Slam Practice: A Review of the Literature

For several years now, there has been an increasing amount of research, clinical, and practitioner evidence, suggesting an increase in the use of new psychoactive substances (NPS), both within heterosexual [1] and men who have sex with men (MSM) populations [1, 2], with a particular focus on mephedrone, 3-MMC, and 4-MEC. These substances are from the family of synthetic cathinones, with new drugs appearing monthly on the illicit drugs market. In 2018, 130 different cathinones were identified by the European Monitoring Centre for Drugs and Drug Addiction [1]. The arrival of these new substances on the drug scene has been associated with the emergence of new consumption behaviours, especially the practice of chemsex and slam. Chemsex and slam have emerged as new phenomena, mostly among MSM, in Western Europe [3, 4] in 2011, as well as in Southeast Asia [5-7], North America [8, 9], and Australia [10, 11], where it is called “Party and Play” or “intensive sex partying.” All these terms refer to the use of psychostimulant drugs to facilitate sex [1]. Public Health England’s definition of chemsex is “the use of drugs before or during planned sexual activity to sustain, enhance, disinhibit or facilitate the experience. Chemsex commonly involves crystal methamphetamine, GHB/GBL and mephedrone, and sometimes the injection of these drugs, known as slam or slamming” [12]. According to the French Monitoring Centre for Drugs and Drug Addiction, slam is a part of the chemsex field and defined by (i) the use of psychostimulants, (ii) intravenous use, and (iii) use in a sexual context [13]. However, slam definitions may vary depending on the country.

Stimulant drugs such as methamphetamine and cathinones are used in slam for the intense feelings of euphoria and sexual arousal they provide [14]. Patterns of drug use among MSM have changed over the past decade [15]. Associations between drugs and sex are not new; however, sex under the influence of previously popular drugs (ecstasy and cocaine) was often incidental, rather than planned and intentional, as it is the case with the use of methamphetamine and cathinones in slam [16].

Slam facilitates engaging in lengthy sex sessions, without condoms, with multiple partners of often unknown HIV and/or hepatitis C virus (HCV) serostatus [17]. Unsafe injection practices by MSM in sex context are of particularly significant concern because they may facilitate HIV transmission, HCV transmission, and multiple sexually transmitted infections (STIs) [18]. Sexual behaviours such as fisting (ano-brachial intercourse), anilingus (ano-oral sex), and uro-scat play can place an individual at a greater risk of blood-borne viruses and gastrointestinal infections [19]. Indeed, drug use has been implicated in HIV/HCV transmission via its association with high-risk sexual practices, particularly anal intercourse without condom among MSM [20]. Furthermore, slam sessions, which can last days, may involve prolonged traumatic sex for one’s mucosa, with multiple partners identified often through smartphone geospatial networking applications [19].

Men’s reasons for using drugs during sex are variable and complex, and, to date, these motives have not been well explored [15, 21]. Weatherburn et al. [21] distinguished 2 types of motivation for combining sex and drugs. The first major group of motivations stems from the fact that drugs provide the means by which men can have the sex they desire by increasing libido, confidence, disinhibition, and stamina [21]. The second major group of motivations stems from the fact that drugs enhance the qualities of the sex that men value: drugs make other men seem more attractive, increase physical sensations, intensify perceptions of intimacy, and facilitate a sense of sexual adventure [21]. Thus, it seems that slam is a complex behaviour motivated by specific expectations that need to be explored.

Significant concern has been expressed by healthcare providers, as well as by gay and mainstream media, about the impact of drug use on the physical, mental, and social well-being of gay men and the broader impact on the gay community [21]. Slam appears as a specific form of chemsex, with specific characteristics. Although some data are available in the international literature, slam prevalence and associated data on health harms among MSM are difficult to determine [22, 23]. Furthermore, despite the growing body of research on drug use in a sexual context among MSM, most studies collected data about chemsex [24, 25] and were not specific about slam; they rarely investigated injection drug use and its correlates in detail. Understanding the extent of the slam phenomenon is essential in identifying its harms and developing our practice as caretakers accordingly. We therefore aimed to synthesize available published evidence through a systematic literature review to precisely describe this phenomenon and to better characterize the subpopulations who practice slam and their specific motives.

A systematic review of the available literature was conducted to identify all relevant publications using PubMed, PsycINFO, the Cochrane Library, and ScienceDirect. For this review, we complied with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [26]. We limited the search by identifying studies published between January 2008 and May 2020. The practice of slam seems to have become visible internationally in 2008; this date also corresponds to the appearance of synthetic cathinones on the European drug market [1]. Our search included a combination of the following keywords: “Men who have sex with men,” “MSM,” “Homosexual,” “Gay,” “Chemsex,” “Slamming,” “Slamsex,” “Party and Play,” “Party Drugs,” “GHB,” “GBL,” “Amphetamine,” “Mephedrone,” “3-MMC,” “4-MEC,” “Club Drug,” “Injection drug use,” “Recreational Drug,” “New psychoactive substances.” The search equation was as follows: men who have sex with men OR MSM OR Homosexual * OR gay AND. The keyword after AND was successively replaced for each new search by another keyword mentioned above. We decided to carry out this research by focusing on MSM for 2 reasons: first, slam practice is statistically more frequent in the MSM population, and second, the data available in the literature focus on MSM [27, 28]. Duplicates were eliminated. The search strategy is summarized in Figure 1.

Articles had to fulfil the following criteria to be included: explicit reference to slam or to intravenous injection of psychoactive substance in a sexual context, the article was written in English or French, and the article was an original article.

First, articles were selected based on their titles and abstracts. Second, the full text of all the included articles was read. Two of the authors (B.S. and M.G.-B.) performed this work independently using the same bibliographic search. In the event of a disagreement, the articles in question were discussed. Additional publications were found by reviewing citations of included papers.

Data were extracted from the articles and reported by data type alongside study design, details of the population assessed, sexuality characteristics, reference period, slam prevalence, sociodemographic characteristics, STIs, substances used, and associated risky behaviours.

Twenty-seven articles met the criteria for inclusion (Fig. 1, PRISMA flow diagram). The main results are presented in tables summarizing prevalence data (Table 1), subjects’ characteristics (Table 2), substance use’s characteristics (Table 3), and sexual practice’s characteristics (Table 4).

Most studies were quantitative; only 3 presented qualitative data [29-31]. Most papers focused on cross-sectional studies; 2 were cohort studies [32, 33] and 1 was a case-control study [34]. Most studies presented data prospectively; 10 were retrospective studies [17, 19, 35-42]. Only 1 study focused on a general population of homosexual and heterosexual men and women [34]. Another study focused on men and women who used drugs [43]. Other studies focused on more specific subpopulations: MSM attending addiction management services [44, 61], MSM drug users [10, 31, 32, 44, 61], MSM admitted to HIV care units [33, 34, 38, 41, 45-48], MSM consulting in sexual health clinics [2, 35, 37, 41, 42, 46, 47], MSM infected with HCV [33, 37], MSM infected with Shigella [17, 19]; MSM being reported to national surveillance systems [36, 39, 40], MSM attending gay venues (bar, sauna, and backroom) [49], and MSM using gay social networks [29, 30, 46, 47].

The prevalence of slam was generally the highest in subpopulations of MSM who used drugs; it was as high as 91% in these subpopulations [10, 32, 36, 39, 43, 50, 61]. Among MSM living with HIV, slam prevalence was extremely variable, ranging from 3 to 38% [33, 34, 38, 45, 48]. Regarding MSM, recruited by gay social networks or attending gay venues, who filled out survey on their practices, the prevalence also varied greatly between studies, ranging from 2 to 50% [29, 30, 47, 49]. Among MSM users attending sexual health clinics, the prevalence was generally around 25% [2, 35, 37, 41, 42]. The prevalence of slammers among MSM infected with Shigella was close to 20% [17, 19]. Regarding other sexually active subjects (excluding MSM), the prevalence was of 8% among heterosexual men, 14% among WSW, and 7% among heterosexual women [43] (Table 1). Reference periods assessed included current [29, 33, 35-37, 39, 40, 44, 45, 50, 61], current and past [2, 31, 34, 46], the last month [41], the last 3 months [38, 42], the last 6 months [10, 30, 32], the last 12 months [43, 47-49], the 2 weeks preceding a Shigella infection [19], and time span of the practice in subjects’ lives [17].

The results related to the characteristics of the subjects are presented in Table 2. The average or median age of users who practiced slam was only reported in 7 studies, and the age ranged from 30 to 48 years [32, 36, 39, 40, 44, 46, 49]. The practice of slam among participants was associated with having a full-time job [10], but compared with participants who had not engaged in slamming, those who engaged in slam were almost 4 times more likely to experience financial struggle [49] and were less likely to have a university degree [10].

HIV serostatus was reported in 20 studies; HIV-positive prevalence varied widely across studies, ranging from 0.6 [43] to 100% [33, 38]. The risk of being infected with HIV was 5 times higher among slammers [49] and 2 times higher among cocaine slam users [10] than other participants.

HCV serostatus was less conveyed (13 studies); HCV-positive prevalence was highly variable, ranging from 3 [10] to 100% [33, 37]. Compared with participants who had not engaged in slamming, those who engaged in slam were 14 times more likely to be infected with HCV [49]. The risk of being infected with HCV was almost 3 times higher among regular users of methamphetamine [10] than non-users.

Only 5 studies reported STI diagnosis; almost one-quarter [37] to four-fifths [48] of subjects were infected, while being infected with an STI was significantly associated with slamming [49]. The risk of being infected with an STI was 1.5 times [10] to 6 times higher [45] among slam users. Moreover, one-third of slammers reported using HIV pre-exposure prophylaxis (PrEP), and they used it significantly more than participants who had not engaged in slamming [49]. PrEP is the use of an antiretroviral medication (tenofovir plus emtricitabine) to prevent the acquisition of HIV infection by uninfected persons considered at risk for HIV infection.

Regarding slammers’ sexual and relationship choices, one-fifth had had at least 1 sexual partner infected with HCV in their lifetime [37]; slammers were significantly more likely to visit a dating website for gay men [49], to have gay friends, and to get involved with homosexual men, more specifically with homosexual men who inject drugs [32].

The results related to the characteristics of substance use are presented in Table 3. The type of psychostimulant substances used was noted in only 11 studies, and they were mainly methamphetamine [2, 10, 32, 33, 38, 45, 47, 48] and mephedrone [36, 43, 45, 48, 49]. Polydrug use was found in three-fifths to four-fifths of users [36, 48]. The risk of injecting mephedrone and ketamine among MSM and WSW was 2–10 times higher than among heterosexual men and women [43]. Moreover, methamphetamine-injecting MSM were twice as likely to consume poppers, 10 times more likely to consume GHB, and 2 times more likely to consume drugs for erectile dysfunction [10]. According to a study, there was a significant and positive association between the number of drugs already used and the recency of injection [32]. Syringe or small-equipment sharing was explored very differently among the studies and concerned no subject [33], to almost 20% of subjects in some studies [32, 38, 47, 49] to almost the majority of subjects in other studies [43, 48]. This highly risky behaviour was significantly more frequent among MSM and WSW than among heterosexual men and women [43]. Three-quarters of users reported using a new syringe or needle when injecting, while two-thirds reported bringing their own syringes and utensils to parties [47]. Furthermore, recent injection involved fewer than 1 in 10 users, but almost half of these participants used injection drugs at least once a month [32]. Regarding the origin of injection equipment, almost one-third came from community associations, one-third from sexual partners, and the last third from needle exchange programmes [32]. Compared with participants who had engaged in non-injecting sexualized drug use, those who engaged in slam were 5 times more likely to have experienced withdrawal symptoms, 7 times more likely to have experienced intense craving [48], and more than half injected more than once per hour during a typical slamming session [49].

The results related to the characteristics of sexual practice are presented in Table 4. Among Australian MSM who used drugs, recent injectors (during the last 6 months) were more likely to have an older slam practice than were other participants [32]. Recent injectors had resorted to transactional sex 3 times more often than those who had used intravenous drugs over 6 months prior [32]. Moreover, the risk of having transactional sex was nearly twice as high among the UK injectors of mephedrone, ketamine, and cocaine [43] compared to subjects who used drugs in a sexual context other than intravenously. Regarding reasons for methamphetamine use, Australian MSM participants who had recently injected were significantly more likely than other participants to report using methamphetamine for disinhibition and endurance [32]. Fisting prevalence among slam users infected with HIV in Madrid [48] and the level of sexual sensation-seeking among Australian MSM slammers [32] were significantly higher than in non-slammers. A quarter of the slammers in Madrid had a stable partner, and almost three-quarters of the slammers declared having had >20 partners in the previous 6 months [48]. Moreover, one-quarter of the French slammers attending gay venues reported >50 sex partners in the last year and there was a significant difference from non-slammers [49]. The mean of sexual partners was >7 per year among MSM slammers infected with HCV [37]. MSM and WSW injectors from the UK and Australia were significantly more likely to have had over 10 sexual partners in the last 6 months compared to other participants [32, 43]; furthermore, recent injectors were 3 times more likely to have had >10 sexual partners during that time [32]. Almost two-fifths of French slammers attending gay venues reported BDSM sexual practices, and there was a significant difference from non-slamming users [49]. Nearly half of slammers infected with HCV had group sex (sex with more than 1 partner at the same time) [37]; recent Australian MSM injectors had nearly 3 times more group sex than those who had used intravenous drugs over 6 months prior; they were 1.5 times more likely to have this type of sex [32]. Over 70% of Australian MSM drug users and slammers infected with HIV or HCV had had unprotected anal sex during the year [32, 37, 48]. The risk of having unprotected anal sex among MSM methamphetamine users, French MSM attending gay venues, and MSM living with HIV was 1.4 times [10], 4 times [49], and 6 times higher [45], respectively, among slammers compared to non-slammers. Among Australian MSM who used drugs, recent injectors were nearly twice as likely to have unprotected anal sex [32] than those who had used intravenous drugs over 6 months prior.

Through our review, we have shown that this topic has been little studied, given that the slam phenomenon appeared only 10 years ago. We found that slam prevalence data varied greatly in the international literature, probably because of the heterogeneous design of the studies (quantitative, qualitative data, cross-sectional, case-control, and cohort), the way in which data were collected, the populations assessed, and so forth. Few studies included a large number of subjects [38, 46, 49], leading to difficulties in obtaining accurate measures. We mainly found prevalence results from small samples of studies focused on very specific subpopulations: generally, MSM drug users or MSM admitted to HIV care units or consulting in sexual health clinics. The great diversity of percentages can also be explained by the evaluation period (reference period), which is different across studies (lifetime, past year, last month, regular practice, etc.). It is difficult to establish whether the number of slammers has been increasing every year, as the studies are not reproducible, but there seems to be a trend suggesting an ever more frequent slam practice by MSM at the international level. The fact that more studies are present could also indicate that there is more interest for this topic from a research/practice point of view. The phenomenon seems to have become more visible since 2011, year when we find the greatest number of studies measuring slam prevalence [2, 38, 39]. Finally, the data about slam prevalence seem similar to those found for chemsex [10, 30, 51-54]. Furthermore, studies were mainly UK-focused and from urban clinics that provided care for people living with HIV/AIDS. The majority of the available data were collected through cross-sectional surveys, providing a snapshot at one point in time. Nevertheless, we managed to extract relevant data. Most subjects were young and employed; many were infected with HIV, HCV, or STIs. Studies focused mainly on MSM, and moreover, they focused on small samples from subgroups of MSM rather than the whole population; we observe that data found in international literature cover a large number of practices and very specific subpopulations. Mephedrone and methamphetamine appeared to be the most often used drugs among participants, and polydrug use was frequently reported. The predilection for methamphetamine or mephedrone uses in slamming depends on the country and on the drug-use patterns in the gay community of each country explored. For example, methamphetamine is almost absent in France or only sold in Paris at very high prices, explaining the preferential use of stimulants such as cathinones in the practice of slam, while methamphetamine is widely available in the USA [8, 9, 55, 56], Australia [10, 32], and Asia [5, 7, 30]. Therefore, slam is not necessarily associated with NPS in all countries, and its emergence is closely linked to the availability of cathinones and the appearance of mephedrone in 2007. Moreover, 3-MMC and 4-MEC [1, 13] have supplanted mephedrone, which currently remains the reference molecule when slam is discussed in the literature (this is related to the delay between the publication of articles and the rapid evolution of the NPS market). Regarding sexual practices, participants reported primarily injecting psychostimulant drugs in the context of sex to enhance sexual pleasure and improve sexual performance, a practice described as “intensive sex partying.” Men who reported injecting drugs in the context of sex were more likely to have group sex, a high number of sex partners, transactional sex, and unprotected anal sex. It seems that the novelty of practice (recent slamming) is also associated with more risk-taking (search for multiple partners, unprotected sex with strangers, and prostitution).

To our knowledge, this is the first review of its kind, aiming to summarize available data on slamming among MSM in the international literature and to highlight gaps that limit its comparability and synthesis. Regarding weak points, there are very few selected articles and data were collected heterogeneously. Throughout the search in the published literature, we also found significant variations in the definition of slam or injection drug use in a sexual context. These definitions are not always clear, which could explain why we found only 27 articles and thus have limited data. Slamming was sometimes incorrectly referred to as “sex under the influence of any illicit drug” without qualifying that it actually refers to the use of drugs before or during planned sexual activity to sustain, enhance, disinhibit, or facilitate the experience. Thus, studies are not reproducible not only because of their design but also because of the different definitions of slam.

This systematic review was carried out according to recommendations. This is a recently described phenomenon; however, this review could allow us to draw a “portrait” of slam users. It provides a basis from which to build a better understanding of the extent of slamming among MSM and other populations (such as WSW or other populations where slamming may arise) and offers recommendations as to how best to target future data collection.

Our findings help to identify fields for harm reduction and health promotion interventions among MSM who inject drugs in a sexual context. First, it is necessary to discuss their health issues in order to understand their needs and what to offer them. The key point is to adopt an integrative medical approach, according to the biopsychosocial model of addiction. Support could be provided at 2 levels, community-based and health professional levels.

The 4 main missions of health workers are information, screening, prevention, and harm reduction. Indeed, sexual and drug harm reductions are essential and must accompany screening and prevention [16, 50, 55, 57]; in France, it is mainly the AIDES association that has developed specific support. AIDES workers organize self-support groups and sexual health events, including the realization of HIV and HCV rapid antibody tests. Furthermore, association workers provide single-use injection kits, with coloured syringes to avoid sharing; donate condoms; and provide lubricant and STI self-testing kits. The association also creates and gives flyers and booklets for slammers, which contain tips and tools on substance use in a sexual context, on sexual health, and on risk reduction in the context of slamming. All this information is available on its website, and it created a 24-h emergency hotline for chemsexers. It is also essential to transmit messages using direct language, to provide factual information, and to conduct interviews with peers to allow identification [57]. This community-based health approach could greatly reduce the fear of being judged or misunderstood about one’s practices; it facilitates the spreading of verified information on prevention and harm reduction, particularly on injecting-risk education, support, and drug testing by thin-layer chromatography [2, 15, 57].

Health professionals (physicians, nurses, and psychologists) must discuss with the user about his/her relationship to drugs and detect substance use disorders. They have 3 main missions: to treat infections; to motivate to enter treatment, when addictive disorders exist (substance use and sex); and to treat sexual dysfunctions, using an integrative approach. Clinicians must assess both drug use and sexuality as well as their positive and negative consequences (psychic, physical, and social), as part of a motivational interview. They should use motivational interviewing, as it is effective in changing attitudes and behaviour for which ambivalence, or no wish to change is present. Drug abstinence or reduction of drug consumption should be advised to patients. Health professionals should support them in the process of regaining their sexuality without drugs. Amphetamine withdrawal management is based on the prescription of symptomatic treatments. However, for those who are not ready to pursue abstinence, drug harm reduction interventions may be useful to reduce sexual risks in the context of slam. The harm reduction approach aims to increase knowledge about frequent drug overdose, harmful drug combinations, needle-sharing risks, and the undesirable effects of cathinone use. Professionals could work with patients on the transition or on rotation with other ways of administering drugs that would be associated with lower risks (intranasally or orally).

Sexological care is also essential because the presence of sexual dysfunctions is common and could partially explain the recourse to the practice; indeed, studies have shown that the substances are used for sexual stimulation, among other things [14, 21, 55, 58]. Professionals should also check blood-borne virus status and STIs, ask questions about sexual intercourse practices, and look for other possible damages. Regarding sexual and infectious harm reductions, we could offer different ways of protecting against contamination: condom use, HIV PrEP, gloves, disposable no needle-sharing injection equipment, regular STI screening (every 3 months), and sex toys to be used personally. It would also be advisable to limit the duration or intensity of anal sex, considering the pain it can provoke.

Slamming seems to concern few drug users and does not seem representative of the drug user subpopulation; however, there are no epidemiological data on the general population. Future studies should be conducted in the general population, with a longitudinal design to monitor the evolution of the practice.

Further work is therefore required to establish a precise and unifying definition of slam that will facilitate international comparisons. Drug policy is different in each country, which complicates the interpretation of the results and therefore the characterization of the practice, allowing it to remain hidden. We believe that the definition of slamming needs to be more precise. We suggest that the definition encompasses all the following elements: sexual context, psychostimulant drug use, intravenous injection [49, 59], and the use of drugs before or during planned sexual activity to sustain, enhance, disinhibit, or facilitate the experience [4].

Available studies did not collect accurate data on the use of psychoactive substances in sexual contexts; namely, they neglected to characterize the substance use (dosage, frequency of use in the same session, negative effects, tolerance, craving, weaning characteristics, and substance use disorder), its evolution, and all the negative consequences that users face. There is a lack of pharmacological data on users’ preferences for methamphetamine and cathinones in slam practice. From our clinical experience, we could advance the following facts: unlike other conventional psychostimulants such as cocaine, which could be consumed for a sexual aim but also for a social purpose and disinhibition, these substances seem to provide an intense sexual pleasure, an excitement, an extreme enjoyment, and an unbridled sexual appetite. They seem to allow some users to experiment with new sexual practices, especially group sex, BDSM, receptive anal penetrations, and fist fucking. Others, without necessarily changing their practices or adopting extreme sexual behaviour (hard), would discover a more intense sexuality with stronger sensations. It is necessary to better understand the pharmacological mechanisms that underlie these behaviours.

Most studies focused on the use of psychoactive substances but did not question the notion of drug addiction or sex addiction. Indeed, few studies included patients treated in addiction centres for addictive behaviours. We do not have any information about slam practice in relation to the notion of hypersexuality or sex addiction, sexual dysfunctions, or evolution of sexual practice. Only 1 study [30] mentioned users’ motivations for practicing slam; moreover, no study explored users’ personalities.

About this MSM subpopulation, diagnosing a drug use disorder, sex addiction, or sexual dysfunction is a necessary precondition to the decision of therapeutic management. At present, care plans for patients who use drugs and patients with sex addiction are differentiated; the current proposals for standard care for addictions, which separate substance use disorder and sexual addiction, do not correspond to those patients with a dual diagnosis [49]; they need a global comprehensive management of their addictive behaviours. Future studies should set up tools to screen for addictive disorders (sex and substance use) and sexual dysfunctions in MSM users.

Our findings help in identifying paths for harm reduction and health promotion interventions among MSM who inject drugs in a sexual context. Professionals must ensure confidentiality and protect the anonymity of these men who bear at least 2 or 3 stigmatized identities: gay, drug users, and possibly HIV-positive/HCV-positive. The intersecting stigma may drive this subpopulation and this behaviour underground [57]. Drug-using MSM often suffer from shame and guilt, and slam could be an escape from this stigma. Carrying out qualitative studies to give a voice to slammers and thus better understand the motivations for risky behaviour could be the first step in destigmatizing users. Thus, future qualitative studies should investigate psychosocial factors (role of stigma, depression, social isolation, and homophobia) and the needs of this subpopulation of MSM in order to know what type of care to offer them [21, 60].

In the end, there is a need for a coordinated response among HIV treatment, mental health, addiction, and sexual health services. Physicians and nurses should know about slam practice because serious health problems can derive from this. Community-based health associations seem to be at the forefront, but health professionals need to be trained in this sexual practice to help associations distribute harm reduction messages and take care of slammers. A public health policy should be supported to limit harm and damage and to avoid the stigmatization of this subpopulation.

We would like to sincerely thank A.F. Goalic for her assistance in the manuscript preparation.

For this review, we complied with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).

The authors have no conflicts of interest to declare.

The authors received no specific funding for this work.

B.S. and M.G.-B. conceived the search, collected the data, designed and performed the analysis, and wrote the paper. C.V.-V., E.L., and M.G. helped draft the manuscript and participated in the discussion. All authors read and approved the final manuscript.