Harm reduction services for people engaging in chemsex in Brighton,UK: A pilot qualitative study

Abstract

Objective

A broad range of stakeholders commission and provide harm reduction support for people who engage in chemsex, including public health, sexual health, mental health, HIV services and substance misuse services. Understanding the experiences of stakeholders could provide important insights and suggest ways to improve outcomes. We aimed to explore the experiences of stakeholders providing harm reduction support to people who engage in chemsex in Brighton, UK.

Methods

We conducted semi structured interviews with chemsex harm reduction stakeholders who provide support for people in Brighton, UK. The semi-structured interviews were recorded, transcribed, and analysed thematically using NVivo 1.6.2: Braun & Clarke framework.

Results

We recruited ten stakeholders with at least 6 months of experience in providing commissioning, managing or providing harm reduction services to people who engage in chemsex. Five themes emerged from the stakeholders: stakeholder perception of client pathways (inefficiency in client pathways, inequitable access to services, unmet client mental health needs) and stakeholder experiences (having to use an ‘empathy’, ‘non judgement’ and ‘guiding hand’ approach), and experiencing emotional burnout as a result of the chemsex harm reduction work.

Conclusions

This pilot study of stakeholders suggests that to improve chemsex harm reduction outcomes, a more integrated approach between providers with clear client pathways and a broader reach including services tailored towards non-MSM, and offering services outside of typical business hours is needed. Furthermore, the sustainability of services requires increased workplace support for chemsex service providers to prevent burnout and maintain service quality.

Keywords

chemsex men who have sex with men harm reduction

Introduction

Chemsex describes the use of psychoactive drugs (e.g., gamma-hydroxybutyrate (GHB), mephedrone, and crystal methamphetamine) to enhance sexual encounters most commonly described in men who have sex with men (MSM).^1–4 Chemsex is associated with poor health outcomes (including mental ill-health, sex without consent, sexually transmitted infections and HIV transmission and overdose) requiring harm reduction interventions.^2,5–7 Generic drug-support services are usually not specifically resourced to address the specific needs of people engaging in chemsex.³

Brighton has a large population of MSM and other sexual minorities with a large burden of sexually transmitted infections and people living with HIV.⁸ Previous data suggest that chemsex is frequently reported amongst MSM in Brighton compared to other areas of the UK, including significant harm and death.^9–11 Attempts to reduce harm experienced by MSM and other chemsex users has led to the piecemeal development of local support services from varied disciplines and backgrounds. A broad range of stakeholders locally provide varied, non-integrated; harm reduction services for people who engage in chemsex, including counselling services, sexual health support from the Terrence Higgins Trust, and the generic substance misuse service who have a single dedicated substance misuse nurse for MSM. There is little coordination or communication between of the current services. Nationally, there are no agreed benchmarks or key performance indicators for the support or rehabilitation of chemsex users, however previous data suggests that many services are inadequate, are not specifically tailored to chemsex users or are unable to meet their needs.¹² It can be challenging to explore the needs and experiences of chemsex users actively accessing harm reduction services. Little is known about the experiences, knowledge and skills of stakeholders providing support services to chemsex users. To date, studies have provided insight into the harm caused and a framework for any interventions.¹³ Understanding the experiences and viewpoints of stakeholders providing harm reduction support to chemsex users may identify strengths and weaknesses among existing services. The aim of this study was to explore the experiences and viewpoints of stakeholder harm reduction providers for people who engage in chemsex in Brighton. Themes generated from this study can be used to re-evaluate service coordination, redevelopment and improvement including stakeholder training.

Methods

Design and setting

We conducted a qualitative study to explore the experiences of chemsex harm reduction stakeholders including the local public health commissioning team. To gain insight and generate themes, we conducted semi-structured interviews (conducted by GMcG) with key staff who provide or commission harm reduction services for chemsex users. Using purposive and snowballing sampling, we recruited individuals from four organisations via gatekeepers and email: the Terrence Higgins Trust (THT), Change Grow Live (CGL), Lunch Positive (LP), and Brighton and Hove City Council’s public health team, to participate.

Data collection and analysis

Data was collected via recorded online (Zoom) semi-structured interviews between May–August 2022. The interview focused on participants’ perceptions of their role, the skills they consider essential to providing high-quality support, and challenges or obstacles commonly faced in their role and among their clients. The recorded interviews were transcribed and thematic analysis was conducted in NVivo 1.6.2 using the Braun and Clarke framework.¹⁴ This study received ethical and governance approval from the BSMS Research Governance and Ethics Committee (ERA/BSMS9P1B/1/1).

Results

We recruited ten participants (for a single 45–60 min interview) with at least 6 months of experience of commissioning, managing, or providing harm reduction services to people who engage in chemsex. Detailed demographic information on participants is not included to protect anonymity. Roles included: sexual health support worker, public health administrator, charity support worker, LGBTQ (lesbian, gay, bisexual, transgender, queer) substance use worker, recovery peer volunteer, chemsex service organizer, charity director, HIV and sexual health service director, and substance use service intake assessor.

Saturation was reached and five themes emerged: stakeholder perception of client pathways (inefficiency in client pathways, inequitable access to services, unmet client mental wellbeing needs) and stakeholder experiences (needing to use an empathy, non-judgement and guiding hand approach and experiencing emotional burnout) (Figure 1).

Figure 1.

Visual representation of themes: stakeholders’ perception of client pathways and experiences of harm reduction.

Inefficiencies in client pathways

Participants believed that clients experienced difficulties navigating service pathways including being “cycled” between organizations without receiving tangible support. (Table 1) Participants suggested that inefficiencies in client pathways resulted in inappropriate, repeated use of resources. Participants described interactions with clients who had presented to emergency services, received stabilization care, but were unable to proceed in a care pathway due to their substance use.

Table 1.

Themes from chemsex stakeholders with examples.

Theme	Example
Inefficiencies in client pathways	“I suppose the biggest problem is the people who fall– won't be seen by any agency, because of the intensity of their using…if they don't get through that pathway of substance misuse provider level to get into a detox program, then they just tend to go round and round in circles” (HIV and sexual health service director)
Inefficiencies in client pathways	“... he took himself up to A&E because he was hallucinating really, really badly…they’ve just given him a couple of diazepam to stop the agitation, but he will be discharged and if he goes back to using crystal meth, then he won’t be picked up” (Substance misuse service intake assessor)
Inequitable access to services	“I feel like there's other sections of the community that gets [sic] ignored and not talked about and whilst they may be smaller in number, that doesn't mean that they're not– they're not getting harmed or they might be hidden within this sort of MSM population…I just wish kind of people were kind of talking about it.” (Sexual health support worker)
Inequitable access to services	“I was still working, the help that I needed was outside of work hours, yeah? I couldn't afford to take any time off during the day to go and see kind of a- a health worker…my life was so chaotic at the moment. I was just trying to keep my job down.” (Recovery volunteer)
Unmet client mental wellbeing needs	“If, however, you want to access NHS-provided service for your mental health—mental ill health—if you are still using drugs, you will not be able to get access to the mental health service, and that is hugely problematic…What we need is better collaboration between mental health, substance misuse, and psychologists and social health to say, ‘What can we– what is our offer? Where do we start with these individuals?’” (Public health administrator)
Empathy, non-judgment, and the “guiding hand”	“...putting the people who are actually experiencing the problems at the heart of the decision-making about how we approach it, rather than just coming at it from a kind of, ‘you’re a problem, and we're here to solve you,’ it's more about working with them to try and support them…” (Sexual health support worker)
Burnout and emotional burden	“There’s plenty of people that have been burnt out, but because it's their skill set, come back and keep working in the sector that's already drained them and they shouldn’t really be working there at all. So, I think, generally speaking, there needs to be more support for workers.” (Sexual health support worker)

Inequitable access to services

Participants described inequitable access to harm reduction chemsex services; currently services are exclusively designed for cisgender MSM. Participants reported interactions with clients from other populations who had encountered difficulty trying to seek support. Participants described their client base as “high functioning” (maintaining employment and relationships while simultaneously engaging in harmful chemsex). Many services are offered during typical business hours which participants believed reduced accessibility to those who work.

Unmet client mental wellbeing needs

Participants identified unmet mental wellbeing needs as a challenge faced by clients. Drug abstinence requirements were an obstacle frequently described by participants when attempting to secure mental and emotional health support for clients.

Empathy, non-judgment, and the “guiding hand”

Participants described using a “guiding hand” ‘non-judgment’ and ‘empathy’ approach to harm reduction; they aimed to treat clients as equals (horizontal approach) rather than a hierarchical “giver” and “recipient” (vertical approach). This horizontal framework was used to minimize stigma and maximize engagement. Participants also emphasized the importance of placing the focus on the ‘person’ rather than simply their substance use or sexual behavior. Participants stressed the importance of a skills “toolbox” including empathy, non-judgment, and active listening skills. These skills facilitated an environment where clients felt comfortable to share details about their chemsex use, providing context for them to offer appropriate support.

Burnout and emotional burden

Participants described “burnout,” a psychological state characterized by emotional exhaustion and a suppressed sense of personal accomplishment, as a challenge. Support available to service providers was varied (clinical supervision and reflective practice), but others perceived a lack of help available.

Discussion

This pilot study has highlighted some novel themes from harm reduction providers of chemsex services including inefficiency in client pathways, inequitable access to services, unmet client mental wellbeing needs, needing to use a ‘empathy’, ‘non-judgement’ and ‘guiding hand’ approach with clients, and emotional ‘burnout’ was experienced by the providers. Previous work from a European chemsex forum also identified that chemsex users require a holistic approach to recovery using a non-judgmental approach as users follow a trajectory from adverse childhood and other experiences (e.g., living with HIV) to loneliness/emptiness, searching for (sexual) connections, chemsex and an impact on their health.¹³ Similar to our study, they propose that integration of harm reduction services and appropriate pathways into sexual health and other services is vital.

Inefficient client pathways and inequitable access to chemsex harm reduction services poses significant risks to harm reduction support.⁴ Participants discussed difficulties with linking clients into sustainable mental health support in Brighton, often due to the abstinence prerequisites to receiving counseling. Similar to other work, our study suggests the need for integrated pathways for chemsex harm reduction services, including accessible entry points, targeted towards a broader population including non cis-MSM.^6,15 While the prevalence of chemsex in non-MSM is poorly understood, there appears to be unmet needs, particularly in gender diverse groups.¹⁶ The findings also suggest the need for chemsex harm reduction outside of typical business hours.

The “toolbox” of essential skills, consisting of using empathy, non-judgment, and active listening, is supported by existing literature.¹⁵ Participants’ perception of their role as a “guiding hand” to clients through behaviour change interventions aligns with harm reduction principles.¹⁶ However, providers require adequate support to maintain their wellbeing and to provide high-quality services.⁶ Studies examining occupations enduring similar levels of emotional burden have identified inadequate supervisory support as a cause of employee burnout.¹⁷ Therefore, difficulties associated with emotional burden and inconsistent support available to providers must be addressed to minimize their contribution to inefficiencies in client pathways.

A recent review of MSM living with HIV who were chemsex users in four European countries suggests that a quarter of MSM living with HIV engage in chemsex including 6.5% who inject (slamsex).¹⁸ This study reported that chemsex had negative effects on work, friends/family and relationships, however only 15% accessed any harm reduction services and 67% of these felt that the services met their needs. This shows that harm reduction interventions can be effective for MSM, but these need to be specifically tailored to the social and cultural circumstances of MSM.¹²

A review of the need for harm reduction interventions suggests that actions and collaborations are needed, aimed at developing a greater understanding of chemsex as a practice and to develop tailored harm-reduction models for MSM who engage in chemsex.⁶ However the limited research on chemsex harm reduction strategies focus on medical interventions, and similar to our study, it has been highlighted that such a focus obscures the ‘chemsex users’ psychological toolbox to adapt their behaviour.¹⁹

Following a review of harm reduction services in Sydney, Australia, ACON (AIDS council of New South Wales) a community organization were commissioned to provide a multi-dimensional chemsex harm reduction initiative.²⁰ This initiative included support for individuals seeking to control their chemsex; support peer education; partnerships with research institutions to better understand the local cultures of chemsex. The approach employs culturally relevant terminology and imagery; uses content designed, created and delivered by peers; and operates within a pleasure, harm-reduction and community-led framework. These interventions have led to increased service uptake and a strong community engagement. Furthermore, ACON in Sydney have developed a digital health pathway using a mobile phone application to support individuals who are affected by chemsex using cultural specific co-designed material and pathways into care and preliminary results suggest this approach can be effective for some people.²¹

There are several limitations to our pilot study including interviewees coming from a single provider network with a small number of participants. We used purposive sampling with snowballing and some stakeholders may not have been able to share their experiences due to this methodology. Furthermore, we were unable to provide the voices of chemsex users which may be at significant odds to the experiences of the stakeholders. The findings of this study may not be generalizable to all populations either in the UK or overseas due to the complex nature of chemsex use and its intersectionality in different social settings. This study is focused on a high income setting where healthcare is free at source (via the NHS), and the experiences of chemsex stakeholders in other geographical settings with different healthcare structures may be different. However, the themes described in this study may be generalizable for some services both in and outside of the UK and attempts to set out some important principles which can be used when considering harm reduction services for chemsex users.

To improve chemsex harm reduction services, the results of our pilot study suggest that a more integrated approach should be adopted between stakeholders, with clear client pathways and a broader reach including services tailored towards non-MSM and offering services outside of typical business hours. This study also suggests that the sustainability of services requires increased workplace support for chemsex service providers to prevent burnout and maintain service quality.

Footnotes

Author contributions

GMcG, DR & JV designed this study. GMcG recruited and conducted the semi-structured interviews, data collection and analysis and GMcG, DR & JV all contributed to the final manuscript. At the time of this study, GMcG was a global health masters student who identifies as a queer, white, femme-presenting, non-binary individual.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical approval

Brighton & Sussex Medical School Research Governance and Ethics Committee (ERA/BSMS9P1B/1/1).

ORCID iD

Daniel Richardson

Data availability statement

All the from this work is in the manuscript.

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