Chemsex practice among men who have sex with men (MSM) during social isolation from COVID-19: multicentric online survey Prática de chemsex entre homens que fazem sexo

Práctica de chemsex entre hombres que practican sexo con hombres (HSH) durante período de aislamiento social por la COVID-19: una encuesta multicéntrica en línea Álvaro Francisco Lopes de Sousa 1 Artur Acelino Francisco Luz Nunes Queiroz 2 Shirley Verônica Melo Almeida Lima 3 Priscilla Dantas Almeida 2 Layze Braz de Oliveira 1 Jeremias Salomão Chone 4 Telma Maria Evangelista Araújo 2 Sandra Mara Silva Brignol 5 Anderson Reis de Sousa 6 Isabel Amélia Costa Mendes 1 Sónia Dias 4 Inês Fronteira 4


São Paulo
Rib
irão PretoBrasil

Jeremias Salomão Chone 
Instituto de Higiene e Medicina Tropical
Universidade NOVA de Lisboa
LisboaPortugal

Telma Maria Evangelista Araújo 
Universidade Federal do Piauí
TeresinaBrasil

Sandra Mara 
Silva Brignol 
Instituto de Saúde Coletiva
Universidade Federal da Bahia
SalvadorBrasil

Anderson Reis De Sousa 
Escola de Enfermagem
Universidade Federal da Bahia
SalvadorBrasil

Isabel Amélia 
Costa Mendes 
Escola de Enfermagem de Ribeirão Preto
Universidade de São Paulo
Ribeirão PretoBrasil

Sónia Dias 
Instituto de Higiene e Medicina Tropical
Universidade NOVA de Lisboa
L sboaPortugal

Inês Fronteira 
Instituto de Higiene e Medicina Tropical
Universidade NOVA de Lisboa
LisboaPortugal

A F L Sousa 

Escola de Enfermagem de Ribeirão Preto
Universidade de São Paulo. Av. dos
Campus Universitário, Ribeirão PretoBandeirantes 390014040-902SPBrasil

Chemsex practice among men who have sex with men (MSM) during social isolation from COVID-19: multicentric online survey Prática de chemsex entre homens que fazem sexo com homens (HSH) durante período de isolamento social por COVID-19: pesquisa online multicêntrica Práctica de chemsex entre hombres que practican sexo con hombres (HSH) durante período de aislamiento social por la COVID-19: una encuesta multicéntrica en línea
95E0A4D7A1A5A10C1C766351E04D912710.1590/0102-311X00202420


Abstract

The aim of this tudy was to investigate factors associated with sex practice under the effect of drugs (chemsex) among men who have sex with men (MSM) during the period of social isolation in the context of the COVID-19 pandemic.A multicenter online survey was applied to Brazil and Portugal in April 2020 when the two countries were under restrictive health measures due to the pandemic.Participants were recruited with an adaptation of the respondent driven sampling (RDS) method in the online environment.Data were collected using social networks and dating apps for MSM.We used bivariate and multivariate logistic regression to produce crude (OR) and adjusted odds ratios (aOR).In a universe of 2,361 subjects, 920 (38.9%) reported engaging in chemsex practice, which involved casual partners in 95% of the cases.Higher OR of engaging in chemsex were associated with Brazil (aOR = 15.4;95%CI: 10. 7-22.1),not being in social isol

ion (aOR
= 4.9; 95%CI: 2.2-10.9),engaging in casual sex during social distancing (aOR = 52.4;95%CI: 33.8-81.4), group sex (aOR = 2.9; 95%CI: 2.0-4.4),not presenting any symptom of CO-VID-19 (aOR = 1.3; 95%CI: 1.1-1.8),not living with the sex partner (aOR = 1.8; 95%CI: 1.2-2.6), and using pre-exposure prophylaxis (aOR = 2.6; 95%CI: 1.8-3.7).The occurrence of chemsex was high, especially in Brazil, where the proposed social distancing did not gain adherence by MSM.


COVID-19; Sexual Behavior; Men Who Have Sex with Men; HIV; AIDS


Introduction

The social distancing implemented worldwide in recent months is a public health measure recommended by epidemiologists and adopted by many policymakers in previous pandemics to reduce the probability of an infectious agent's spread in the population, thus slowing the pace of trans ission of a disease 1 .In addition to the intended impact of reducing transmission, social distancing can produce impacts on the mental and sexual health of individuals that adhere to it, besides reducing social suppo t, which is particularly important and necessary for a large share of the LBTQ+ population 2 .

Men who have sex with men (MSM) are among the populations for whom the restrictive measures adopted by governments have created difficulties for executing or maintaining affective and sexual practices 2,3 .A recent survey found that Brazilian and Portuguese MSM experience difficulty in remaining socially isolated, since 53% reported engaging in casual sex during social distancing, despite the growing risk of acquiring SARS-CoV-2, the cause of COVID-19.They also reported increased consumption of alcohol and other drugs 3,4 , sometimes associated with sex, thus chemsex 5,6 , or sexual practice under the influence of drugs and chemical substances.Widely reported among MSM 7 before the pandemic, this practice has the purpose of prolonging and enhancing pleasure from the sex act.

The combined use of psychoactive substances during chemsex significantly increases the exposure to sexually transmissible infections (STIs), including in anal sex without condoms, exchanging sex partners during group sex, desiccation, dehydration, and loss of sensitivity, increasing the odds of lesions and bleeding 8 .Meanwhile, the impairment of reasoning can often decrease the capacity and disposition to use condoms, to adopt pre-exposure prophylaxis (PrEP) properly, and to take protective measures to minimize the risk of SARS-CoV-2 infection 8,9 .

Since this scenario of social isolation with its current proportions is a recent and unprecedented experience for he population, particularly for MSM, and given the lack of studies on this topic in the literature, our objective was to investigate the factors associated with chemsex among MSM during social isolation in the context of the COVID-19 pandemic.


Methods

The results are from the project entitled 40tena, derived from the cohort study In_PrEP Brazil/Portugal, led by the Institute of Hygiene and Tropical Medicine, NOVA Univertisy of Lisbon (IHMT-NOVA), Portugal, and the University of São Paulo (USP), Brasil.It is an online multicenter survey applied to all 26 states of Brazil and the Federal District as well as to 15 of Portugal's 18 districts.The data were collected dynamica ly in two weeks of April 2020, while the two countries were experiencing restrictive health measures such as social distancing and isolation.The research project and presentation of these manuscripts were oriented by the STROBE (checklist of items that should be included in reports of observational studies) tool and the CHERRIES (The Checklist for Reporting Results of Internet E-Surveys).

Participation in the survey included 2,361 MSM, 1,651 (69.9%) from Brazil and 710 (30.1%) from Portugal.For this study, 920 (38.9%)MSM were eligible, having practiced chemsex during social distancing and isolation.

Participants were recruited using the respondent driven sampling (RDS) method in the online environment.In this method, the participant himself is responsible for recruiting other individuals from their same category, using social networks.To meet the method's requirements, we selected 15 MSM with different characteristics in relation to: location in the country (divided according to the two countries' regions); race/color (white and non-white); age (youth, adults, and elderly); and schooling.These 15 individuals were the first participants and were called "seeds".Each participant received the link and was oriented to announce the survey and invite MSM fr m their social network until a significant sample was obtained.The seeds were identified through two dating apps based on geolocation (Grindr and Hornet), by direct chat with users online, through an adaptation of the time location sampling (TLS) technique b

ed on pr
vious methods 10,11,12 , as shown in Figure 1.

Cad. Saúde Pública 2020; 36 (12):e00202420

The researchers also used push on the Facebook social network to address the MSM population from 18 to 60 years of age (the age limit imposed by the social network).Through a fixed posting on the official survey webpage (https://www.facebook.com/taafimdeque/),accompanied by an electronic link, access was provided to the free and informed consent form and the survey questionnaire.We only enrolled individuals that identified as men (cis or trans), 18 years or older, and living in Brazil or Portugal.People that did not speak Portuguese and tourists were excluded.

A data collection form was created and validated in its European Portuguese and Brazilian Portuguese versions (face-content) by a team of three experts from the two countries.This form was hosted in a specific data collection site that only allowed one answer per IP (internet protocol), for security reasons.The

into four s
ctions with 46 questions, mostly multiple choice, some mandatory before proceeding to the next item.The questions addressed:

(1) Sociodemographic information (age; gender identity; schooling; sexual orientation; type of relationship; country; state; place of residence);

(2) Social well-being and coping during social distancing;

(3) Sexual practices and activities during the pandemic (casual sex; sex under the effect of drugs; group sex; sex with condoms; protective strategies; partner-seeking strategies; sexual frequency; and protective measures against COVID-19); (4) sexual practices and activities prior to the pandemic (use of prep and pep -post-exposure prophylaxis; partner-seeking strategies; knowledge on stis; and testing);

To describe the target factors, we conducted descriptive analyses of the numerical and categorical variables.We then developed a multivariate model with variables previously associated with the outcome in the bivariate analysis: "practiced chemsex".The binary dependent variable was sex under the effect (1) or not under the effect (0) of legal and/or illegal drugs.


Figure 1

Fluxograma de coleta de dados.MSM: men who have sex with men.

Cad. Saúde Pública 2020; 36(12):e00202420

The bivariate and multivariate logistic regression generated odds ratios (OR) and adjusted odds ratios (aOR) with the explanatory variables and the respective 95% confidence intervals (95%CI) indicating the odds of practicing chemsex, categorized as yes or no.The analysis considers the multivariate model's best performance in terms of accuracy, sensitivity, and specificity (receiver operating characteristic -ROC), proving that the resulting statistic performance was superior to chance.

The primary project obtained the proper authorizations and ethical approvals in Brazil and Portugal, and due to the addition of questions, an amendment was submitted and approved, allowing to conduct the study.Free and informed consent was obtained online.


Results

Mean age of participants was 31.03 years (18-66), and the median number of sex partners was 2.0 (1 to 32) during social isolation.Chemsex practice in Brazil (69.9%) was more than twofold that of Portugal (30.1%), and nearly all of the participants (95%) engaged in casual sex.Group sex was reported by 31.4%, and sex without condoms was reported by 47.6% (Table 1).

Multivariate analysis of factors associated with chemsex evidenced that MSM in Brazil show 15.4 higher odds (95%CI: 10.7-22.1) of practicing sex under the effect of drugs when compared to those living in Portugal.Independently of living in Portugal or Brazil, MSM that claimed they were not in social isolation presente 4.9 higher odds (95%CI: 2.2-10.9) of practicing chemsex.Meanwhile, MSM that reported casual sex during the social distancing period presented 52.4 higher odds (95%CI: 33.8-81.4) of engaging in sex under the effect of drugs, a result corroborated by the strong correlation (0.7) between the variables.

Those who reported group sex during the social distancing period presented 2.9 higher odds (95%CI: 2.0-4.4) of engaging in chemsex.We found that MSM who reported occasions when they did not want or could not adopt any protective measure against COVID-19 showed 2.2 higher odds (95%CI: 1.7-3.1) of practicing chemsex, and those with no symptoms of COVID-19 had 1.3 higher


Table 1

Descriptive analysis of target factors during social isolation and strategies understood/used as protective against COVID-19 infection by men who have sex with men (MSM) that practiced chemsex.Brazil and Portugal, 2020 (n = 920).


Target factors n %
Gender

Discussion

This was the first study so far to an lyze chemsex practice associated with sociodemographic factors and sexual behaviors during the social distancing period caused by the COVID-19 pandemic in Brazil and Portugal.A significant portion (95%) of MSM that engaged in chemsex did so in sex with casual partners during the pandemic's upward epidemiological curve in both countries (April 2020).

Engaging in casual sex was the factor with the highest odds of chemsex practice according to the study's findings and may be related to the alse feeling of security in the adoption of some socalled protective practices against COVID-19.Corroborating this hypothesis, users of PrEP/Truvada showed higher odds of engaging in chemsex, and a relevant share of MSM (21.8%) adopted PrEP/ Truvada as a measure they viewed as protection against SARS-CoV-2.A possible explanation for this practice may be the incorrect understanding of the discussion on the potential effect of prophylactic drugs for SARS-CoV-2 in the popular media 13 .Some MSM may h ve confused PrEP as a strategy, that is, pre-exposure prophylaxis, as having a similar mechanism for SARS-CoV-2, which may have motivated the maintenance of sexual relations during the pandemic.This attitude may also have been influenced by the publication of preliminary re ults of recent studies 14,15 in Brazil on the potential of tenofovir, one of the antiretrovirals used in Truvada, to decrease the length of hospitalization for SARS-CoV-2.This situation merits watching among MSM who access PrEP in the healthcare system, in order to strengthen health education activities.In the absence of evidence of efficacy for the prevention of COVID-19, the assumption runs the risk of inducing people using PrEP to neglect efficacious measures to protect against SARS-CoV-2 infection that are recommended by health agencies during social isolation 3 .Another mistaken measure was to verify the presence of symptoms between the sex partners.The mechanism of infection in COVID-19 makes th s measure basically useless, because COVID-19 has a high proportion of asymptomatic individuals (80%) 16 , there is transmission during the incubation period 17 (1 to 14 days after contact with the virus), and after improvement in the signs and symptoms, the virus can still be found in the rectal canal for up to 15 days, with the risk of transmission through oral-rectal sex (rimming or analingus) 18 .Such findings indicate the need for implementation of highimpact measures directed to sexual healthcare for MSM, in order to reduce the knowledge gaps and stereotypes in health and raise the awareness of these men to care for their health.

Our results show that chemsex practice in Brazil exceeded that in Portugal by more than twofold, which may explain why living in Brazil was associated with higher odds of chemsex practice.Studies prior to the onset of the COVID-19 pandemic already howed that sex under the effect of psychoactive substances was quite common among Brazilian MSM 19 , and that maintenance of this practice at high levels raises concern, potentially reinforcing the thought that social isolation was not effective in the country, especially among MSM.Although social distancing is currently the most effective nonpharmacological measure to prevent SARS-CoV-2 infection, it is still happening ith a heterogenous and only partially effective pattern in Brazil's states 20 , which are seeing their social distancing rates decreasing while the mortality curve and the curve of new cases are only slightly flattened 21 , so that "not practicing social distancing" was a factor associated with engaging in chemsex.

However, Brazilians' situation appears to be particularly emblematic, since the continuous growth of cases has already forced them to stay at home for more than two months (at the time this survey was being conducted), pressuring the p pulation into social isolation.Thus, during the prolonged "quarantine", moments of casual sex with anonymous partners under the effect of drugs and with multiple partners may be interpreted as a brief moment of "relaxation" and escape from reality 22,23 .

The search, even though hedonistic, also involves acknowledging limits 24 and balancing risk reduction strategies, although of dubious effectiveness.Thus, the search for physical pleasure may be a response to a prolonged period of stress and isolation, in which mentally exhausted persons seek to cope with an "invisible" danger 25 .In the attempt to release these tensions, the search for psychoactive substances ref ects the desire for pleasure and for release from worries/search for control 26 .

Historically, periods of mandatory quarantine have been met with resistance, especially among the male population, since the transgression of norms may be associated with the social construction of masculinities, which may also influence affective and sexual standards 27 .

In fact, t e pandemic has caused an abrupt break in persons' social interaction, jeopardizing daily flows, practices, and affective and sexual encounters.Both in Brazil and Portugal, no educational and/or instructive measures have been taken by the governments to present alternative strategies for dealing with the repercussions on sexual and repr

uctive heal
h imposed by social isolation, unlike other countries such as Argentina and the United States, which have published official documents with orientation and recommendations on alternative sexual practices including masturbation, virtual sex, sexting (posting erotic messages), besides orientation on preventive measures during sexual prac

ce 27 .
Persons that practice chemsex associate it with a significant improvement in the quality of sex, due to the decreased inhibition and increased sexual arousal and pleasure.When drugs are combined with sex sessions, the latter can be prolonged and in