No simple relationship between drug use and risky sex in London gay men

Gay men involved in ‘chemsex’ (taking recreational drugs such as mephedrone, GHB/GBL and crystal methamphetamine during sex) have a range of experiences, with no single narrative able to sum up the impact of drug use on sexual behaviour and possible HIV transmission. While some men describe taking sexual risks that they subsequently regret, others are able to maintain consistent condom use or are HIV-positive men practising serosorting.

Thirty men living in south London who practise ‘chemsex’ took part in in-depth interviews with researchers from the London School of Hygiene and Tropical Medicine, whose report was published last week.

In recent years, there has been a flurry of anecdotal reports, sometimes sensationalist press coverage and health organisations’ expressions of concern about the phenomenon. Many have suggested that drug use among London gay men has reached unprecedented levels and that it is fuelling the transmission of HIV, hepatitis C and other sexually transmitted infections.

Particular concern has been expressed about the numbers of men – apparently increasing – who inject drugs, use crystal meth, attend sex parties, have chaotic patterns of use or overdose at commercial venues.

However, reliable data and relevant research are generally lacking.

Public health officials in Lambeth, Southwark and Lewisham (three south London boroughs with a very large population of gay men) therefore commissioned the new study, which aims to deepen understanding of chemsex. It was carried out in two parts: a re-analysis of quantitative survey data from 2010, plus more recent qualitative interviews with 30 gay men who practised chemsex. 

Quantitative data

The European Men Who Have Sex with Men Internet Survey (EMIS) recruited over 15,000 respondents living in England, including 1142 residents of Lambeth, Southwark and Lewisham, in 2010. While this survey cannot reflect the most recent patterns of behaviour, many of the broad trends and comparisons described are likely to remain valid.

Alcohol was by far the most commonly used drug by men living in Lambeth, Southwark and Lewisham (93.2% in the past month), as it was for men living in other parts of England. Far fewer men had recently used GHB/GBL (10.5%), mephedrone (10.2%) or crystal meth (4.9%). But for each of these drugs local residents were about twice as likely to use them as residents of other parts of London. Far fewer men living in other parts of England used these drugs.

Only 3.5% of men in the south London boroughs had injected a drug in the past year. However, men with diagnosed HIV were predominant among those injecting drugs (64%) as well as among those taking crystal meth through any route (69%).

Whereas one-in-four local men were concerned about how much they drank, one-in-ten men were concerned about their drug use. The number of men who were concerned about their drug use – and therefore might welcome professional help – was highest in men with diagnosed HIV (16%) and men who sometimes injected drugs (19%).

Qualitative data

In-depth interviews were conducted in the past six months. Participants had to have used crystal meth, GHB/GBL or mephedrone during sex in the previous year and to live in Lambeth, Southwark or Lewisham. The youngest interviewee was 21, the average age was 36 and the oldest was 53. Around one third had diagnosed HIV and one third had acquired a sexually transmitted infection in the previous year.

Although the quantitative data would suggest that chemsex remains a minority pursuit, most interviewees perceived drug use to be ubiquitous on the gay scene, especially in and around Vauxhall (a gay nightlife area in Lambeth). Chemsex most often occurred in private homes (often with multiple men present), saunas and other sex-on-premises venues. The rise of sexual networking apps on smartphones had made drug use and sex parties far more visible than they had been before. 

Respondents said that mephedrone and GHB/GBL had largely displaced ecstasy and cocaine as drugs of choice, owing to their cheapness, easy availability and more consistent quality. However, crystal meth polarised views among the participants – some saw it as the ultimate chemsex drug, heightening sexual appetite and stamina, while others feared its addictive qualities and associations with injecting drug use.

The practice of injecting (‘slamming’) drugs was reviled and feared by many interviewees, but there was widespread agreement that it was becoming more common on the chemsex scene. One third of respondents (nine men) did report injecting drugs, including men who appreciated the intense and immediate high it afforded, as well as men who regretted the taboo they had broken. All men who injected reported safe injecting practices, with no sharing of needles. 

Drugs and sex

Many men appreciated drugs’ ability to boost their sexual self-confidence and remove feelings of self-doubt. One man said:

“I think when I was using drugs I did not have body issues. I did not think, I am feeling a bit too fat or feeling that I do not really feel that attractive so it reduces inhibitions physically and psychologically in terms of having sex and with people you would not feel comfortable, like, having sex with normally.”

Most participants said that drugs could enhance sexual desire, provide a more intense sexual experience and facilitate sexual connection with a partner.

“It kind of makes me feel like I’m so much in that one moment and with those people and in that moment physically in a very sensual, passionate, physical way.”

Some men felt that they had become reliant on drugs, including this interviewee who described the "horrible" experience of having sex when sober:

“I just think I’ve had too much chemsex. It’s just boring and just doesn’t feel right.”

Using drugs also facilitated lengthier sexual sessions, sex with multiple partners and sex that was more diverse or adventurous.

“Crystal meth, when you inject it, it just feels very dirty. Just very sleazy. All your inhibitions just lower… You do stuff that you wouldn’t normally do, you would be into different fetishes that you probably wouldn’t usually be in to.”

While this sense of sexual adventure was valued by most participants, some were concerned that they had, at times, pushed their own sexual boundaries too far.

Moreover, when asked if they were happy with their sex lives, two thirds of respondents said they were not. Many desired the intimacy and emotional connectedness of a long-term partner:

“It can get a bit lonely after a while when it’s just fuck and go, fuck and go, fuck and go. It’s not as if anyone stays the night anymore.”

Risk behaviour

The researchers say that there were, broadly speaking, four narratives of drug use and sexual risk taking.

One group of men, all with diagnosed HIV, had made decisions – when sober – to have unprotected anal intercourse with other HIV-positive men (‘serosorting’). Many were concerned by the thought that they could infect others, although some did rely on assumptions and visual cues to determine their partner’s HIV status.

While their drug use may have led to an increase in the amount of sex they were having, it was not the main driver of the non-use of condoms. This group had taken steps to avoid transmitting HIV but were at risk of acquiring hepatitis C and other sexually transmitted infections.

“There was a sense of relief that I didn’t have to use condoms anymore… So that’s why I tend to prefer to have sex with people that are HIV positive as well.”

A second group frequently engaged in chemsex but felt in control of their actions, enjoyed their sex lives, and were, for the most part, engaging in sex with very limited chance of HIV/STI transmission.

“I treat every person as if they are infected. It’s a morbid way to look at it, but it’s a way of keeping myself safe.”

A third group described numerous instances of unintended and regretted risk behaviour while under the influence of drugs. Some described being so focused on sexual gratification that they could not consider the longer-term consequences, while others described being unsure of what they had done while incapacitated. These men often had pre-existing problems negotiating safer sex, which were exacerbated by drug use.

“I try to have protected sex but the thing is that when you’re in a euphoric state, things happen. You might not be totally aware of what actually people are doing [to you] because you are that fucked.”

The final group of men – much smaller in number than the other three – acknowledged that their relationship with drugs and sexual risk-taking behaviour was more complex. The drugs enabled them to push sexual boundaries and to play out sexual fantasies of danger and transgression.

“Maybe you only allow yourself to have sex when you’re high or drunk because being high and being drunk is an excuse to not care anymore. It’s not necessarily that the drugs make you not care, it’s that you’re using them as an excuse so you can go off into this separate little bubble and say that’s not really me.”

Professional help

While the majority of interviewees saw their drug use as being relatively unproblematic, men recounted a number of negative impacts of their drug use, including a range of problems with their physical or mental health. A number had overdosed (usually while using GHB/GBL) and the response of their peers to the situation had generally been inadequate. Three men reported being the victim of sexual assault under the influence of drugs. Many regretted the loss of time that they could not spend on other activities and the impact on their performance at work.

Some men were seeking greater control over their drug use. A minority told emotional stories of recovery and relapse and described the steps they had taken to limit their involvement in chemsex or their dependency on drugs. This often involved leaving London for a while.

While half the respondents had not sought out any professional help, others had called a helpline, received counselling, been admitted to rehab or received other forms of support. Where it was available, men valued clear, honest and non-judgmental information about how to use drugs and have chemsex safely – the researchers recommend better provision of harm reduction information.

Respondents said they felt most comfortable getting help from sexual health services – both clinical and community organisations. The authors further recommend better access to gay-friendly drug and sexual health services that are competent to address the psychosocial aspects of their health and any harms arising from chemsex.

They also recommend work with managers of saunas and other sex-on-premises venues so as to develop harm reduction in their venues (for example, so that staff can recognise and help men who have overdosed or been sexually assaulted). Moreover, they recommend engagement with companies providing sexual networking apps and websites, to explore opportunities for health promotion and harm reduction as part of their corporate responsibility to their users.

However, the researchers do not recommend a social marketing campaign on the dangers of chemsex, which they judge unlikely to resolve the needs identified in their research.