Needs and experiences of people practising chemsex with support services: toward chemsex-affirmative interventions

3.1 Sample composition

The majority of people in the study self-identify as cisgender men (83.9%). Other participants self-identify as non-binary (6.5%), queer (4.8%), trans (1.6%), two-spirit (1.6%), or are questioning their gender identity (1.6%). As for sexual orientation, 81.3% of the participants identify as gay, 7.8% as bisexual, 7.8% as pansexual, and 3.1% identify as queer. The age of the participants was also diverse, ranging from 23 to 75 years old, with a mean age of 44. In terms of cultural diversity, 15.6% identified themselves as other than Québécois or Canadian in cultural or ethnic origin. Of the entire sample, 14.1% of the participants were born outside Canada. In terms of employment status, it should be noted that 32.8% of participants were without a job at the time of the interview.

3.2 The needs of people practising chemsex

The participants identified several needs requiring support resources, in particular addiction services. While the needs varied from one participant to the other, based on their substance use trajectory, their objectives around substance use and chemsex, and their life history, the needs expressed can nevertheless be grouped into two main categories: intervention needs and community needs.

In terms of intervention needs, the participants stressed the importance of having access to a safe space for receiving adapted services. Above all, this space must be supported by a health and social services professional, a peer helper or a fellowship sponsor, who is able to listen, and be respectful and understanding about their chemsex experiences. This sense of safety can also be bolstered by the resource offering a flexible structure that respects the self-determination of the person seeking help. The following participant stressed the importance of offering a safe intervention framework by sharing their experience with an organization that address sexual and gender diversity:

It went really well. I was welcomed and the (worker) was really great with me. I felt like I was being listened to, heard, understood, respected. It really did me a lot of good (…). I never felt judged by the workers at (community organization addressing sexual and gender diversity). For sure this is the basis, feeling like when you talk about something, the person understands. Someone who’s not destabilized, someone who, above all, is respectful, empathetic, who gives you the space to talk and express yourself. —Liam, 47 years old, identifies as cisgender and gay.

Of course, the participants talked about more direct intervention needs as well. They are looking for support around their methamphetamine use and chemsex. Some of them mentioned the importance of responding to primary needs. The need for rest predominated for several participants, especially following a period of intense and prolonged substance use. Responding to this need is essential, specifically in living environments and community resources, as it can pave the way to better adherence to the structure and interventions proposed by a resource. One participant highlighted this need as follows:

I needed to go rest somewhere else. I needed to get out of my environment, to not feel ashamed about what was happening to me, to just relax, and take care of myself. —Owen, 35 years old, identifies as cisgender and gay.

Several participants also raised the need to talk to professionals about issues specific to people who practise chemsex, in particular in terms of sexual health. However, this can sometimes depend on having been given prior information regarding the effects and repercussions associated with methamphetamine and chemsex, yet the participants were unaware of reliable information resources. Overall, many of the participants identified psychological support as an intervention priority. There were distinctions in terms of the type of intervention wanted. Some of the participants stated that they preferred more concrete interventions, specifically, an assessment of their substance use and chemsex experiences that would lead to the regular availability of more tangible tools and resources to respond to their objectives regarding sexualized substance use and other dimensions of their lives. Other participants talked about the need for interventions that use a more humanist approach, that is, based on introspection about the causes associated with practising chemsex, as well as an exploration of the emotions experienced during chemsex. This participant talked about the balance between his needs and interventions involving concrete tools:

My need was twofold: I wanted to maintain my abstinence and I wanted guidance on if I could return to work, or if I should return to school. (The public addiction treatment centre) offered both. The morning looked at the helping relationship to maintain abstinence from substance use, and the afternoon focused on access to work. We did tests, we did research, it was really focused on a return to work or to studies. The two combined was very appealing, very motivating. (…) It was perfect for where I was in my process. —Adam, 59 years old, identifies as cisgender and gay.

Most of the people we interviewed expressed a need for community. In order to better respond to this need, several participants pointed to the importance of being able to integrate into a community, particularly one in which people share a similar chemsex experience. For several participants, the development of community ties and socialization with people in recovery was essential. These ties represent an opportunity for them to express themselves and talk about their chemsex experiences, but also their own perspectives on recovery. Moreover, some of them pointed to the importance of developing relationships that do not revolve around psychoactive substance use and sexuality, as expressed by one of the participants:

And then there’s something important after crystal use. Our only interactions, in any case for me, my only interactions with gay men, or men who have sex with men, is through sex, through substance use. Developing ties with the same demographic of people, on a basis other than sex or substance use (…) it’s important to learn that. —William, 25 years old, identifies as queer and bisexual.

The participants manage to meet some of their community needs through a community with a chemsex experience. This community provides a space to reflect on substance use by listening to other people’s experiences and perspectives, and by revealing their true selves to other members of the community. Indeed, according to the participants, sharing a testimonial with a community in recovery is a way to give back to your community. Participants also stressed the importance of community support for inspiration, motivation and, above all, hope.

3.3 Experiences with support services among people practising chemsex

People who practise chemsex and are seeking support or a response to specific needs can turn to various resources. Many of the participants in this research project had received services from public, private or community addiction treatment centres; mental health and sexual health community organizations; organizations that address sexual and gender diversity; sexual health clinics; and housing resources. The participants reported that these resources provided only a partial response to their needs. The service trajectory of people who practise chemsex appears complex. In this section, we look at this community’s experiences with support resources, focusing on the resources that responded to their needs as well as those that fell short.

Firstly, the actual organization of services is reflected in the experiences of people seeking support, particularly with respect to accessibility. A few participants felt that it was generally fast and easy to access resources, particularly when another professional referred them to a resource adapted to their needs, such as a family physician. However, many others reported having difficulties accessing support services. The current saturation of resources, particularly those addressing addiction, and the resulting waiting lists, is one of the major causes of these difficulties. Moreover, the cost of private therapies, as well as the dearth of resources in certain regions, particularly outside urban centres, complicates access to support services. Several participants stated that they had to jump through many hoops and do a lot of research to receive support adapted to the practice of chemsex. The lack of information on resources that could provide them with support negatively affects accessibility, and also impacts professionals who would like to refer someone practising chemsex to a more specialized resource.

Some of the participants also deplored having to repeat a major part of the support process once they had accessed an additional or new resource. They explained how demanding it is to once again explain their substance use and chemsex trajectory, especially because they have yet to establish a relationship of trust with that professional. Some of the participants stated there should be collaboration between the different resources involved as well as a system navigator to better respond to the plurality of their needs.

I had a worker who was really incredible. She followed me. She strongly advised me to get therapy. (…) It wasn’t a therapy centre, as such, but a rehabilitation, reintegration centre, for abstinence, to fight addiction. It was really an appropriate therapy centre for me, for my problem. But she still followed me during my entire process, which involved 11 centres or places I went to over a period of just under a year. I was in contact with her. I’d go see her and she’d come see me in the various places I was. (…) I had permission to go see her at her office, or she’d come see me. So, I’m really indebted to the (addiction treatment community centre). —Oliver, 56 years old, identifies as cisgender and pansexual.

The above-mentioned factors are not the only ones that affect service accessibility. The fear of being stigmatized or judged by professionals, or the other users of a resource, also constitutes a considerable barrier to service accessibility. Participants anticipate stigmatization with regard to their methamphetamine use and the associated sexual practices, and, more generally, their sexual orientation. One of the participants talked about their fear of being seen as a sex addict:

There are (professionals) I didn’t feel comfortable talking to, that they’d see me as imperfect, trash, an addict, like a dirty sex addict with no class in some ways. I don’t think the workers actually did judge me. But it was a space that didn’t allow me to be comfortable enough to show all my colours. —Grayson, 32 years old, identifies as cisgender and gay.

We have already mentioned the need to be welcomed and understood by the professionals working in support services. Many of the participants reported that the posture adopted by some workers made it possible to respond to this need, because they showed an acceptance and understanding of their experiences and the issues specific to chemsex. A few participants stated that a worker’s understanding must go beyond the experience of chemsex, by considering the person as a whole, from an intersectional perspective. This posture is supported by a horizontal approach to intervention, in other words, supporting the person’s self-determination with respect to their sexualized use of methamphetamine.

It was a really humanist approach. She was truly focused on my emotions, my needs. She set all the paperwork aside, she didn’t use it, at my request. Drug use in itself was never, ever, the issue. We talked about what made me use, my suffering in my relationships with people. It was extraordinary. —Noah, 55 years old, identifies as queer.

However, other participants talked about intervention experiences in which the professional did not assume this kind of posture. Instead, the professional would sometimes assume the posture of the expert in the situation. In this context, the participants expressed a sense of depersonalization of the services offered, and that their needs were no longer fully taken into consideration by the professionals. In fact, they were sometimes insensitive to the specific issues being experienced by the person seeking support. According to these participants, when professionals assume the posture of expert, their interventions are solely based on the methamphetamine addiction, without taking into account the person’s individual characteristics, particularly their interests and their recovery goals. This professional posture is also associated with an alarmist discourse on methamphetamine use and chemsex, hindering the possibility of opening up about drug use experiences, and receiving adapted support. Here, a participant talked about developing a sense of blame as a result of a sexologist’s alarmist discourse:

I went to see a gay sexologist, and he told me: “crystal meth is the monster, the devil.” I was so terrified of seeing my sexologist, because I was blaming myself so much. —Benjamin, 40 years old, identifies as cisgender and gay.

Several experiences that responded to the specific needs of people who practise chemsex were the result of a welcoming posture. With respect to psychological support, some of the participants particularly appreciated receiving tools and practical advice specific to sexuality and methamphetamine use, tools that were suitable to the person’s recovery goals. This enabled them to engage in a harm reduction process, or in complete abstinence from sexualized substance use. Adapted tools based on the person’s goals seem to be essential to a process of self-determination. A few participants talked about concrete tools that responded to their specific needs. In particular, these tools enabled them to be more aware of methamphetamine use, by establishing a weekly quantity. Other participants talked about tools that specifically address sexuality, such as practical advice for developing a healthier relationship to pornography. Along the same lines, those seeking interventions focused on exploring the causes associated with sexualized substance use based on history of use but also on emotions, were more comfortable pursuing this process when the professionals they met adopted a welcoming, open and understanding posture.

Beyond psychological support, experiences with support services responded to some of the participants’ other needs. Interventions that take into account sexual health are important for people practising chemsex. The respondents reported that rapid access to testing for BBSTIs, as well as the possibility of obtaining the pre-exposure prophylaxis (PrEP) against HIV and the associated follow-up, are also an essential aspect of responding to their sexual health needs. Moreover, those actively using methamphetamine appreciate that certain resources provide safe drug use supplies that are also adapted to the different methods of methamphetamine use. Moreover, particularly in residential addiction treatment centres, several participants appreciated the workers’ flexibility in terms of the structure established in the resource, in order to better respond to the need for rest at the beginning of the recovery process. In the following excerpt, the participant talks about how a professional’s flexibility, in the context of a group intervention, responded to his immediate need:

And when I was in the workshop, I was sleeping standing up. I was at the corner of the table, sleeping there. The workshop leader said “Oh (Owen), maybe you’d like to just go rest in your room, that’s fine. You don’t have to do the workshop if you’re sleeping standing up!” They sent me back to my room to sleep. It was wonderful. I just needed to rest. —Owen, 35 years old, identifies as cisgender and gay.

According to the participants, peer helpers, people who have had a life trajectory that has involved chemsex, seem particularly well equipped to provide a suitable response to the needs of people seeking support. With their lived experience of chemsex, peer helpers have an excellent understanding of the issues and potential repercussions of methamphetamine use in a sexual context. The participants expressed feeling comfortable reflecting and talking about their experiences in the context of chemsex, with all the nuance and complexity involved. Comparing this with talking to a professional sexologist, this participant highlighted the relevance of the approach used by peer helpers:

“I feel that, it sounds so crazy because I love my sexologist but there’s something I was getting from speaking with a previous crystal meth user that was in the PnP scene that I saw, that I knew that he had a healthy relationship with drugs and stuff like that umm well not my counsellor necessarily, but like I knew that they were kind of like, sex positive, they didn’t say, prescribe everyone that they were addicts and they had to quit or something like that.” —Mateo, 23 years old, questioning their gender identity, identifies as gay

Unlike the above experiences, several participants were faced with a professional who did not understand their reality, particularly with respect to the cultural elements associated with chemsex, but to other aspects as well. Several participants talked about the professional’s ignorance of methamphetamine use, the culture of sexual diverse men, and the sexual health of men having sex with men and non-binary people. According to the participants, workers’ incomprehension of their trajectory can lead to the stigmatization and judgment of people practising chemsex. Therefore, while they would like to receive support, some of them prefer to keep quiet about their sexuality, even though it is intimately linked to their methamphetamine use. Moreover, in the face of this incomprehension, some of them have found themselves in the position of having to educate professionals about methamphetamine use and chemsex.

In this excerpt, the participant talks about a worker’s incomprehension, and stresses the importance of being aware of elements specific to sexual diversity in order to be able to intervene in a way that answers the needs of the communities concerned:

I think that, more often, I felt like I shouldn’t say anything. That it was better that way, so that I wouldn’t be judged. I think it’s more about being ignorant about the problem and the milieu. I don’t think the people were there to judge. (…) But, gay, bisexual, whatever sexual orientation, other than straight in the street, is another story. It’s a whole other world. And you need to be aware of that. —Oliver, 56 years old, identifies as cisgender and pansexual.

The above results are transversal to all of the intervention contexts and resources used by the participants. Now, we will focus more specifically on the experiences reported by the participants in group interventions and living environments, as well as with the Crystal Meth Anonymous fellowship.

3.4 Avenues for reflection to better meet the needs of people who practise chemsex

Based on their experiences with support resources, many of the participants offered possible solutions for improving interventions for people practising chemsex. More specifically, these suggestions focused on raising awareness of the realities of people who practise chemsex, access and continuum of care, and diversifying the resources.

For many of the participants, a good place to start is with interventions at the macrosocial level. In particular, they pointed to the importance of raising awareness among professionals of the specific realities and issues facing people who identify as sexual diverse or gender diverse, in order to deconstruct the ever-present heteronormativity and cisnormativity of support resources. Several of the participants also stressed the importance of destigmatizing methamphetamine use by offering specific training to health and social services professionals on this psychoactive substance, as well as on chemsex. For the participants, raising professionals’ awareness of the practice of chemsex was important so that they could better understand the chemsex subculture. This would allow them to be better informed of the social and emotional dimensions of chemsex, as well as sexual practices in a context of sexualized substance use. Moreover, raising workers’ awareness of methamphetamine use would enable them to provide accurate, non-alarmist information about this psychoactive substance, particularly with respect to the effects and potential repercussions of methamphetamine. In short, specific training on chemsex would provide workers with the knowledge needed to maintain a welcoming and understanding posture when people practising chemsex come in search of support. Some of the participants stressed the importance of giving voice to people who have practised chemsex, and having members of this community lead projects, in order to raise awareness among professionals of their specific trajectories and life experiences.

The participants pointed to the importance of rapid and easy access to support resources. They discussed the relevance of developing free services within the public network adapted to the needs of people practising chemsex. On this point, they stressed the geographic dimension and that these services should be accessible everywhere on the territory, not just in urban centres. Some of the participants suggested democratizing teleconsultations as an interesting alternative, because it would provide access to people living in the regions, in a context in which most of the resources are concentrated in Montreal. This did not take away from the importance of making sure resources adapted to people practising chemsex are available everywhere on the territory. The participants reported that teleconsultation can, however, make certain interventions more difficult, particularly when it involves sharing one’s substance use trajectory and related emotional experiences, in all its nuance. Moreover, the participants pointed out that people practising chemsex are often unaware of the resources available. It is important to publicize them in spaces used by people who practise chemsex, such as bars, saunas and sexual health clinics.

The participants made various recommendations to improve the organization of services for people practising chemsex. Firstly, given the plurality of their needs, they suggested as one possible solution the development of resources led by interdisciplinary teams. They said that a single professional cannot respond to all of their needs, and that close collaboration among professionals in sexology, psychology, social work, medicine and psychiatry could be key to receiving adequate support in their recovery process. The participants stressed the inclusion of peer helpers in these multidisciplinary teams, as their experiences can significantly add to the interventions led by the professionals. The participants believe peer helpers who have had chemsex experiences make a specific contribution that cannot be replaced by external knowledge, although this too is important to the development of resources adapted to this community.

The participants also talked about the importance of service continuity, stating that they “have no desire to have to retell (their) story.” For them, service continuity is all the more important during a transition period, for example, when leaving a therapy centre. More concretely, service continuity could include a system navigator offering varying degrees of follow-up, based on the needs and objectives of the person seeking support.

Some of the participants pointed to the relevance of receiving spontaneous support, from a harm reduction perspective. For example, it would be beneficial to set up a specialized telephone helpline, a messaging service or a mobile app for people practising chemsex, particularly for support in making informed decisions about psychoactive substance use associated with chemsex.

While Crystal Meth Anonymous has played an important role in the recovery of many participants, others find that their approach does not correspond to their needs. For them, it is necessary to develop community support groups where it would be possible to share their methamphetamine use trajectory in greater depth. The following excerpt summarizes the relevance of these different approaches in the context of community intervention:

I think it would maybe take two approaches. I think that there should be a variety of choices. Maybe a support group approach for those who want to completely stop, who no longer want to have anything to do with it, who are counting the weeks, months, years, a little like Alcoholics Anonymous. But also, a group of people who come together just to talk about what crystal is, why I take it, what I experience. I’m not saying whether or not I want to stop. I just want to talk about it, hear others, discuss, and maybe I’ll even meet people who are using in that group, but everyone is on the same path, saying “We’re raising questions about our use.” —Maverick, 47 years old, identifies as cisgender and pansexual.