On the face of it the death of Miguel Jimenez from a drugs overdose last year, should not have attracted the attention it did. There were, after all, 3-4000 similar deaths in the UK.
But this was a world away from the dead-end lives and squalor usually associated with an overdose. Jimenez was given the drugs by his boyfriend, a top barrister; their dealer was a BBC radio producer and the lethal substance was not heroin or even a synthetic opiate, but GBL, a class c drug which is a staple of the ‘chemsex’ parties which all three men attended. Defined as ‘intentional sexual intercourse under the influence of psychoactive drugs, mostly among men who have sex with men’,1 chemsex is rapidly becoming a public health concern.
The dangers of combining sex and drugs are nothing new in this demographic. The Gay Men’s Sex Survey,2 released in June 2016, found that 42% of men living with HIV felt alcohol/drugs played a part in their contracting HIV.
But chemsex is a perfect storm, attributed to two comparatively recent developments: the emergence of a new generation of psychoactive drugs, some of which are easily available over the internet; and the rise of smartphone-enabled ‘hook-up’ culture.
‘Newer drugs like mephedrone, GBL and crystal meth to a slightly less extent, in combination with Grindr and other dating apps, giving the ability to network with wider groups of people, have all conspired to create a phenomenon that wasn’t there 10 years ago,’ says Mike Flanagan, nurse consultant and clinical lead at Surrey and Borders NHS Foundation Trust’s drugs and alcohol service.
Getting a full picture of the problem is still difficult and there is no national data, although all the indicators are that is on the rise. ‘In my clinical experience, my colleagues and I all noted an increase in people willing to talk about chemsex and admitting engaging in it [in the past few years],’ says Hannah McCall, a senior nurse in genitourinary medicine, and sexual and reproductive health, and runs specialist drop-in clinics, at Central and North West London NHS Foundation Trust. ‘Even if a client wasn’t engaging in chemsex themselves, being asked about chemsex wasn’t surprising for them and they knew of others in their social circle whom were part of the scene,’ says Ms McCall.
A pioneering study4 into gay and bisexual men participating in chemsex in south London found that men who use drugs such as mephedrone, GBL, and crystal meth were significantly more likely to engage in unprotected sex. High-risk sexual behaviour and hard drug use are both associated with a range of severe health problems, such as cardiovascular, respiratory and mental health conditions, alongside sexually transmitted infections such as HIV, hepatitis and gonorrhea.
According to a piece commenting on the south London survey,2 a fifth of respondents said they frequently engaged in chemsex. It also found that two thirds (69%) of men in south London who had used crystal meth in the last four weeks had diagnosed HIV and a similar proportion (64%) of men who had injected (non-steroid) drugs in the last 12 months had diagnosed HIV. This is particularly worrying when chemsex users note that a lowering of inhibitions mean that condoms are often not used.
‘Some of the awareness of the risks around HIV have become diminished over recent years, particularly as the medication management regimen has meant it has been downgraded from a terminal to a manageable condition,’ says Mr Flanagan. ‘That means that is not seen as such a risk as it was.’
Certainly with STIs in general, men who have sex with men are bucking the downward trend. Data from Public Health England shows a large rise in STI infections among this group between 2013 and 2014. Syphillis diagnoses increased by 46% gonorrhoea diagnoses by 32%, chlamydia by 26%, and genital herpes by 10%.
The practice is also associated with GBL, mephedrone and crystal meth, which have been linked to liver, kidney and lung damage, as well as paranoia and psychosis. ‘The issue around the new psychoactive substances like GBL and mephedrone, is that we don’t really know what they are. They are untrialed, and unresearched substances and nobody really knows what the potential long-term impacts might be,’ says Mr Flanagan. ‘With drugs like cocaine and ketamine, they’ve been around for donkey’s years, and there is a lot of knowledge around the risks those drugs present with, but there is little of this with new drugs.’
GBL in particular is seen to be a risk, according to Mr Flanagan. The substance was connected to 20 deaths in 2014. ‘It has a very narrow margin between the doses that can cause euphoria and disinhibition and an overdose.’ Additionally, continued use of GBL can cause physical addiction, making it ‘a very complicated drug to detox people from.’
Additionally, chemsex drug users often describe ‘losing days’ – not sleeping or eating for up to 72 hours, which can damage general health, particularly in immunocompromised patients, such as those with HIV. But it also contributes to an overall detrimental effect on mental health. Ms McCall recently co-authored a BMJ editorial about chemsex which noted that ‘mental health services are seeing a small but important uptake in services by chemsex drug users’.2
‘Very often, where people have engaged in risky sexual practices and disinhibited behaviour, it is not uncommon for people to have a crash in self-esteem. Combined with coming down off stimulants (due to a drop in dopamine levels), this can cause significant depression and feelings of worthlessness. Taken one step further, it can create a suicide risk in people who are already vulnerable’ says Mr Flanagan.
The burden of treating substance abuse falls largely on the shoulders of primary and community care. Nearly 300,000 patients requiring interventions for drug use are being seen in primary and community settings. This is over 90% of the total number. However, the problem may be hidden from nurses in non-specialist settings, although clinicians may be able to discern patients engaging in the practice through recurrent presentation of infections linked to high-risk sexual behaviours.
Ms McCall says that the stigma around chemsex can be a barrier to treatment. This relates to LGBT communities feeling uneasy about attending mainstream drug services. ‘Mainstream services tend to focus on alcohol, cocaine and/or heroin addiction – the triggers, effects and social fallout of which are different from chemsex drugs,’ she says. ‘LGBT communities are fairly comfortable with accessing sexual health clinics (at least in large cities) and small-scale research has found that LGBT communities show a preference for accessing specialist chemsex drug services, linked to sexual health services.’
‘Sexual health and specialist chemsex drug services are more aware of the issues surrounding chemsex and are less “shocked” when a client discloses their behaviour and any related risk-taking activities,’ adds Ms McCall.
A respondent to the South London survey agreed, saying that they would be much more comfortable attending a specialist clinic than a non-specialist setting such as a general practice. He said: ‘I think sexual health places seem more aware of gay issues from what I’ve seen and there seem to be more services available so I think that’s the best place for it. A general practice might be seen as more of a family place, so it could be a bit awkward sitting in the waiting room with the children then go and talk about the extreme sex that you had the night before.’
56 Dean Street, a medical practice in Soho, runs a walk-in clinic specifically targeted at those who engage in chemsex. Patients who attend the clinic can access advice on how to improve safety when having chemsex, as well as information and support on moving away from drug-dependent sex lives. The clinic has also produced a collection of resources for nurses and other healthcare professionals who encounter patients partaking in chemsex.
Clear links between local sexual health services and drug support units can be used to minimise the risk of harm associated with chemsex. ‘It’s reliant on nurses to know about local treatment options and to establish and foster links with specialist services so people can be referred,’ concludes Mr Flanagan. ‘Some drug treatment services provide in reach into sexual health centres, which is the optimum model if you have shared clinics, so people can be seen jointly where necessary.’
But commissioning such treatments is complex, and in the case of sexual health services, the costs are charged back to local authorities, whose public health budgets are currently under threat.
In the early 1980s, men who have sex with men were failed by the initial response of NHS to HIV. We should hope that history does not repeat itself.
|How you can assess the impact of chemsex on a patient|
|For clinicians who have clients disclosing chemsex behaviour assessment should consider immediate, secondary and tertiary concerns: |
- 1a. Is the client on a come-down? Are withdrawal symptoms a danger? For instance, those discontinuing use of G (GHB/GBL) should have medically supported detox, as withdrawal can lead to seizures.
- 1b. Is the client a victim of rape or sexual assault? Does there need to be forensic examination and timely psychological support?
- 1c. Is there HIV risk, does the client need post-exposure prophylaxis?
- 2. Secondary concerns include STI and BBV risk - clients should be offered/referred for STI screen, including HIV and hepatitis screening. Other concerns could be trauma related to BDSM-type sexual activities, mental health concerns relating to drug use and personal safety – do they have a safe space to be discharged to?
- 3. For those who don’t present any significant immediate concerns, information giving regarding the dangers of chemsex and how to access support should be given. Referral to a specialist drug service should be considered.
1. Office of National Statistics. Deaths Related to Drug Poisoning in England and Wales: 2014 registrations. www.ons.gov.uk
2. McCall H. What is chemsex and why does it
matter? BMJ. 2015. http://www.cnwl.nhs.uk/wp-content/uploads/bmj.h579...
3. Sigma Research. State of Play:findings from the
England Gay Men’s Sex Survey 2014. sigmaresearch.org.uk/files/GMSS-2014-State-of-Play.pdf
4. Sigma Research. The Chemsex Study: drug use in sexual settings among gay and bisexual men in
Lambeth, Southwark and Lewisham. www.lambeth.gov.uk/sites/default/files/ssh-chemsex...
5. Public Health England. Sexually transmitted infections and chlamydia screening in England, 2015. www.gov.uk/government/uploads/system/uploads/attac...