I was recently asked by a colleague to cover our afternoon senior emergency trainees teaching session at short notice. I naively agreed to help out not knowing what I had volunteered for. A few hours later, I walked into the room where half a dozen of emergency trainees were sitting impatiently waiting for me to facilitate their session. Everyone tried to hide an uneasy giggle when I was informed on the spot that the topic for the afternoon would be…chemsex.
You might not have heard this term before, in which case I think you should definitely read through this blog post. It covers something that is becoming a major public health concern and not just in major cities. The BMJ recently covered this and warned about the effects of this rising trend.
I have to say I was very impressed by how well our trainees coped with a topic that is rather difficult to cover as it might feel uncomfortable to discuss (or even shocking for some).
So what is chemsex?
Chemsex also called “party and play” (“P and P” or “PnP”) in the USA, is the name given to the increasingly popular practice of using recreational drugs in a sexual context. Often referring to group sex that can last for hours or days, chemsex has led to many being trapped in a vicious circle of sex, addiction and dependence. It must be noted that the words chemsex and recreational drug use/abuse are not interchangeable as they mean two completely different things.
Before we continue, I feel there are two myths that need to be dismissed.
- Chemsex is exclusively linked to the LGBT community.
In terms of relative percentage, there is probably no doubt that this is a concern that mostly involves the lesbian, gay, bisexual and transgender community. It must be said however that there is no evidence whatsoever to suggest that the heterosexual community does not engage in this type of activity. It is just probably less researched and published primarily due to poor reporting.
56 Dean Street Clinic, a pioneering sexual health clinic in London, was the first to establish a chemsex clinic to try to address this public health concern. We have since seen other clinics outside London opening special sessions for patients who would self-refer with similar problems.
Simply type #chemsex into the Twitter search engine and you will come across different blogs/tweets/links etc related to the topic. This is a worldwide trend which is increasingly popular.
Please consider visiting the website for the 56 Dean Street Clinic as they have a variety of free access chemsex terms dictionary for both clinicians and patients, toolkits and other relevant documents.
2. Chemsex is a completely new phenomenon.
I guess it depends on how long you go back in time and what substances you define as drugs. This is a debate that would merit its own blog post but what substances do we consider to be drugs? Illegal drugs like cocaine? Legal drugs that are socially more accepted like alcohol? Alcohol does impair your mind so strictly speaking, it can be seen as a drug. We could therefore say that many of us have had chemsex after that a particularly drunken Saturday night out.
I would therefore argue that chemsex has always been present but it probably just gets more attention nowadays. With the rise of social media, it is receiving more publicity and with the exponential rise in sexually transmitted infections and better organised public health services, it garners greater attention.
This is obviously my personal interpretation and I am more than happy to be challenged on the above statements.
I just hoped it would make you look at things from a different perspective but also put you at some ease with a topic that is frankly not easy to cover with trainees or your patients.
What happens during a chemsex party?
During these parties, consensual men (and sometimes women) will take a variety of drugs ranging from GHB/GBL to methamphetamine (crystal meth – have you watched the HBO series Breaking Bad?), mephedrone or other less well-known/well-understood substances. There is often combination of agents to further enhance their effects. It is important that you seek professional assistance if you are unfamiliar with the pharmacology of any of these. In the UK, we would be accessing the Toxbase web portal or calling the National Poison Information Service (NPIS) which are reserved for health professionals seeking advice on clinical management/treatment.
The above-mentioned substances induce euphoria, enhance libido and reduce some of our sexual and social inhibitions. During chemsex parties, people will engage in extended hours of sexual activities or extreme sex due to complete disinhibition.
Below is a trailer for a recently released and very successful film documentary on the issue of chemsex.
Why do people engage in chemsex?
I am not sure we can cover this specifically in this blog post as the self-reported reasons range from the desire to feel sexually free to a desire to have a long sexual act combined with some psychological aspects like a desire to overcome a fear of rejection. There is no doubt that there is often a combination of a myriad of reasons which results in people engaging in this type of activity which is frowned upon by many in our society as it is felt not be conforming to the norm (by whom the “norm” should be defined is another matter altogether…!).
What are the risks?
Apart from risks linked to the use and abuse of drugs, there are some real concerns around the practice of safe sex or, more precisely, the lack of it. Barrier protection is simply not used or is lost during acts that can last anything from a few hours to several days. This results in (repeated) exposures to STIs like viral hepatitis or HIV. There has also been a recent resurgence of infections thought to be of the past (like syphilis and gonorrhoea) due to lack of appropriate protection in metropolitan cities like London, Amsterdam and Manchester.
There is a great presentation by David Stuart on the characteristics of Chemsex use in London (and probably in lots of other places too). David is a great professional to follow on Twitter too to keep up to date with the topic.
If intravenous drugs are used (slamming – a slang term used for injecting drugs), needle sharing practice obviously results in increased risks for HIV and viral hepatitis. It is worth noting that the use of bank notes for snorting drugs has been associated with an increased risk for hepatitis C due to the presence of blood particles on the notes.
How to talk to my patient about chemsex?
Taking a sexual history is not an easy task for someone who does not work in genito-urinary medicine. This can be even trickier in an emergency department where time pressures do not always allow for a detailed history. We addressed this in a previous blog post here; you might find it helpful to refresh yourself on it.
Patients will often attend the ED after they have “sobered up” after a long party. These patients’ first point of contact is very often EDs as sexual health clinics are in general not open at weekends. It is therefore extremely important that EPs take a concise history of exact events, time of events and carry out a risk assessment on the degree of potential exposure, broken down to different infections. This is particularly important because delayed presentations often mean patients miss the 72-hour window for post-prophylaxis for HIV, for example.
As covered in our sexual history post, it is extremely important to take a history after you have put your patient at ease in a completely non-judgmental manner. I am not particularly a religious person but I was very impressed by the comments made by the current Pope when asked about this opinion on homosexuality. “Who am I to judge?” – he replied. I ask you back, who are you to judge anyone else’s lifestyle? Are you sure you are better person, citizen, wife, partner? Are you sure you lead a better life?
Do not use terms you are not familiar with and do not hesitate to ask the patient back if they use terms you have never heard before (this might be a great opportunity to expand your vocabulary and sexual life too!). Remember that confidentiality and discretion are key: this might not be easy to ensure in a heaving emergency department.
What to do? Who to refer to?
In the UK, your duty as an emergency physician will often be limited to be carrying out a risk assessment on presentation and decide on initiation of post-exposure prophylaxis for HIV, a vaccine booster for hepatitis B or emergency contraception. Specific swabs and blood tests can often be undertaken later at specialist clinics to which the patient should be referred for further screening and follow-up.
In the institution where I work, we have a very good and well established Sexual Health Clinic but also an on-call service for GUM/HIV and virology. I always found them very helpful if stuck with something I had not come across before: you should not hesitate to use these resources should they be available to you too.
Not all sex is consensual, particularly under the influence of drugs and alcohol. Any non-consensual aspects may not be disclosed immediately but it is important to give your patient an opportunity to disclose – and to know what to do if a disclosure of rape or sexual assault is made (it’s also important you understand the legal definitions of these terms which may differ from what is meant by the patient).
This is not an easy public health topic to cover for emergency physicians as it is an always evolving picture influenced by your local drug and sexual trends. There is no doubt however that you will come across these distraught patients seeking your help as first point of call in an ED near you.
As a professional EP, you should:
- be open-minded
- be non-judgemental
- seek help from experts
- involve your patient
- ensure appropriate follow-up
- Daily Telegraph (UK) Chemsex: the alarming new trend of 72 hour drug-fuelled sex sessions
- Guardian (UK) Review of Chemsex documentary.
- Chemsex support at 56 Dean street
- 56 Dean street on facebook
- Illicit drug use in sexual settings (‘chemsex’) and HIV/STI transmission risk behaviour among gay men in South London: findings from a qualitative study. Sex Transm Infect. 2015 Dec;91(8):564-8. doi: 10.1136/sextrans-2015-052052. Epub 2015 Jul 9.
- “Chemsex” and harm reduction need among gay men in South London. Int J Drug Policy. 2015 Dec;26(12):1171-6. doi: 10.1016/j.drugpo.2015.07.013. Epub 2015 Jul 26.
- Sex, drugs and smart phone applications: findings from semistructured interviews with men who have sex with men diagnosed with Shigella flexneri 3a in England and Wales. Sex Transm Infect. 2015 Dec;91(8):598-602. doi: 10.1136/sextrans-2015-052014. Epub 2015 Apr 28.
- Recreational drug use, polydrug use, and sexual behaviour in HIV-diagnosed men who have sex with men in the UK: results from the cross-sectional ASTRA study. Lancet HIV. 2014 Oct;1(1):e22-31. doi: 10.1016/S2352-3018(14)70001-3. Epub 2014 Sep 7.