent and treat problematic chemsex. Interventions in hospital and clinical settings typically seek abstinence, whereas community-based services are more likely to provide harm reduction (HR)-related support, usually consisting in developing and informing about strategies to reduce HIV-, drug-, and sex-related risks.¹ Yet, multidisciplinary interventions should also consider patients’ motivations, including health issues that may contribute to motivate engagement in chemsex.¹⁷ Such tailored interventions to prevent or treat problematic chemsex hence require complex, multidisciplinary approaches.¹⁸ The literature highlights the value of networks of trained multidisciplinary professionals and advocates offering HR and treatment services.¹⁹ Any intervention should begin with the development and administration of tools to aid routine assessment of drug use especially in sexual health services catering to GBMSM,^13,18 to adapt interventions to diverse chemsex practices and avoid missed opportunities.¹² Implementation of HR interventions could benefit sexual health services, but such interventions must be well-integrated, to ensure efficient and equitable access to services, optimise patient experience, and avoid providers’ emotional burnout as a result of the HR work.²⁰

At the Infectious and Tropical Disease Unit (henceforth, the Unit) of Hôpital Saint-Louis (Assistance publique - Hôpitaux de Paris), a university infectious disease and sexual health centre located in Paris, France, we initiated an intervention consisting of comprehensive HR consultations for GBMSM engaging in chemsex. Our objective is to assess patients’ consumption and sexual or general health issues related to chemsex, and describe their perspective, in terms of satisfaction and perceived usefulness, with this intervention.

Materials and methods

This cross-sectional study is based on an online survey administered to patients attending comprehensive sexual health and HR consultations for chemsex at the Unit. This research did not receive any specific funding and was approved by the Institutional Review Board of the French Infectious Disease Society (CER-MIT No. IRB00011642).

Results

Between September 2019 and December 2021, 172 Unit patients attended the intervention and were offered to complete a survey. These patients attended a total of 633 HR consultations. Of these, more than three-quarters (132/172 patients, 77%) attended at least two HR consultations (average number of total consultations = 4), and over three-quarters were not followed up after 2 years (107/172; 81%). The average age was 41 years old. Of these 172 patients, a total of 96 patients (55.2% response rate) completed the survey.

Discussion

This cross-sectional study assessed a hospital-based inclusive and transversal centre intervention based on principles of HR in a French setting. The intervention consisted of increasing awareness among clinical staff and training them to identify and screen people practising chemsex, provide HR consultations involving therapeutic education and motivational interviewing to establish with patients personalised objectives and realistic action plans, and reference patients towards other specialists when needed.

Motivational interviewing and therapeutic education, with psychosocial and multidisciplinary options, are starting points to chemsex HR interventions, given the paucity of resources and support centres.²¹ In this intervention, these strategies benefitted from services already provided in the Unit, including sexual health screening, vaccinations, post- and pre-exposure HIV prophylaxis, and psychotherapy, sexology, and addictology counselling services, among others, which are also important in chemsex interventions.²² Multidisciplinary care may explain the insignificant relationship between perceived usefulness of intervention and reporting a follow-up in another specialised service. Other HR strategies could also be implemented, such as clean needles/safe injecting equipment.²²

Our results show a high patient satisfaction with the intervention. Most participants attended more than one consultation, found the intervention useful, were satisfied with the tools or action plans provided, and reported some reduction of their risks. In the assessment of HR interventions, patient perspective is important to verify whether interventions are tailored to contexts, needs, and specificities and variations existing among patients.¹ Indeed, this study is important to ensure that it is patient-centred; i.e. that is respectful and responsive to patients’ preferences, needs, and values. Participants’ frequency of consumption and substance used show that the diversity of chemsex practices in the sample. About one-third of participants practiced Slam, which is higher than what is generally mentioned in other similar studies,⁶ and a majority reported negative impacts on their personal or professional life. This may indicate a selection bias in early implementation. Indeed, the intervention may have then been disproportionately attended by patients who had gone further along their consumption journey and who experienced complications.

Our results moreover indicate that an intervention with trained multidisciplinary healthcare professionals was greatly needed among Unit patients. Indeed, one-quarter of participants had attended emergency services in relation to chemsex prior to initiating the intervention, an increasing phenomenon and life-threatening problem.^23,24 About two-thirds of participants reported a sexual health issue prior to initiating chemsex, and a substantial portion of participants reported having some kind of follow-up in psychiatry. These characteristics imply a heightened risk of addictive behaviour,²⁵ and it is possible that in many cases, drug use in sexual contexts constituted a risky and inefficient way of self-medicating or coping with sexological or psychiatric issues.²⁶ These findings reveal a need among GBMSM for preventive, diagnostical, and therapeutic sexological and psychiatric interventions, which could reduce the incidence of consumption as self-medication. General practitioners catering to this population should be made aware and trained to the needs of patients engaging with chemsex. Our results also show the value of providing hospital-based HR consultations that allow discussions of individual patients’ concerns and needs, key in providing patient-tailored interventions.

The multidisciplinary and integrated approach, involving the whole clinical team and specialists, of the intervention optimised its flexibility, accessibility, and equity. People practising chemsex go through transitions that include states of opportunity, or moments when patients are the most susceptible to health behaviour change, and states of vulnerability, or moments when they are likely to experience negative health outcomes.²⁷ As transitions can happen quickly, interventions concerning chemsex practices should be easily and rapidly accessible when people want it and providers should be ready to adapt to people’s needs, preferences, issues, and lifestyles.¹² Patients are more likely to accept and adhere to an intervention provided in a centre where they already receive care.²⁸ Along this line, the intervention benefitted from being easily accessible, after a rapid evaluation by healthcare professionals or on patients’ demand, within a sexual health service where patients went for STI and HIV screening, prevention, or treatment. Several professionals provided consultations, therefore increasing access and decreasing risks of professionals’ emotional burnout.²⁰ Importantly, almost two-thirds of our sample asked for the intervention themselves, which is important for its acceptability and uptake by patients. Other studies have shown the importance of maintaining a balance between easy access and over-exposing people practising chemsex to chemsex interventions when they do not want to or do not seek them, which can be stigmatising or yield resistance to partake in such interventions.²⁷ The fact that a majority of participants are likely to recommend the intervention to others is an important finding and reveals a possibility to collaborate with community-based organisations, given the importance of peers in chemsex interventions.²⁹

There were some strengths and limitations in this study. We estimated that about 1400 patients engaged in chemsex at the Unit when we initiated the study, and 172 of them had received a total of 633 HR consultations in December 2021. These consultations were implemented in September 2019, and patients were gradually included as they attended their infectious diseases regular follow-up, which occur either every 3 months (PrEP), between 6 and 12 months (HIV), or irregularly (e.g. STI screenings). Additionally, inclusion in HR consultations depended on patient’s readiness, willingness, and acceptance of such care. As more patients are expected to gradually receive HR consultations, this study provides compelling insights on the perspective of ‘early adopters’; i.e. the first patients engaging into chemsex and receiving HR consultations within a hospital setting. Also, substantial segment of the data was collected during the SARS-CoV-2 (COVID-19) pandemic and its associated prevention and lockdown measures, which heightened chemsex-associated risks, in particular mental health conditions (e.g. loneliness, loss of sense of meaning), and reduced access to health care.⁷ This may partially explain that a majority expressed a need for the intervention. Data was collected retrospectively and was self-reported. Results may thus have been affected by memory loss and social desirability. It may have also introduced a sampling bias; e.g. privileging patients who had a positive experience of the intervention, and we have no information about chemsex practices in the overall population of Unit patients. It is therefore difficult to determine whether these results are representative of the population. Still, over half (96/172; 56%) of patients who did attend consultations participated in the survey.

Conclusion

Chemsex practices are an expanding phenomenon, and health services attended by at-risk populations, especially sexual health services already attended by GBMSM, should be ready to adjust to patients’ needs and preferences. This includes offering multidisciplinary interventions to prevent, diagnose, and treat complex psychiatric and behavioural issues potentially associated with sexual and consumption practices. Our results show that users sought care for specific health issues associated with substance consumption, and they were highly satisfied with the intervention. Tailored HR interventions for people practising chemsex should be provided by healthcare professionals who are made aware, educated, and organised to reduce barriers and increase simplicity and timeliness for patients, to make sure patients benefit from interactions with trusted professionals early in their chemsex journey.

Supplementary material

Supplementary material is available online.