CSIRO PUBLISHING

Sexual Health, 2018, 15, 173–175

Case report
https://doi.org/10.1071/SH17139

Towards a continuum of care concerning chemsex issues

Ingrid Bakker A,B and Leon Knoops A

A
Mainline Foundation, chemsex team, Frederik Hendrikstraat 111-115, 1052 HN Amsterdam, The Netherlands.
B
Corresponding author. Email: [email protected]

Abstract. In response to the apparent rise in chemsex in the Netherlands Mainline Foundation interviewed 27 MSM
about their crystal meth use and/or experience with injecting in a sexual context. These men were interviewed about their
motivation for methamphetamine use, their sexual risk-taking behaviour, methods and context of their drug use, and their
information- and care needs. In 2015 this resulted in the status report Tina and Slamming: MSM, Crystal Meth Use and
Intravenous Drug Use in a Sexual Context. Following the publication of this report Mainline foundation has been offering
harm-reduction intervention for MSM and promoting the development of a continuum of care by building networks,
training professionals and investing in advocacy. In our view, a continuum of care means the availability of a sufficient
level of qualitative and effective preventive interventions, harm reduction services and treatment facilities that are
connected, can track and intervene in the ‘lifecycle’ of individual drug use, and are easily accessible by the target group.
This case study describes the various interventions of Mainline foundation, that make up their continuum of care approach
concerning chemsex issues.

Received 14 August 2017, accepted 8 December 2017, published online 6 February 2018

Introduction In 2014, our informants in the gay scene and professionals

Drug use and injecting in a sexual setting seems to have risen working in sexual health, both reported an increase of
significantly within certain parts of the Dutch men who have methamphetamine use among MSM. In response, our
sex with men (MSM) population over the last few years. In outreach workers began looking for MSM who had used
response, Mainline foundation has been offering harm-reduction methamphetamine (also known as tina) in a sexual context.
intervention for MSM and promoting the development of a We found 27 men who were willing to talk about this, and 20 of
continuum of care by building networks, training professionals these men had experience with injecting in a sexual context,
and investing in advocacy. The continuum begins with the a practice known in the gay scene as slamming. We interviewed
prevention of chemsex-related harm for all MSM involved in them about their motivation for methamphetamine use, their
chemsex,a and ends with appropriate treatment where needed. sexual risk-taking behaviour, methods and context of their drug
Mainline was founded in the early 1990s, and offers, use, and their information and care needs. This resulted in the
implements and promotes various forms of harm-reduction 2015 status report Tina and Slamming: MSM, Crystal Meth Use
intervention for people who use substances. For us, harm and Intravenous Drug Use in a Sexual Context,2 which was
reduction is a holistic approach that helps people minimise the written in close collaboration with SoaAids Nederland, the
harms of their drug use, which could also mean supporting them national organisation for STI/HIV prevention and sexual
in their attempts to control or quit their drug use.1 We work health. The report concluded with several recommendations
cyclically and are driven by demand; our outreach workers regarding practical improvements in monitoring, prevention
are trained to be on the lookout for signals from the field and and care — in short: the development of a continuum of care
identify drug-related health trends. If an issue is flagged, Mainline for MSM with chemsex-related issues.
investigates it. We observe the target group and start a dialogue. A brief review of available Netherlands/Amsterdam-specific
The knowledge we gain is used to create pragmatic interventions, studies showed some indirect supporting evidence, although the
such as flyers and pamphlets that we tailor to the target group. data we found was somewhat dated, non-specific to chemsex,
Outreach workers and other professionals use this Information slamming or methamphetamine use or came from small cohort
Education and Communication (IEC) material to provide essential studies.3 The European MSM Internet Survey (EMIS), the first
health-related information to people who use drugs. study in 35 European and neighbouring countries in which

a
Chemsex is a term mostly used by professionals to signify sexual practices under the influence of substances such as GHB/GBL (gamma-hydroxybutyrate/
gamma-butyrolactone), mephedrone and methamphetamine. Mainline includes substances such as ketamine, basecoke and several other new psychoactive
substances because these are sometimes used with similar intent to enhance the sexual experience.

Journal compilation Ó CSIRO 2018 www.publish.csiro.au/journals/sh

174 Sexual Health I. Bakker and L. Knoops

a direct comparison of data on homosexuality, homosexual through sexual health clinics, HIV consultants and other
behaviour and drug use was made, also justified our focus on facilities that are frequented by MSM, such as particular bars
the issue. Secondary analysis of EMIS’s 2010 data4 shows and saunas. Professionals often use our IEC material to start
that Amsterdam ranked in the top five European cities with conversations about chemsex with their clients.
the highest prevalence of chemsexb and the highest rates of
recent methamphetamine use (5% in the previous 12 months). A continuum of care
In our view, a continuum of care means the availability of
Information, education and communication material a sufficient level of qualitative and effective preventive
The research was translated into a range of IEC material centred interventions, harm-reduction services and treatment facilities
on harm reduction. We included information gleaned from that are connected, can track and intervene in the ‘lifecycle’ of
ongoing online, face-to-face and telephone conversations with individual drug use, and are easily accessible by the target group.
MSM in the chemsex scene. This material is available in Dutch Since methamphetamine use, injecting in a sexual context
as well as English.5,6 and chemsex in general are relatively recent phenomena in
the Netherlands; there still remains a lot to be done. Besides
*
Slamming: Dos and Don’ts: This booklet explains safer addressing the more preventive side of the continuum ourselves,
injecting practices and includes information on matters like by producing and distributing IEC material, we have been
fluid intake and psychosis. educating professionals working with MSM and encouraging
*
Chemsex NL: This series, with lots of personal accounts them to develop their own services, intervention and treatments.
and a colourful design, is about HCV (hepatitis C virus) When the report Tina and Slamming was published in
prevention, testing and treatment alongside safer sex October 2015, we organised an expert meeting for
strategies. It contains harm-reduction tips and tools relating professionals to draw attention to the issue of chemsex. Most
to substance use in a chemsex context. of the participants either worked with MSM or in sexual health.
*
sexntina.nl: A website for MSM about methamphetamine, At that time, the number of men experiencing serious problems
developed in collaboration with SoaAids Nederland. It on account of their methamphetamine use still seemed relatively
contains general information about methamphetamine and low. We observed that people generally tend to put-off seeking
other common drugs, tips on self-control and harm reduction help until they become desperate, thus few chemsex-related
for those already using methamphetamine, a section about issues were seen within the mental health or drug service
quitting methamphetamine – with tips and referral options – community. The lack of referral options for sexual health
and finally a section about sexual health and risk reduction in professionals hoping to direct clients to facilities with the
a chemsex setting. capacity to offer more in-depth treatment remains a glaring
area for improvement for the continuum of care.
The importance of tone of voice Among MSM in our study, many had regular and dependable
contact with sexual health and/or HIV care professionals.
In our experience, content that corresponds with the reality of Because chemsex-related issues most often came to light at
the target group delivered in a relatable tone of voice is the key STI clinics and HIV care facilities, our first priority was to
to effective IEC material. We use the slang of the scene and increase chemsex knowledge there. As these professionals are
direct language when we talk about sex and drugs. For example, already in conversation with MSM about sex, they can address
our research revealed that anal sex without a condom was chemsex and related issues before or when they become
often a conscious choice (barebacking), and only in a few problematic. Thus, they are an essential link between MSM
cases the result of diminishing resolve following substance and other care providers, and can be instrumental in monitoring
use. Barebacking appeared to be the norm among our trends connected to drug use in a sexual context.
respondents. Meanwhile, the persistent focus on condoms as To rouse the interest of Dutch sexual health organisations
the only option for gay men was a regularly voiced irritation. and get them motivated to take action, Mainline and SoaAids
So, we refrain from emphasising condom use, and discuss Nederland organised an expert meeting with one of the leading
alternative risk-reduction strategies such as regular testing, figures in addressing chemsex in a sexual health setting in the
treatment as prevention and PrEP (pre-exposure prophylaxis). UK. In addition, we created a free online training module7
We convey our messages with factual information and peer based upon chemsex, for professionals in the sexual health
interviews to enable identification. field. Besides giving information about chemsex, the module
prompted participants to consider their disposition towards
Keep contact addressing chemsex issues within their own practice, and the
In response to the expressed need for peer contact, Mainline possibilities of doing so. In the numerous face-to-face training
initiated two weekly support groups for men to talk about their sessions for professionals we conducted all over the country,
experiences: one group for men involved in chemsex and one professionals provided us with valuable information on the sort
specifically for men who had quit chemsex. By facilitating these of drug-related issues they see in their practice. And on the
groups, we can share our knowledge with the participants and occasion that a client approaches them with questions they can’t
distribute IEC material, while at the same time get feedback and answer or if one of their clients is looking for a support group,
keep up-to-date with the scene. We also distribute our material they often refer them to us.
b
In this case chemsex was defined as sex under the influence of ketamine, mephedrone, GHB/GBL or methamphetamine.
Mainline chemsex interventions Sexual Health 175

We have hosted several Amsterdam chemsex network many stories of men with such problems who nevertheless
meetings to facilitate the exchange of information and avoid treatment or rehabilitation, either because they are too
encourage cooperation among an ever-growing and varied ashamed to do so or simply because they doubt they will find
group of professionals. And we are gratified to see that after appropriate support, or have tried and did not get suitable help.
approximately 2 years of establishing the foundation for a We are currently consulting with several professionals who have
continuum of care specific to chemsex, more and more chemsex treatment programs in development, and we plan to hold
parties, both locally and nationally, are aware of the issues another expert meeting in 2018 to address chemsex-related
and have started to develop interventions of their own. treatment within mental health and drug treatment facilities.

Challenges Conflicts of interest

Mainline dealt with two recurring issues while laying the The authors declare no conflicts of interest.
foundation for a broad-based response to the chemsex
phenomenon. One has been the media attention and the risk of References
stigmatising the whole LGBT community. We do not generally
solicit mainstream media attention, and focus solely on the 1 Mainline. Harm reduction. Amsterdam: Mainline; 2018. Available
online at: http://english.mainline.nl/page/harm-reduction [verified 04
relevant target group and professionals. In case mainstream
January 2018].
media attention is unavoidable, we are always careful to 2 Knoops L, Bakker I, Bodegom R van, Zantkuijl P. Tina. Slamming:
emphasise the gravity of the issue without stigmatizing an MSM, crystal meth and intravenous drug use in a sexual setting.
already stigmatized minority population. Amsterdam: Mainline, Soa Aids Netherlands; 2015. Available online
The other issue has been the lack of reliable recent at: http://mainline-eng.blogbird.nl/uploads/mainline-eng/Tina_And_
national data on the number of MSM engaging in chemsex, Slamming_ENG_compressed2.pdf [verified 04 January 2018].
methamphetamine use or slamming, which is necessary to 3 Heiligenberg M, Wermeling PR, van Rooijen MS, Urbanus AT,
legitimise the attention we try to bring to the issue. Creating Speksnijder AG, Heijman T, Prins M, Coutinho RA, van der Loeff
the framework for amassing representative quantitative MF. Recreational drug use during sex and sexually transmitted
research data on a subject of relevance to the national public infections among clients of a city sexually transmitted infections
clinic in Amsterdam, the Netherlands. Sex Transm Dis 2012; 39(7):
health is a long and slow process. Consequently, we have so far
518–27. doi:10.1097/OLQ.0b013e3182515601
had to make do with rough estimates and a growing amount of 4 EMIS Network. Chapter 9. Substance use. In EMIS Network, editors.
anecdotal evidence. The EMIS Network. EMIS 2010: The European Men-Who-Have-
Sex-With-Men Internet Survey. Findings from 38 countries.
Next steps Stockholm: European Centre for Disease Prevention and Control;
It is early days yet, so it is hard to make any grand claims 2013, pp. 149–156.
about the effect of our interventions and efforts, but we strongly 5 Knoops L, Bakker I. Slamming: Dos and Don’ts. Amsterdam:
believe that knowledge is the first step in addressing issues Mainline; 2015. Available online at: https://english.mainline.nl/page/
webshop [verified 04 January 2018].
and encouraging behavioural change. We know that more and
6 Knoops L, Bakker I. Chemsex NL. Amsterdam: Mainline; 2016.
more sexual health clinics are starting to address chemsex. Available online at: https://english.mainline.nl/page/webshop [verified
Our next focus of attention will be on establishing good 04 January 2018].
referral options within the sexual health setting or mental 7 Zandkuijl P, Bakker I. Chemsex. Amsterdam: Mainline & SoaAids
health and drug treatment facilities for clients for whom Nederland; 2017. Available online at: https://moodle-sanl.nl [verified
chemsex has become problematic. We have heard far too 04 January 2018].

www.publish.csiro.au/journals/sh