「藥愛」的反應正在重塑「性健康服務」並重新改造「減害」計畫

 

「藥愛」的反應正在重塑「性健康服務」並重新改造「減害」計畫

資料來源:Aidsmap News,作者:羅傑·皮特; 201843日發佈,財團法人台灣紅絲帶基金會編譯

 

「藥愛」的現象導致法國社區愛滋防治組織AIDES將兩項先前獨立的工作合併在一起。Fred Bladou於最近在柏林舉行的歐洲藥愛”Chemsex”論壇上表示,他說,AIDES已開始與同志們談論藥物的使用,並且亦與注射藥癮毒者談論性行為。

 

其策略的第一部分是制定促進性健康和教育的新方法。在巴黎的同志聚集區Le Marais之邊緣,AIDES開設了一個名為“Le Spot”的社區健康中心,除提供愛滋病毒檢測,更方便取得保險套和其他預防器材,並協助社區對「暴露前預防性投藥」(PrEP)以及「檢測不到病毒=不會造成傳播」(U = U)等之瞭解。

並且更強烈地強調同伴的支持,包括針對涉入藥愛活動的男性提供每週一次的同儕對同儕之會議 - 被形容為是建置一個讓孤立之男性可被傾聽和支持的空間,以重建社交聯繫。

 

該策略的第二部分是制定「減害」的新方法,包括調整作法使其適應正在服用不同藥物的新人群。提供更安全的注射實務方面的教育,包括工作人員觀察藥物使用者的注射過程,並就如何更安全地用藥提供回饋。

藥物使用者可以攜帶他們在市面上購買到的藥物進行測試,以便他們能更好好地了解其實際服用了什麼藥物,並提供無菌的注射用具。

 

AIDES所服務的15個法國城市以及「藥愛」已成問題的地方採取了類似的做法。外展活動是在私人性愛派對、桑拿浴室和性愛俱樂部中進行的。

該組織還調置了一個擁有約1200名參與者的私人臉書群組和一個WhatsApp群組,這兩個群組都允許人們分享信息並讓其感覺不是那麼地孤立。

 

AIDESStephan Vernhes表示,在巴黎每週的會議約有15名男性出席,過去一年中共有約180名男性參加。Vernhes說,在塑造安全的空間環境上建立基本的規則至關重要。

每週聚會時都會提醒參與者有關指導方針中遵守不批判、保密、積極傾聽和相關的事項。為了維持大家的興趣,每週都會討論不同的主題,比如性行為和愉悅、如何處理藥物渴求、放映關於藥物問題的紀錄片等,並由性學家、精神心理專家和成癮專家等進行介紹。

隨著參與者越來越多,現在也有一個禁慾的目標,有些會議單元中會針對如何在生活中免除毒品或如何不依賴藥物的性生活等議題去進行討論。

 

在藥物領域中,存在於「減害」倡導者(旨在減少因藥物使用有關的直接傷害,而不改變已潛在的藥物使用)和禁慾的支持者(旨在幫助人們完全停止使用藥物的計畫)之間經常存在著緊張關係。然而,在論壇上許多人認為這是一種錯誤的二分法。

倫敦迪安街診所的David Stuart說,最重要的是以人為本的工作方式,幫助服務對象實現自己設定的任何目標。

他建議,對於許多人來說,在這整個過程開始時「禁慾」是過度的雄心勃勃。“這是一個非常大的目標,非常英勇”,他說。“但是從小的步驟開始可能更為明智”。

 

他概述了他開發的藥愛照護計畫,這是一種男性可以自行使用的線上工具,但也可以由醫療專業人員和顧客一起使用。

對於藥愛知識或經驗有限的工作人員來說,照護計畫提供了對話溝通與介入措施的結構,它亦有15種不同的語言可供應用。照護理計畫旨在幫助人們確立目標並朝前努力。

它要求人們針對藥愛上去思考他們究竟喜歡和不喜歡什麼以及他到底想要改變什麼。這個工具可以幫助人們辨識他們可能“觸發”渴求的情境,並思考自己將如何管理它們。

 

Ingrid Bakker介紹了荷蘭「減害」組織Mainline如何在阿姆斯特丹為注射甲基安非他命的男性提供服務。

大約四年前,透過與同志社區的聯繫,其工作人員意識到“藥愛中採注射方式施打藥物”是一個新興問題,但在對應藥愛的其他專業人士卻未能有所警覺或知曉其他國家的情況。她說,他們沒有時間去深入討論問題的性質或制定詳細的計畫。相反地,他們採取了務實的態度。“我們寧願盡可能少浪費時間,並捲起袖子來開始工作”。

她說,“我們做了一些基礎性的工作,以了解發生了什麼情況以及其中最大的需求,並採取了優先的步驟”。很多人當他們第一次經歷使用甲基安非他命時,對它的了解都很少。他們往往採用了差勁的注射技術,而這些技術是他們彼此相互學習來的。人們還說,他們在網上找到的唯一訊息是美國人的資料且採取“只是說不”的方法,對他們來說並不適合。因此Mainline開發了網頁和小冊子等資源以滿足這些需求。

 

由於人們已經開始與性健康診所接洽互動,並經常與工作人員討論他們的性生活,因此培訓工作的重點是在性健康之專業人員。

由於Mainline是一個減害組織,通常與使用毒品的人一起工作,所以他們與Soa Aids Nederland展開合作,因該組織擁有基礎設施和關係可以提供臨床醫生相關培訓。

Bakke說,找到一個能夠以不同方式解決問題的“協同對應者”是非常重要的。“荷蘭的多部門(跨單位)應對措施正蓬勃地發展,各個組織都在努力地工作並共同合作以進行改變,每個單位或部門都對其所對應的各個部分負責”她說。

 

在柏林SchwulenberatungJanGroßer說,德國醫療服務的複雜和分散的結構,使得提供聯合服務變得具有挑戰性。由於不同的資金來源和預防與醫療照護之間的分工,很難在同一屋簷下提供整體的服務。這在關於藥愛方面上尤其成問題,處理藥愛需要具備性少數族群之文化、性場域的藥物使用、心理和性健康等方面的能力。

他說,未來努力的方向是建置可以規劃和協調服務的網絡。Großer說,人們可能會在各種環境中出現問題。當人們遭遇如人際關係或工作困難等問題而尋求專業協助時,似乎顯示與吸毒無關。但透過了較靈敏的詢問後,藥愛就成了問題中的一部分。“當人們表現出遭遇某些困難時,其腦海裡常沈潛著藥愛”。他建議道,“當你在處理藥愛時,首先應先考慮到性。”

 

針對這些族群的服務必須能夠處理性和藥物。復健機構Tannenhof Berlin-BrandenburgUdo Beckmann說,他看到太多的人在治療中心接受治療後病情又再復發,這些治療中心的工作人員都具有處理成癮問題的技能,但對於談論性這方面卻感覺到不舒服。

 

David Stuart評論道,“同志間的性愛是這個問題的核心”。這一切都是關於同志間之交友文化。”

 

The chemsex response is reshaping sexual health services and reinventing harm reduction

Aidsmap News, Roger Pebody, Published: 03 April 2018

Chemsex has led the French community-based HIV organisation AIDES to bring two previously separate strands of its work together, Fred Bladou told the recent European Chemsex Forum in Berlin. AIDES began to talk about drug use with gay men and to talk about sexuality with people who inject drugs, he said.

The first part of its strategy was to develop a new approach to sexual health promotion and education. On the edge of Paris’ gay district le Marais, AIDES has opened a community health centre called ‘Le Spot’ that provides HIV testing, easy access to condoms and other prevention materials, and helps develop community understanding of pre-exposure prophylaxis (PrEP) and undetectable = untransmittable (U=U). There is also a strong emphasis on peer support, including weekly peer-to-peer meetings for men involved in chemsex – described as a space that allows men to be listened to and supported, recreating social connections for men who have become isolated.

The second part of the strategy was to develop a new approach to harm reduction, including adapting it to a new population who are taking different substances. Education is provided on safer injecting practices, including staff observing an individual’s injecting practice and giving feedback on how it could be safer. Users can bring substances they have purchased in for testing, to better understand what drugs they are actually taking. Sterile equipment is provided.

A similar approach has been taken in 15 French cities where AIDES works and where chemsex is an issue. Outreach is done at private sex parties, saunas and sex clubs. The organisation also moderates a private Facebook group with around 1200 participants and a WhatsApp group, both of which allow men to share information and feel less isolated.

Stephan Vernhes of AIDES said that the weekly Paris meetings were attended by around 15 men each time, with a total of around 180 men attending in the past year. Establishing ground rules was crucial to creating a safe space, Vernhes said. Each week, participants are reminded of guidelines on non-judgement, confidentiality, active listening and related issues.

To maintain interest, different themes are addressed each week, such as sexuality and pleasure; dealing with cravings; screenings of documentaries on drug issues; and presentations by sexologists, psychiatrists and addiction specialists. As an increasing number of participants now have a goal of abstinence, some sessions now address life without drugs or sex without drugs.

There’s often a tension in the drugs field between proponents of harm reduction (aiming to reduce immediate harms related to drug use without necessarily changing the underlying drug use) and proponents of abstinence (programmes which have the aim of helping the person completely stop using). However, many at the forum felt that this was a false dichotomy. David Stuart of the 56 Dean Street clinic in London said that what was most important was to work in a person-centred way, helping the client work towards whatever goal he had set himself.

For many people at the beginning of the process, abstinence is over-ambitious, he suggested. “It’s a very big goal, very heroic,” he said. “It might be wiser to take it in small steps.”

He outlined the ChemSex Care Plan he has developed, an online tool which men can use on their own, but which is also designed to be used by a healthcare professional together with a client. For a worker who has limited knowledge or experience with chemsex, the care plan provides a structure for a conversation and an intervention. It is available in 15 different languages.

The care plan aims to help people identify a goal and work towards it. It asks men to reflect on what they like and dislike about chemsex and what they want to change. The tool helps men identify ‘trigger’ situations when they may have cravings and to think about how they will manage them.

Ingrid Bakker described how the Dutch harm reduction organisation Mainline developed services for men injecting crystal meth in Amsterdam. Around four years ago and through their connections with the gay community, staff members realised that ‘slamming’ was an emerging issue but were not aware of other professionals responding to chemsex or the situation in other countries.

They didn’t have time to have in-depth discussions about the nature of the problem or to develop detailed plans, she said. Instead they took a pragmatic approach. “We prefer to waste as little time as possible, roll up our sleeves and get to work,” she said. “We did some ground work to find out what’s happening and what are the biggest needs, and took the first steps.”

Many men knew little about crystal meth when they had their first experience. They often had poor injecting techniques that they had learnt from each other. Men also reported that the only information they had been able to find online was American and took a ‘just say no’ approach that they did not find appropriate. Mainline therefore developed web and booklet resources to meet these needs.

As the population were already engaged with sexual health clinics and often talked to staff about their sex lives, training efforts were focused on sexual health professionals. As Mainline is a harm reduction organisation that works with people who use drugs, they developed a collaboration with Soa Aids Nederland, an organisation which has the infrastructure and relationships to deliver training to clinicians.

Bakker said that it’s important to identify ‘co-responders’ who can address the issue in different ways. “The multi-sectoral response in the Netherlands grew organically, with various organizations working hard and working together to make a change, each taking responsibility for various parts of the response,” she said.

Jan Großer of Schwulenberatung Berlin said that the complex and fragmented structure of health services in Germany made it challenging to provide joined-up services. Because of different funding streams and divisions between prevention and healthcare, it is difficult to provide holistic services under one roof. This is particularly problematic in relation to chemsex, which requires competencies in sexual minority cultures, drug use in a sexual setting, psychology and sexual health. The way forward is to build networks that can plan and co-ordinate services, he said.

Großer said that men may present with problems in a wide variety of settings. The issue that a man is seeking professional help with – such as relationship or work difficulties – may appear to be unrelated to drug use. But with sensitive questioning, it often becomes apparent that chemsex is part of the problem.

When people present with some difficulty, have chemsex in the back of your mind,” he advised. “And when you are working with chemsex, think about sex first.”

Services for this population have to be able to deal with the sex as well as the chems. Udo Beckmann of the rehabilitation organisationTannenhof Berlin-Brandenburg said that he sees too many cases of men relapsing after having been treated at treatment centres where staff have skills in dealing with addiction, but are not comfortable talking about sex.

Gay sex is at the very centre of this,” commented David Stuart. “It’s all about gay hook up culture.”