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


Abstract
The aim of this study 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 isolation (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.

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 transmission 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 support, 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 the 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 dynamically 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).
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 from 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 based on previous 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 instrument was divided into four sections 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 presented 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).

Discussion
This was the first study so far to analyze 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 false 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 have 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 results 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 this 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 showed 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 with 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 population 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 reflects 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, the 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 reproductive health 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 practice 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 involve multiple partners and more challenging sexual practices such as fisting and double penetration 28 .Corroborating this assertion, menáge or group sex was an important factor associated with engaging in chemsex.This finding becomes even more Cad.Saúde Pública 2020; 36 (12):e00202420 problematic due to the juxtaposition of exposures, since the use of drugs can decrease the perception of risk in MSM, reducing adherence to preventive measures against STIs, while meeting multiple persons with different histories of exposure to SARS-CoV-2 in the same place for long periods of time can increase the odds of infection with the virus 29 .
The use of technologies to facilitate casual encounters may also play an important role in this practice, since it easily, anonymously, and conveniently allows MSM to align their desires and practices with those of users in the codes for posts on social networks, such as CF (chill fun) or the use of emojis (snowflakes, ice cream, lightning) as "codes" known by the MSM community for an invitation to chemsex practice 30 .
The apps, as environments for MSM sociability, can increase the exposure to STIs.They can also be viewed as platforms for harm reduction interventions, serving as ambivalent tools for risk and protection 10,11,12 .These strategies are even more important in the Brazilian scenario when compared to the Portuguese, since their implementation in Portugal is seen as a model even in the European Union, while in Brazil there is a prevailing prohibitionist climate that limits the activities in education and prevention focused on sexual life in general.
Given the MSM population's needs and situation of vulnerability (historically to STIs and now to SARS-CoV-2 infection), it is essential to develop risk reduction strategies and policies targeted to these men in order to educate them and emphasize the importance of healthcare.We need to understand the reasons leading MSM to expose themselves to these situations, even in crucial moments like the present.Publicizing information on sexual practice and on the less harmful use of drugs with a smaller group of people, or at least with less turnover of sex partners, and encouraging combined prevention of STIs and COVID-19 can be effective actions in the current pandemic.
We acknowledge a series of limitations in this study.The first is that it was conducted in countries with major cultural, economic, and population differences.The second limitation is the crosssectional design, which did not allow assessing causality or whether the on-going social isolation increased the occurrence of risky sexual practices for STIs and COVID-19.
Finally, the online data collection method was based on self-reported information by occasional sampling, and although the study was conducted in all regions of both countries, the lack of a sample calculation hinders the data's generalization and may have limited the sample to MSM who are more familiar with the use of internet tools.

Conclusion
The occurrence of chemsex was high, especially in Brazil, where the proposed social isolation had not raised the awareness of MSM for adherence, given the option for casual sex.Evidently, the search for pleasure proved more relevant than the proposed protective measures against COVID-19, thus leaving MSM more exposed to the disease.

Table 2
Bivariate and multivariate analysis of factors associated with chemsex during social isolation.Brazil and Portugal, 2020.