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針具交換服務可以傳遞藥愛之減害嗎?

針具交換服務可以傳遞藥愛之減害嗎?

Chemsex 不是一個新現象,但它是物質使用障礙治療提供者的某些……

娜塔莉.戴維斯 / 2022 年 2 月 25 日 / 成癮研究協會 (SSA) / 財團法人台灣紅絲帶基金會編譯

 

Chemsex 並不是一個新現象,但它是物質使用障礙治療提供者和政策制定者某些正在尋求努力解決的問題。 Natalie Davies 檢查了最近發表在《藥物:教育、預防和政策》上的關於主流針具交換服務是否易於減少藥愛危害的研究。

“Chemsex”是在性行為之前或期間使用藥物——通常是為了增強或改變體驗。對於政策制定者和醫藥從業者而言,藥愛性行為會帶來以下風險:(1)吸毒,(2)性活動,以及(3)性吸毒的獨特背景。當然,對於從事藥愛性行為的人來說,這三個因素——吸毒、性和性吸毒的獨特背景——也是潛在的快樂來源。

英國政府的 2017 年藥物策略將藥愛性行為稱為「不斷發展的或新興的威脅」——指的是危害鮮為人知的新型影響精神物質的威脅,尤其是對最常從事藥愛性行為的次文化。 2021 年發布的最新藥物策略也提到了這一現象,稱圍繞藥愛問題的治療和支持需要額外的資金。

chemsex 有幾種不同的定義,但其中大多數在人口中那些族群、環境以及與行為相關的藥物使用類型上描述為零,例如:

馬修·彼得·希伯特 (Matthew Peter Hibbert) 及其同事在「對 LGBT 人群於性愛中藥物使用和性健康結果的敘述性系統評價」中表示,「Chemsex 是一種特殊形式的性愛中藥物使用 (sexualised drug use, SDU),是男男性行為者 (MSM) 中新興的公共衛生問題」。

「[Chemsex 涉及] 在藥物影響下從事性活動。 [它] 通常在一次場合中涉及集體性行為或大量性夥伴」。 Chemsex 研究的 Adam Bourne 及其同事表示。

「chemsex 一詞是指男同性戀和雙性戀男性之間的集體性接觸,其中消費了娛樂性藥物 GHB/GBL、4-甲基甲基卡西酮 (Mephedrone)和結晶的甲基安非他命」。傑米·哈基姆(Jamie Hakim)在「藥愛的興起:新自由主義倫敦的酷兒集體親密關係」中表示。

「‘Chemsex’是在計畫的性事件之前或期間使用藥物來促進、增強、延長和維持體驗」。 Steven Maxwell 及其同事在「男男性行為者中的藥愛性行為:文獻系統回顧」中表示。

「Chemsex 是指在計畫的性活動之前或期間使用藥物來維持、增強、解除抑制或促進體驗的術語」。英國政府 2017 年藥物策略。

目前沒有針對 chemsex 的最佳實踐工具套組或「黃金標準」之介入措施;然而,針具和注射器交換計畫——存在於英國各地的城市——可能是提供減害建議和資源的便利場所。 Claire Smiles 及其同事在 2022 年進行的一項研究涉及與英國兩個城市的 17 名針具交換工作人員交談,了解他們對藥愛的了解和想法,以及他們減少這群藥癮者傷害的能力。

一般性和特殊性

研究中的從業者沒有全面的藥愛知識。正如所料,許多人都是減害的專家,但研究發現這並不總是能轉化為對藥愛性行為的危害和適當反應的理解。例如:

原始文章:「針頭交換從業者為藥愛提供減害建議的說明:對政策和實踐的影響」。透過Claire Smiles和其同事。發表於《毒品:教育、預防和政策》(2022 年)。

• 大多數人可以給出藥愛性行為的一般定義,但不熟悉藥愛性行為中常用的藥物類型,並且沒有太多與藥愛性行為最相關的人群(即男男性行為者)工作的經驗

• 大多數人知道在性愛藥物使用的背景下討論快感可能是減害的機會,但表示他們更願意談論風險而不是快感

挑戰之一是「藥愛場景」一直在發生變化,特別是隨著新的影響精神物質的出現。例如,2016 年 1 月至 6 月在曼徹斯特(英格蘭)進行的早期研究發現,人們已經從使用搖頭丸和可卡因等物質轉變為使用“slamming”(用於描述靜脈注射的術語)等高風險行為注射甲基安非他命或4-甲基甲基卡西酮。

在「主流」服務中工作

倫敦和英格蘭北部服務機構的從業人員表示,男男性行為者中減害的需求尚未得到滿足;這一人群中很少有男性參加針具交換服務。

研究中一個有趣的發現是,一些從業者確信男同性戀者參加過針具交換服務,但沒有明確地說明他們吸毒的背景。如果屬實,這可能意味著將從藥愛減害中受益的男性正在走入治療服務的大門,但卻無法獲得他們需要的全部訊息和建議。

「……絕對可以保證人們已經透過服務,他們可能在某個時候或仍在從事藥愛性行為並且永遠不會透露它」。

從業者表示,該研究中的許多「主流」或「一般」之服務旨在為依賴阿片類藥物、興奮劑和酒精的人提供介入措施,這可以被解讀為既是一項解釋也是一項「我的過錯」,導致了為從事藥愛的人提供服務方面上的差距:

當很少有人參加他們的針具交換以獲得這種類型的支持時,則從業者如何能發展出藥愛方面的專業知識呢?當雙方都認為該服務不適合他們時,為什麼人們還會參加他們的針具交換以獲得有關之藥愛的建議呢?

我們可以補充一下先前的研究,該研究顯示從事藥愛性行為的男性可能會將自己視為傳統的毒品和酒精服務「顧客」之外。與傳統的注射藥癮人群相比,許多從事藥愛性行為的男性是全職工作,需要更靈活和更長的開放時間才能獲得減害的服務。

專題研究中的一些服務提供從業者表示,他們嚴重依賴 LGBTQ 專家服務,這些服務「更有能力為從事藥愛性行為的 MSM 提供針具交換和減害的建議」。其他人則表示,他們已制定策略以更加明顯地包容 LGBTQ 社區——例如,通過佩戴彩虹掛繩的工作人員,並在等候區放置旗幟和海報。

曼徹斯特的研究建議,減害服務應考慮多種策略,讓邊緣化的藥物使用者社區參與治療和支持。這可能包括有針對性的外展,在藥物使用流行的社區或環境中定位服務(例如,在 LGBTQ 社區的中心設立針具交換服務),以及嘗試新的營銷策略。

了解為什麼邊緣化人群的健康狀況可能不佳

英國公共衛生部確定了三個不同但重疊的領域,男男性行為者在這些領域中承擔著不成比例的健康不良負擔:(1)性健康和愛滋病毒狀況; (2) 心理健康; (3) 使用酒精、藥物和菸草。藥愛就是這種重疊的一個例子,它有可能增加對男男性行為者的傷害,例如透過促進性傳播之感染和血液傳播病毒的傳播。

特色研究檢查了針具交換服務是否可以為從事藥愛性行為的人提供適當或特定的減害服務,並且它是從一小群從業者的角度進行的。這只是一個重要的觀點,需要結合對從事藥愛性行為的人的思想、需求和背景的研究。

資源的設計藉由男男性行為者來設計並為其所用

在與男性發生性關係的男性中,從事藥愛性行為的原因可能包括想要減少抑制、增加快感、促進持續性興奮、與性伴侶建立即時融洽的感覺,以及管理缺乏自信等負面情緒,自尊、內化的同性戀恐懼症和對愛滋病毒狀況的污名。

當認知同性戀和雙性戀男性從事藥愛性行為的複雜原因,並且可能會繼續這樣做時,由男男性行為者設計並為其所用的訊息資源,可能有助於解決與藥愛性行為相關的危害。這包括:

• 「藥愛急救」,「加入了一個由機構資源和『在同志族群中具有口碑且從事藥愛的人』的減害生態系統」,並且是「酷兒男性中『長期激進主義歷史的一部分……會分享信息和故事,以及互相關注者』」。

• “Slamming”,改編自開創性的荷蘭出版物,基於人種學研究,探索在“Slamming”之派對上使用注射藥物之情況,以及有效的減害策略。

Claire Smiles 及其同事的研究顯示,成癮治療服務仍然是為使用更傳統類型藥物(阿片類藥物、可卡因等)的人設計的。雖然這可能仍然準確地描述了物質使用問題上的主要人群,但應該更多地承認邊緣化和少數之群體,以及新的影響精神物質對不同群體治療需求上的影響。這項研究側重於少數針具交換服務,強調了成癮治療服務的一些潛在局限性,新的政府投資可能有助於解決這些問題。

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這篇文章中表達的觀點反映了作者的觀點,並不一定代表成癮研究協會(SSA) 的觀點或官方立場。

成癮研究協會 (SSA)不認可或保證外部來源或鏈接中訊息的準確性,並且對因使用此類訊息而產生的任何後果不承擔任何責任或義務。

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Can needle exchange services deliver chemsex harm reduction?

Chemsex isn’t a new phenomenon, but it is something that substance use treatment providers…

25 February 2022 

Chemsex isn’t a new phenomenon, but it is something that substance use treatment providers and policymakers are newly grappling with. Natalie Davies examines research recently published in Drugs: Education, Prevention and Policy about whether mainstream needle exchange services are apt to deliver chemsex harm reduction.  

‘Chemsex’ is the use of drugs before or during sex – typically to enhance or change the experience. For policymakers and practitioners, chemsex poses risks from (1) the drug use, (2) the sexual activity, and (3) the unique context of sexualised drug use. Of course, for people who engage in chemsex, those three factors – drug use, sex, and the unique context of sexualised drug use – are also potential sources of pleasure.

The UK Government’s 2017 Drug Strategy talked about chemsex as an ‘evolving or emerging threat’ – referring to the threat of new psychoactive substances with lesser known harms, particularly to subcultures that most frequently engage in chemsex. The most recent Drug Strategy, published in 2021, also made reference to the phenomenon, saying that additional funding was needed for treatment and support around the issue of chemsex.

There are several different definitions of chemsex, most of which zero in on the groups of people, circumstances, and types of drugs that tend to be associated with the practice, for example:

“Chemsex is a specific form of sexualised drug use (SDU) that is an emerging public health issue among men who have sex with men (MSM).” Matthew Peter Hibbert and colleagues in “A narrative systematic review of sexualised drug use and sexual health outcomes among LGBT people”

“[Chemsex involves] engaging in sexual activities while under the influence of drugs. [It] often involves group sex or a high number of partners in one session.” Adam Bourne and colleagues for The Chemsex Study

“The term chemsex refers to group sexual encounters between gay and bisexual men in which the recreational drugs GHB/GBL, mephedrone and crystallized methamphetamine are consumed.” Jamie Hakim in “The rise of chemsex: queering collective intimacy in neoliberal London”

“‘Chemsex’ is the use of drugs before or during planned sexual events to facilitate, enhance, prolong and sustain the experience.” Steven Maxwell and colleagues in “Chemsex behaviours among men who have sex with men: A systematic review of the literature”

“Chemsex is a term for the use of drugs before or during planned sexual activity to sustain, enhance, disinhibit or facilitate the experience.” UK Government’s 2017 Drug Strategy

There are currently no best practice toolkits or ‘gold standard’ interventions for chemsex; however, needle and syringe programmes – which exist in cities across the UK – may be convenient sites for delivering harm reduction advice and resources. A 2022 study by Claire Smiles and colleagues involved talking to 17 needle exchange workers in two UK cities about what they knew and thought about chemsex, and their capacity to reduce harm among this group of people who use drugs.

Generalities and specifics

Practitioners in the study did not have a comprehensive knowledge of chemsex. As might be expected, many were experts in harm reduction, but the study found that this did not always translate into an understanding of the harms of, and suitable responses to, chemsex. For example:

Original article: Needle exchange practitioners accounts of delivering harm reduction advice for chemsex: implications for policy and practice. By Claire Smiles and colleagues. Published in Drugs: Education, Prevention and Policy (2022).

•most could give a general definition of chemsex but were not familiar with the types of drugs commonly used in chemsex and did not have much experience working with populations most associated with chemsex (i.e. men who have sex with men)

•most knew that discussing pleasure in the context of sexualised drug use could be an opportunity to reduce harm but said they felt more comfortable talking about risks than pleasure

One of the challenges is that the ‘chemsex scene’ has been subject to changes, particularly with the advent of new psychoactive substances. For example, earlier research from Manchester (England) between January and June 2016 found that there had been a shift from the use of substances such as ecstasy and cocaine, to higher-risk practices such as ‘slamming’ (a term used to describe intravenous injection) crystal methamphetamine or mephedrone.

Working in ‘mainstream’ services

Practitioners from services in London and the North of England suggested that there was an unmet need for harm reduction among men who have sex with men; very few men from this population attended needle exchange services.

An interesting finding in the study was that some practitioners were certain that gay men had attended needle exchange services but had not been explicit about the context of their drug use. If true, this could mean that men who would benefit from chemsex harm reduction were walking through the doors of treatment services, but were not able to access the full range of information and advice that they needed.

“…It’s absolutely guaranteed that people have come through service, who might have at some point or still be engaged in chemsex and will never have disclosed it.”

Practitioners said that many of the ‘mainstream’ or ‘general’ services in the study had been designed to deliver interventions to people dependent on opioids, stimulants, and alcohol, which could be read as both an explanation and a ‘mea culpa’ for the gaps in service provision for people engaged in chemsex:

How could practitioners develop expertise in chemsex when few people attended their needle exchange for this type of support?

Why would people attend their needle exchange for advice about chemsex when there was a perception on both sides that the service was not for them?

We can add to this prior research which suggested that men who engage in chemsex may see themselves outside the traditional ‘clientele’ of drug and alcohol services. Compared with traditional populations of people who inject drugs, many men who engage in chemsex are in full-time employment and require more flexible and extended opening times in order to access harm reduction services.

Some practitioners in the featured study indicated that they relied heavily on LGBTQ specialist services, who were “better positioned to offer needle exchange and harm reduction advice for MSM who engage in chemsex”. Others said that they had put strategies in place to be more visibly inclusive to the LGBTQ community – for example, through staff wearing rainbow lanyards, and placing flags and posters in the waiting area.

Research from Manchester recommended that harm reduction services should consider a mixture of strategies to engage marginalised communities of people who use drugs with treatment and support. This could include targeted outreach, locating services within communities or contexts where drug use is prevalent (e.g. siting a needle exchange service at the heart of an LGBTQ community), and trying new marketing strategies.

Understanding why marginalised populations may have poor health outcomes

Public Health England identified three distinct but overlapping areas in which men who have sex with men bear a disproportionate burden of ill-health: (1) sexual health and HIV status; (2) mental health; and (3) the use of alcohol, drugs, and tobacco. Chemsex is an example of this overlap, and has the potential to increase harms to men who have sex with men, for example by contributing to the spread of sexually transmitted infections and blood-borne viruses.

The featured research examined whether needle exchange services could offer appropriate or specific harm reduction to people engaged in chemsex, and it did so from the perspective of a small group of practitioners. This is just one important perspective and needs to be combined with research into the thoughts, needs and contexts of people who engage in chemsex.

Drawing on resources designed by and for men who have sex with men

Among men who have sex with men, reasons for engaging in chemsex may include wanting to reduce inhibitions, increase pleasure, facilitate sustained arousal, induce a feeling of instant rapport with sexual partners, as well as manage negative feelings such as a lack of confidence, self-esteem, internalised homophobia, and stigma about HIV status.

Information resources designed by, with, and for men who have sex with men may help address harms associated with chemsex, while acknowledging the complex reasons gay and bisexual men practice chemsex and will probably continue to do so. This includes:

•“Chemsex First Aid”, which “joins a harm reduction ecosystem of both institutional resources and the ‘word-of-mouth amongst guys that engage in chemsex’”, and is “part of queer men’s ‘long history of activism…of sharing information and stories, and of looking out for each other’”.

•“Slamming”, which is adapted from a groundbreaking Dutch publication, and based on ethnographic research exploring injecting drug use at slamming parties, and effective harm reduction strategies.

The research from Claire Smiles and colleagues indicated that addiction treatment services remain designed for people who use more traditional types of drugs (opiates, cocaine etc). Whilst this may still accurately describe the main population of people with substance use problems, there should be more acknowledgement of marginalised and minority communities, as well as the impact of new psychoactive substances on the treatment needs of different groups. This research, which focused on a small number of needle exchange services, highlights some of the potential limitations of addiction treatment services, which new government investment might be able to help address.

by Natalie Davies

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The opinions expressed in this post reflect the views of the author(s) and do not necessarily represent the opinions or official positions of the SSA.

The SSA does not endorse or guarantee the accuracy of the information in external sources or links and accepts no responsibility or liability for any consequences arising from the use of such information.

 

 

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