The authors’ reply to comments on a paper about chemsex during COVID

• Authors: Álvaro Francisco Lopes de Sousa, Artur Acelino Francisco Luz Nunes Queiroz, Shirley Verônica Melo Almeida Lima, Priscilla Dantas Almeida, Layze Braz de Oliveira, Jeremias Salomão Chone, Telma Maria Evangelista Araújo, Sandra Mara Silva Brignol, Anderson Reis de Sousa, Isabel Amélia Costa Mendes, Sónia Dias, Inês Fronteira
• Publication Year: 2021
• Journal: Cadernos de Saúde Pública, 37(3), e00029921
• Link: https://doi.org/10.1590/0102-311X00029921

LETTER

Dear researchers,

We appreciate the interest in our publication and the comments on the content of the article, which we received with great esteem and consideration. Generally, the authors agree and reinforce the importance of our findings, but question two central points: (1) why our research, against the most recent literature, points to an increase in random sexual relations, and (2) whether the COVID-19 pandemic can truly affect the incidence of sexually transmitted infections (STIs) in high-risk/vulnerable groups.

Regarding the first question, we believe that the authors misunderstood our findings. In our study published in CSP¹ we showed results regarding only individuals involved in chemsex, i.e., 920 people (38.9%) of the 2,361 men who have sex with men (MSM) included in the original survey. Although 95% of these individuals sought casual sex regardless of stay-at-home measures, frequency of sexual encounters as well as number of partners decreased, as we detailed in another publication². The data from the general sample of that study show that the majority of MSM (75.9% in Brazil and 72.5% in Portugal) reported a decrease in the number of sexual partners during the pandemic. Thus, the problem itself is not just quantitative (increase or decrease in random encounters), but the fact that when the encounters occur, they seem to be permeated by unsafe sexual practices, increasing the vulnerability to exposure to STIs and SARS-CoV- 2 simultaneously (due to unknown partners, use of drugs, orgies, and use of ineffective prevention methods). The finding that 95% of chemical sex cases occurred with a casual partner reinforces the maintenance of behaviors and practices similar to the non-pandemic period, which are associated with higher turnover or number of sexual partners³.

Concerning the second question, we believe that the impact of the COVID-19 pandemic on STI incidence in high-risk or most vulnerable groups is notorious, as is the case of chemsex-practicing MSM. In a non-pandemic context, the practice of chemsex already increases exposure to STIs, due to aspects such as diminished capacity for negotiating preventive methods, multiple partners, use of psychoactive substances, or even unorthodox contexts. A pandemic context, on the other hand, imposes physical and social distancing for preventing and controlling the new disease, such measures move bodies away and create barriers to sexual practice, which can increase access to psychoactive substances and also associated sexual practices, e.g., orgies that take place in “hidden” places. Facing the need to escape reality, individuals in our current context can lose focus on safe sex and prevention strategies.

In addition to the conditions already described by the authors in their letter, the male public’s distance from health services was aggravated, mostly due to the need to reorganize these services during the pandemic. This possibly impacted screening and diagnosis of STIs. Guidelines for social distancing and the needs of resource relocation during the COVID-19 pandemic have led to a significant disruption of sexual health clinics worldwide, which may mask STI incidence data, leading to a false sense of decrease.

Regarding the dispensing of medicines for HIV prevention and treatment, the fear of seeking hospitals to access medicines, tests, and other services and getting infected with SARS-CoV-2 can be listed as a determinant impact of the pandemic on STI incidence.

The discussion on vaccination among MSM is, in fact, interesting and should be considered more carefully when planning vaccination campaigns. The literature indicates that the barriers to vaccine completeness in this group are strongly related to social and structural factors, which include non-welcoming environments in health services and a stigmatized minority self-perception, leading to neglect and consequently worse health outcomes.

Finally, we consider as inappropriate the description of the participants’ sexual practices as “bizarre”, which is an opinion that expresses judgment and reinforces a historical stigma; it should not have a place in academic and scientific literature. This fact even goes against the development of prevention and intervention measures suggested in the text. The heteronormative view of sexual practices marginalizes homosexuality and homoaffection and reinforces discrimination, as this perspective labels the practice of vaginal-heterosexual sex as “normal” and all the other sexual expressions as “not normal/bizarre”. In order to improve STI prevention, sexual rights must be guaranteed in the context of public health, and individual autonomy must be respected. We would have more gains in investing in prevention and harm reduction campaigns than in providing greater increased vulnerability of MSM based or focused on sexual practices.

KEYWORDS

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

Sousa AFL, Queiroz AAFLN, Lima SVMA, Almeida PD, Oliveira LB, Chone JS, et al. Chemsex practice among men who have sex with men (MSM) during social isolation from COVID-19: multicentric online survey. Cad Saúde Pública 2020; 36:e00202420