Prevention in Focus

Spring 2019 

Party and play in Canada: What is its impact on gay men’s health?

By Zak Knowles

Some gay, bisexual and other men who have sex with men (gbMSM) use drugs specifically to facilitate or enhance sexual encounters. This phenomenon is commonly called party and play (PnP). There are a variety of reasons why gbMSM participate in PnP. In this article we discuss the drugs most commonly used for PnP in Canada, how common PnP is in Canada, the risks of PnP related to sexually transmitted and blood-borne infections (STBBIs), and how service providers can provide support for men who PnP in their communities.

What is PnP?

PnP is the use of certain drugs by some gbMSM before or during sex specifically to facilitate, sustain or enhance sexual encounters.1 This phenomenon is also known as chemsex.

Participation in PnP has been made easier by the use of online dating sites and hook-up apps that allow gbMSM to quickly locate men interested in PnP in their area.2 Men use certain code words (such as chems, faves, party, blowing clouds) in their online profiles to indicate they want to get together to PnP, either one on one or in a group. PnP may take place at events held in public venues, such as bathhouses and premises with backrooms/darkrooms, or more informally in someone’s house or apartment.3

Why do guys participate in PnP?

There are a variety of reasons gbMSM participate in PnP. Some men use PnP to:

  • increase their sexual confidence and help them overcome their self-doubt, body image issues and sexual insecurities4,5
  • increase their libido or sexual desire, which may have changed as they age5
  • create a sense of community through participation6
  • increase feelings of intimacy and sexual connection with sex partners — some men describe very intense feelings of intimacy and being in touch with their own senses and the desires of their partner when they PnP5
  • increase their sexual longevity, allowing them to have sex for longer periods of time without ejaculating or to be ready to have sex again soon after ejaculating — this can also allow for sex with more partners over the same length of time5
  • participate in a more diverse range of sexual activities because of a loss of inhibition4,5

For some HIV-positive gbMSM, PnP may help them to deal with negative feelings arising from stigma and discrimination related to their HIV status and/or sexuality.5,6

What drugs are used for PnP?

The drugs most commonly associated with PnP in Canada are crystal methamphetamine (crystal meth), gamma-hydroxybutyrate (GHB) and ketamine. These drugs are used because they increase sexual arousal and performance, while encouraging disinhibition.2

Crystal meth

Crystal meth (Tina, T, crystal, ice, meth, speed) can be swallowed, smoked in a glass pipe, snorted, inserted into the rectum (“booty bump”) or mixed with water and injected into a vein (“slamming”). The effects of crystal meth can last up to 24 hours, although doses are usually repeated every few hours to enhance energy or to remain high. The effects of crystal meth include euphoria (experiencing intense pleasure or excitement), increased energy, enhanced confidence, impulsivity, reduced experience of pain, intense sexual stimulation and lowered inhibitions.7

Gamma-hydroxybutyrate/gamma-butyrolactone

Gamma-hydroxybutyrate (GHB, G, Gina) and gamma-butyrolactone (GBL) are taken in very small doses diluted with water or other liquids such as a soft drink. Doses of GHB/GBL are usually repeated every two hours or so, depending on the potency. The effects of GHB/GBL include euphoria, lowered inhibitions and an increased sex drive. Some men have stronger erections and more intense orgasms when they take GHB/GBL. It has relaxant effects so can make receptive anal sex easier or more pleasurable.7

GHB/GBL are considered “date-rape” drugs because although a person may be agreeable to sexual activities, their ability to set and assert sexual boundaries is decreased. This means they may not be able to meaningfully consent to sex.7

Ketamine

Ketamine (K, Special K, cereal) is an anaesthetic. It can be snorted, injected into muscle, swallowed, or smoked mixed with tobacco or cannabis. The effects of ketamine last between 40 and 90 minutes after it is snorted and up to three hours after it is swallowed or injected. How often doses are repeated depends on the way it is taken.

Ketamine numbs physical pain. In small doses it can give a minor energy boost. Moderate doses can induce feelings of relaxation and disconnection or disassociation from the body. Higher amounts induce psychedelic journeys (“K hole”) and hallucinations. Ketamine increases the desire for sex but makes it harder to keep an erection. It also helps relax the anus, which, combined with the drug’s numbing effects, makes it easier for men to have rough sex and be fisted (having a fist inserted into the rectum).7

Other drugs

Men who PnP may also use other substances, such as poppers, cocaine, MDMA (ecstasy), cannabis and alcohol before, during or after a PnP session. Erectile dysfunction drugs (such as Viagra) are used by some men to counter the effects of crystal meth or ketamine, which may make it difficult to get or keep an erection. Mixing different drugs can be dangerous as it can lead to drug interactions or potential overdose. For example, mixing poppers and Viagra can cause a drop in blood pressure, which can lead to fainting, a stroke or a heart attack.

How common is PnP in Canada?

There are a few research studies that provide information about how common PnP is among gbMSM in Canada. However, because of the varying ways the questions in these studies were asked and analyzed there is no clear estimate of participation in PnP. Based on available evidence, the estimate probably falls somewhere between 5% and 20% of gbMSM nationally.8,9,10,11 However, participation in PnP probably varies across Canada depending on the local culture, as is the pattern seen in Europe, where participation in PnP differs vastly between countries and cities.3

gbMSM are more likely to use recreational drugs than heterosexual men, but not all gbMSM who use recreational drugs use them for PnP (in a sexual context).12 The M-Track study, surveying almost 5,000 gbMSM in five Canadian cities between 2005 and 2007, found that approximately 61% of respondents had used one or more recreational substances (excluding alcohol) before or during sex in the previous six months. Participants were not specifically asked if they had used drugs for PnP. However, 21% of gbMSM who participated in the study reported they had used drugs commonly used for PnP in Canada including ketamine, ecstasy, crystal meth, GHB, psychedelics and other amphetamines.8

The most recent European MSM Internet Survey (EMIS) took place between October 2017 and the end of January 2018.9 There were around 134,000 participants from 49 countries, including Canada. Over 6,000 Canadian gbMSM participated, with between 6% and 8% of Canadian respondents reporting they had “used stimulant drugs to make sex more intense or last longer” in the past four weeks.

The online 2015 Canadian Sex Now Survey, a periodic survey conducted by the Community-Based Research Centre for Gay Men’s Health, asked gbMSM about drug use before their last sexual encounter.10 Out of 7,814 respondents, 1.9% had used crystal meth, 1.2% had used GHB and less than 0.3% had used ketamine. In a sub-analysis of Ontario respondents, 130 of 2,819 (4.6%) reported using crystal meth or GHB for PnP in the past year. This study looked at factors associated with PnP in Ontario. Significantly more:

  • HIV-positive men (21.3%) reported PnP in the past year compared with HIV-negative men (3.4%).
  • men aged 35 to 44 (8.4%) reported PnP in the past year compared with men in other age groups (3.5–4.1%)
  • men who identified as gay (5.7%) reported PnP in the past year compared with men who did not identify as gay but had male sexual partners (2.4%)
  • men living in urban areas (6.4%) reported PnP in the past year compared with men in non-urban areas (2.4%)10

The Momentum study, an ongoing prospective cohort study of the health, sexual behaviour and substance use patterns of gay and bisexual men in Vancouver, asked 719 men about their drug use in the previous six months11: 19.6% of the men reported crystal meth use, 19.1% reported GHB use and 12% reported ketamine use. The men were not specifically asked about drug use in the context of PnP. However, men who reported attending a group sex event (sex party, blackout event or darkroom) were significantly more likely to have used drugs (such as crystal meth) than men who hadn’t attended such an event.

What are the STBBI risks associated with PnP?

International research shows that participation in PnP is associated with different sexual practices associated with passing HIV, hepatitis C and STIs.

Compared with gbMSM who do not participate in PnP, HIV-negative gbMSM who do participate in PnP are more likely to:

  • participate in condomless anal sex with one or more partners13
  • participate in more frequent receptive anal sex14
  • participate in condomless anal sex with HIV-positive or unknown-status partners13
  • participate in receptive condomless anal sex with an unknown-status partner13
  • report having 11 or more new sexual partners in the past year13
  • participate in group sex13

Research suggests that some gbMSM are open to exploring activities during PnP that they have no intention of engaging in when sober.4

Given that the use of drugs during PnP sessions can reduce inhibitions, increase sexual adventurism and extend sex sessions, it can also increase the likelihood of participation in activities that can cause damage to the rectal lining. This can increase the risk of passing HIV, hepatitis C and other STIs.15 Damage to the rectal lining can be caused by participation in rougher sex and sexual acts such as fisting because of decreased sensitivity to pain, especially when using crystal meth and/or ketamine.4

Men injecting crystal meth may also pass HIV or hepatitis C if they share injecting equipment. Although men who PnP may be aware of the risks of injecting, they may not be as vigilant as usual when they share equipment during extended PnP sessions.16, 17 Care also needs to be taken to keep the equipment used for injecting and the area of skin to be injected sterile to prevent skin infections that can lead to sores or abscesses.

Do gbMSM who PnP have higher rates of HIV, hepatitis C and STIs?

As a result of their participation in sexual and drug-taking behaviours that could increase their risk for HIV, hepatitis C and STIs, gbMSM who PnP may have higher rates of these three infections.

A systematic review of sexualized drug use among gbMSM found an increased prevalence of gonorrhea and chlamydia, especially in men who used crystal meth.12 Men who used crystal meth or injected drugs were more likely to get hepatitis C than men who didn’t use crystal meth or inject.12

A variety of studies from Europe and North America have found that gbMSM who participate in PnP are more likely to have bacterial STIs (chlamydia, gonorrhea and syphilis) than gbMSM who do not participate in PnP.12,18,19,20,21 Here are some examples:

  • Among HIV-negative gbMSM attending a sexual health clinic in Amsterdam in 2016, gbMSM who participated in chemsex were 1.5 times more likely to have a bacterial STI than gbMSM who did not participate in sexualized drug use.19 In this study, 31.1% of men who reported engaging in chemsex had a diagnosis of gonorrhea, chlamydia or syphilis, compared with 20.7% of men who didn’t report engaging in chemsex.
  • Among gbMSM in New York taking pre-exposure prophylaxis (PrEP), men who reported sexualized drug use were more likely to report a bacterial STI (42%) than men who didn’t report sexualized drug use (9%).20 In this study gbMSM who participated in chemsex were six times more likely to have a bacterial STI than men who didn’t participate in chemsex.
  • Among gbMSM attending two London sexual health clinics in 2014–2015, 70% of men involved in chemsex were diagnosed with an STI compared with 40% of men who reported they did not participate in chemsex.21

A variety of studies from European and other high-income countries have found that gbMSM who participate in PnP are more likely to get HIV than gbMSM who do not participate in PnP.20,22,23 A few examples include the following:

  • A systematic review and meta-analysis found that gbMSM in high-income countries who used amphetamine-type stimulants (including crystal meth) were 1.7 times more likely to have HIV than men who didn’t use the drugs.20
  • A study from a sexual health clinic in Antwerp, Belgium, conducted between 2011 and 2017 found that 33% of gbMSM who used ecstasy/cocaine/amphetamines or GHB got HIV compared with only 13% of gbMSM who did not use these drugs. This study found that gbMSM who used drugs associated with PnP were six times more likely to get HIV than gbMSM who did not.23
  • A study of gbMSM attending two London sexual health clinics in 2014–2015 found that 8.6% of gbMSM who reported using chemsex drugs had a new HIV diagnosis, compared with 1.8% of gbMSM who didn’t engage in chemsex.21

Impact on mental health

There is some evidence that men who have experienced depression or anxiety at some point in their lives may be more likely to take part in PnP.24 Taking PnP drugs is also linked to short-term and longer term mental health issues, such as depression, anxiety and psychosis, which in some cases can lead to suicide.12,25

PnP is also linked to other drug use and addiction issues. For example, crystal meth can be highly addictive, especially if it is smoked or injected.18 It can be extremely difficult to stop using crystal meth after prolonged use because the brain stops producing the chemical dopamine, which helps control the brain’s reward and pleasure centres. Lack of dopamine means a person may have difficulty feeling happy or good about themselves. This may make them want to take more crystal meth to feel better about themselves.

Where should PnP programs be developed?

Most traditional drug and harm reduction services are not well equipped to deal with PnP-related issues.12 Staff at current harm reduction services experienced in the management of opiate use among a mainly heterosexual population may not have the necessary skills to address the needs of gbMSM and the sexual nature of their drug use.4 There is little overlap between people who inject drugs and gbMSM who PnP. Some men who PnP may have limited knowledge of needle and syringe programs, risk reduction strategies and available drug supports.12 They may also not feel comfortable talking about their sexualized drug use to service providers in traditional harm reduction services who have little knowledge of the drugs they use or how they use them.4,12 Harm reduction programs should consider their role in providing programs and services for gbMSM who PnP and ensure their programs are accessible and culturally competent for gbMSM.

Sexual health clinics and other community settings with large numbers of gbMSM clients are ideally placed to develop programs to help men dealing with potential problems related to PnP. Men are likely to feel more comfortable talking about their sexualized drug use as part of a sexual health check-up than by visiting a harm reduction service, as long as they receive non-judgmental support.12

Programs offering support for safer partying

It is important to mention that not all men who PnP experience negative effects from their drug use. Some men take part in PnP sessions occasionally, use it to enhance the kind of sex they want and are able to include it as part of their life with no or limited harms.

However, some men may have a more complicated relationship with the drugs they use and the sex they have. Some may want to manage/reduce their drug use (for example, move from weekly drug use to monthly use), while others may want to completely stop using drugs because they have more chaotic drug use that affects their ability to function on a daily basis.4 Some men find it difficult to stop PnP because when they don’t use drugs they miss the high and sexual adventurism they experienced during PnP sessions.26 Sex and drugs can be so closely linked that men who have engaged in PnP may initially find sober sex boring or difficult to enjoy.

There are a number of programs internationally that work with gbMSM who PnP. One example is 56 Dean Street Clinic, a busy sexual health clinic in London, UK, which has a large number of gbMSM clients. In February 2014, the clinic introduced a program to support gbMSM who report using drugs in a sexual context. By the end of December 2014, 874 gbMSM had agreed to single or multiple interventions to help address their sexualized drug use.27 Men meet one on one with a counsellor who uses motivational interviewing techniques to help determine the client’s goal (perhaps using drugs less or stopping completely), help identify the circumstances or situations that may cause a craving or lapse in behaviour, and suggest tips for managing triggers and cravings.

Several Canadian organizations have developed programs to offer support for gbMSM who PnP. Here are a few examples:

MAX Ottawa has adapted Berlin’s Let’s Talk and Test campaign, which uses social events, such as a cabaret-style evening hosted by a drag queen, to engage gbMSM who PnP in discussions about sexualized drug use and safer partying in a fun and safe environment. MAX calls their campaign Spill the Tea and they held their first event in August 2018. MAX also produces safer partying kits, which contain harm reduction equipment for men who PnP, including condoms and lube, gloves, injecting kits, snorting kits and a meth pipe.

The AIDS Committee of Toronto (ACT) runs the SPUNK! support group. This six-week program uses motivational interviewing, cognitive behavioural therapy and other approaches to help gbMSM make positive changes in the way they use drugs.

AIDS Community Care Montreal’s (ACCM) Kontak program provides safer sex materials (such as condoms, lube, gloves and syringes) to gbMSM who participate in sex parties. An outreach worker is available to facilitate sessions to discuss risk reduction and answer sex- and drug-related questions at parties. Kontak also runs Crystal Meth and Sex workshops and offers one-on-one counselling sessions.

The Gay Men’s Sexual Health Alliance of Ontario (GMSH) is developing a new campaign called Party n Play Your Way. This campaign provides sex-positive information on drugs and harm reduction for gbMSM who are involved in PnP and who may want to make changes related to their substance use during sex. As part of the campaign, GMSH is producing safer party packs based on PIP PACs developed by the Gay Men’s Health Collective in London, UK. The packs contain colour-coded drug equipment such as syringes and spoons to reduce the chance of people sharing equipment while partying, as well as condoms, lube and latex gloves.

What can service providers do to support guys who party?

There is still much we don’t know about the PnP scene in Canada. Service providers have an important role to play in reaching out and understanding the issues related to PnP in their communities.

  • Start a community discussion: There is a lot of stigma around PnP and a reluctance to speak openly about it, so it may be hidden in many communities. Start an open, non-judgmental dialogue with men who PnP in your community to get a better idea of the issues around PnP: How big is the PnP community? What drugs are being used? What language do people who take part in PnP use? What challenges are they facing? What supports do they need? Where are men meeting to PnP?
  • Provide culturally informed or context-specific counselling and support: If they are offered a space to talk, men who PnP may be able to talk more openly about any problems they may be experiencing and will be less likely to withdraw into social networks that include only other men who PnP.
  • Provide accurate information: Men who PnP may need information on safer sex (including safer fisting practices if appropriate) and safer drug use and how to limit harms associated with using drugs in a sexual environment. They may also need access to accurate information about various drugs, their effects, drug interactions, and other risks associated with taking them. Men who want to reduce or discontinue their drug use will need information to help with their decision and on how and where they can access support and treatment.
  • Talk to gbMSM who PnP about consent: As with any sexual interaction, consent must be given before and during sex while taking part in PnP. While someone is under the influence of drugs during PnP it can be hard to gauge if they are agreeing to an activity, especially if they are so high they may not know exactly what is going on. It is important for men to pay attention to the body language and level of consciousness of their partners during sex to ensure they are still enjoying the activity and have the ability to continue to consent to it.
  • Remain sex positive: Any discussion of PnP in the gbMSM community must be open and accepting of diverse sexual interests and behaviours. Men who PnP need to be supported as they define what works for them, without judgment on the kind of sex they are having. It can be difficult for men who have been involved in the PnP scene to have satisfying sex lives without drugs. They may require support and encouragement as they try to develop rewarding and intimate sexual contact without drugs.

Safer sex and harm reduction tips

There are a number of strategies for men who PnP that may help reduce HIV, hepatitis C and STI transmission:

  • If men are using condoms during extended sex sessions with one partner, the condoms should be replaced regularly and lube should be regularly applied to reduce the risk of condom breaks. A new condom should be used with each new partner.
  • If condoms are not used, lube should be plentifully and regularly applied to help reduce irritation of the rectal lining and penis.
  • Lube should also be plentifully and regularly applied for fisting. A new glove should be used for each fisting partner.
  • HIV-negative gbMSM who PnP may be good candidates for PrEP.
  • HIV-negative gbMSM who PnP may be good candidates for post-exposure prophylaxis (nPEP) after a potential exposure to HIV.
  • Men on PrEP and HIV-positive men on HIV treatment can set alarms or program text message reminders on their mobile phones to remind them to take their pills on time. Also it is a good idea for individuals to take more than enough pills in a pill box to ensure they have a sufficient supply if a PnP session goes on longer than anticipated.
  • For men who inject drugs, it is important to always use new needles and other injecting equipment.
  • In the context of the ongoing overdose crisis in Canada, men may want to use drug checking services to determine what is in their drugs and to check if the drugs have not been cut with fentanyl, which may lead to an overdose.
  • Regular HIV, hepatitis C and STI testing is recommended, especially for men having sex with multiple partners. Testing for HIV, hepatitis C and syphilis requires a blood test. For gonorrhea and chlamydia a urine test is necessary, as well as testing at anatomical sites depending on the types of sexual activity. This means that men who are at risk through oral sex should be tested with a throat swab, and those at risk through receptive anal sex should receive a rectal swab. To detect asymptomatic STIs in gbMSM, it is important that all of these tests are conducted routinely.

Resources

Information for gbMSM who party and play

Toronto Vibe – safer drug use information for gbMSM who party

MONBUZZ.ca – French online resource from RÉZO for gbMSM who want to address their alcohol and drug use and the relationship of these substances to their sex lives.

The High Life – an online information resource about club and party drugs from Health Initiative for Men (HIM)

When the ParTy’s Over?– HIM’s online information resource for men who use crystal meth

Chemsex documentary

Safer sex

8 Questions about PrEP for Guys – Basic information about pre-exposure prophylaxis for gbMSM

Safer Sex Guide

Condoms for the prevention of HIV transmission

Oral pre-exposure prophylaxis (PrEP)

Post-exposure prophylaxis (PEP)

HIV treatment and an undetectable viral load to prevent HIV transmission

References

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About the author(s)

Zak Knowles is CATIE’s Manager, Online Content and Publications. Before coming to CATIE, he worked as an HIV counsellor at Hassle Free Clinic, a sexual health clinic in downtown Toronto.