An object-oriented analysis of social apps, syringes and ARTs within gay Taiwanese men’s chemsex practices

Abstract

Critical drug studies explore the discursive and material dimensions of sexualised drug use to overcome individualised and often pathologising notions such as risk, safety, responsibility and pleasure. This article uses an object-oriented approach—following the use and flow of social apps, syringes and antiretroviral therapy (ART)—to analyse gay and bisexual Taiwanese men’s drug practices. Interview data from fourteen men are used to articulate how objects were brought into gay and bisexual men’s chemsex repertoire in ways that shaped individuals’ safe-sex communication, intimacy maintenance and stigma negotiation. An object-oriented approach scrutinises risk, pleasure and identities in assemblages of the human and nonhuman, and can help identify new opportunities for implementing health promotion interventions and policies.

Keywords:

• chemsex
• materialisation
• object-oriented approach
• slam
• Taiwan

Introduction

Over the past decade, a growing body of research on chemsex has identified sexual activity combined with recreational drug use as an increasingly widespread sexual practice among gay and bisexual men who have sex with men (Bourne et al. 2015; Bourne, Ong, and Pakianathan 2018; Kong and Laidler 2020; Lim et al. 2018). With a Western metropolitan focus, many studies have reported on commonly used drugs, including crystal methamphetamine (meth), gamma-hydroxybutyric acid (GHB)/gamma-butyrolactone (GBL), mephedrone (here called the 4-chems) and cathinone (Bourne et al. 2015; Li et al. 2021; Platteau et al. 2019; Schmidt et al. 2016; Stuart 2013). Among them, the prevalence of methamphetamine use has become a particular concern among public health researchers who worry that drug-enhanced sexual activities may lead to gay and bisexual men’s disinhibition and poor health outcomes, despite the fact that the exact mechanism between drugs’ chemical properties, men’s sexual behaviours and HIV infection rate remains debated (Maxwell, Shahmanesh, and Gafos 2019; Strong et al. 2022).

The rise of chemsex in urban gay communities has prompted researchers to pursue three lines of inquiry, exploring (1) chemsex’s relations with sexual risk and HIV prevention and treatment (e.g. Carrico et al. 2016; Colfax et al. 2010; Halkitis et al. 2014; Lim et al. 2018; Maxwell, Shahmanesh, and Gafos 2019; McCall et al. 2015; Peacock et al. 2019; Stevens and Forrest 2018; Souleymanov et al. 2019), (2) the affordances of digital technology in shaping gay and bisexual men’s sexual practices (e.g. Drysdale et al. 2020; Race et al. 2017; Race et al. 2021; Møller 2020) and (3) gay and bisexual men’s sociosexual relationships, or ‘sex-based sociality’, associated with drug practices (e.g. Bryant et al. 2018; Hakim 2019; Møller and Hakim 2021; Race et al. 2017; Race et al. 2021; Souleymanov et al. 2019; Van Hout et al. 2019). Despite their different emphases, these approaches stress the behavioural, mediated and social significance of drug use, also revealing a profound concern over how and where drug practice occurs and with what effects.

Lately, an increasing number of critical studies have gestured toward a materialist approach to chemsex research by discussing, for example, how digital technology, HIV treatment and prevention medicines, and injecting drugs together shape gay and bisexual men’s management of pleasure, intimacy and identities in Western contexts (e.g. Bryant et al. 2018; Hakim 2019; Møller and Hakim 2021; Milhet et al. 2019; Pienaar et al. 2020; Race et al. 2017; Race et al. 2021; Souleymanov et al. 2019; Van Hout et al. 2019). Importantly, object-oriented accounts shift attention away from dominant public health models that stress the importance of individualised, biomedical, and behavioural approaches towards a perspective that problematises the seemingly straightforward link between chemically informed behaviours and individuals’ health outcomes. This approach highlights the need for a less stigmatising and more culturally grounded set of interventions. To date, however, relatively little attention has been paid to chemsex practices among gay people in East Asia—a place where ‘slamming’ (the act of injecting meth) has become increasingly prevalent in the past years, and where the novel notions of PrEP and U = U were introduced relatively late (in 2016) compared to many Western countries. This paper contributes to the dialogue by reporting on how gay men’s drug practices are contingent upon the use of various material objects and their circulation in Taiwan.

In Taiwan, recreational drug use has increased since the 2010s. Since then crystal meth has replaced ecstasy as one of the most commonly used drugs among men who have sex with men in Taiwan (Ko et al. 2012; Li et al. 2021). Researchers reported that up to 24% of gay and bisexual men have tried slamming, and that many have developed drug dependency, mental health problems and sexually transmitted infections as a result of these practices (Li et al. 2021). As many community workers have observed, those who use drugs and those living with HIV have invented community-specific texts and symbols to navigate stigma associated with their drug/HIV identities. Meanwhile, state surveillance continues to escalate as police authorities in Taiwan reportedly use social networking apps and Internet slang to entrap gay men for the possession of illegal substances. Despite Taiwan’s introduction of pre-exposure prophylaxis (PrEP) in 2016 and its progress in passing same-sex family legislation in 2017, the health rights of sexual minorities remain threatened.

This paper offers a qualitative account of how material objects are woven into gay Taiwanese men’s drug-sex relationships and how, during this process, gay men develop situated knowledges for managing sexual risk, pleasure and identities. We begin by outlining, based on a critical drug studies framework, what an object-oriented approach to chemsex implies. Next, based on interview data with fourteen gay and bisexual men who had ever injected meth, we explore three topics: (1) the digital materiality of chemsex, (2) injection as a form of outsourced labour in the on-demand economy and (3) gay and bisexual men’s drug-sex-based sociality in the context of the affordances of antiretroviral therapy (ART). Focusing on the digital, spatial and biomedical assemblage of these objects allows us to move between sexual, material and medical registers in our analysis, which avoids constraining our understanding of gay men’s complex drug-sex relationships to any one domain. Based on our empirical data, we identify gay and bisexual Taiwanese men’s strategies for managing health risks surrounding chemsex, while also considering how individuals’ drug experiences are shaped by the nuances of sociality.

Object-oriented chemsex

The field of critical drug studies has stressed the importance in public health research of going beyond an individualised approach to drug use. Norman Zinberg’s book Drug, Set and Setting: The Basis for Controlled Intoxication (1984), for example, theorises drug use in terms of rituals (patterns of behaviours) and social sanctions (values and rules of conduct) (also see Zinberg, Harding, and Winkeller 1977). Informed by Zingberg, Ido Hartogsohn (2017) elaborates on ‘set’ as the intrinsic features (i.e. personality, preparation, expectation and intention of the person having the drug experience) and ‘setting’ as the extrinsic components of the physical, social and cultural environment in which the drug experience takes place. Focusing on drug-related harm in the context of HIV, Tim Rhodes emphasises ‘risk environment’ in ways to overcome the limit of individualism characterising most HIV prevention and interventions so as to better appreciate the intersection between drug-related harm, health and vulnerability. Rhodes points to how the intersection of four types of risk environments (e.g. physical, social, economic and policy environments) and two levels of environmental influences (micro and macro) prompts new ways of shifting the responsibility for harm and the focus for change from individuals alone to the social situations and structures in which individuals find themselves (Rhodes 2002). Finally, by stressing the non-human factors involved in drug use, Kane Race (2015, 2017, 2019) encourages an exploration of assemblages of objects, infrastructures and subjectivity to conceive of sex not simply as behaviour, but as practical relations, experiments, play and interaction. Kane’s work focuses on digital, chemical and communal infrastructures as frameworks for these explorations. Such critical drug scholarship is noteworthy for how it considers the material specificities of drug use, theorising drug effects in light of the networks and assemblages in which bodies, drugs, technologies, practices and environment are embedded. These studies also reveal that a tension between sexual risk and drug-evoked pleasure arises from the types of behavioural interventions and pathologisations of individuals’ drug identities typically enacted in public health practices (Dennis 2019). An object-oriented analysis of chemsex is therefore based on the premise that risk, pleasure and identities related to chemical practices need to be examined with attention paid to their social and material circulation.

In order to support an object-specific reading of chemsex practices in Taiwan, this paper is organised around readings of three objects commonly reported to be utilised in chemsex. First, the paper focuses on how the use of cameras, along with the digital exchange of text, image and video content (among other forms of digital interaction), is an integral part of many chemsex repertories (Frederick and Perrone 2014; Møller 2020; Platteau et al. 2019; Race 2015; Van Hout et al. 2019). Møller and Hakim (2021), for instance, who work from Race’s articulation of the infrastructure of sexual encounters, look at how digital platforms, drugs and other environmental objects frame the body’s capacities during virtual chemsex interactions. A second type of object-focused study reports on the use of syringes in relation to gay and bisexual men’s management of risk and pleasure. As an active part of chemsex sociality in the way they materially and socially constitute addiction as an activity, syringes can be considered in terms of their design, accessibility and circulation for insights into health policy implementation (Vitellone 2011, 2017, 2018). For example, Race et al. (2021) work on slamming among gay and bisexual men encourages us to see injection as not merely a mechanical act but an integral part of sexual practice, creating new relationships of trust, intimacy, obligation, arousal and identity. A third type of object-focused analysis emphasises the role that antiretroviral therapy (ART) plays in drug scenes. Although the combination of meth, pre-exposure prophylaxis (PrEP), and erectile dysfunction treatment has been reported in chemsex and harm reduction practices among gay and bisexual men (Hammoud et al. 2018), some public health researchers express concerns that drug use among people living with HIV may affect their engagement with the cascade of HIV care (Strong et al. 2022). Against that notion of chemsex as risk, this study investigates how ARTs are also used by drug users to manage harm, disclose serostatuses and produce embodied knowledge related solidarity and intimacy.

Synthesising the approaches above, this paper considers how human and nonhuman factors come together to produce drug effects as an entanglement of practices, objects, and social relations (Dennis and Farrugia 2017). The speculative approach adopted here reorients attention away from the harms associated with drugs’ pharmacological properties and towards the forms of ethical engagement created by and maintained within the chemsex environment, aiming to identify the often neglected struggles experienced by those using drugs and, in turn, identify new opportunities for health promotion intervention.

Methods

Participants were recruited from the Chemsex Online Survey for Men who Have Sex with Men in Taiwan (COMeT). The design and results of the COMeT study are described in detail in Li et al. 2021). Respondents were recruited via a range of mobile applications that targeted gay and bisexual men who had sex with men. To be eligible for inclusion, participants needed to (1) be at least 20 years old and reside in Taiwan, (2) report ever having had sex with other men, (3) have used crystal meth at least once in the preceding 12 months and (4) have injected drugs (slammed) at least once in the preceding 12 months. In total, 14 eligible participants were recruited, ranging from 21–45 years old (mean = 33.9). All participants had college degrees or higher. At the time of their interviews, four were unemployed, and ten lived in the capital of Taiwan. Eleven interviewees reported that they had used ecstasy before turning into crystal meth. Ten interviewees had a positive HIV status. The average drug use history was six years. Participants received no compensation for participating in the study. The study was approved by the Institutional Review Board of National Cheng Kung University Hospital, Taiwan. The publication of this article was supported by the National Science and Technology Council, Taiwan.

The interviews lasted 2–3 hours and were conducted by the first and second authors between August and October 2019. Interviews were conducted in person or, if requested by participants, via FaceTime, Skype, or LINE. Semi-structured interview methods were applied. Standard interview questions covered topics that included (1) participants’ perceptions regarding HIV risk; (2) their experiences of technology use; (3) their strategies for revealing their HIV status and negotiating the issue of protection via condoms, PrEP, or Undetectable Viral Load (UVL); and (4) their learned skills of inhaling and injecting drugs into their bodies. Specific attention was paid to things, objects, events and their interactions, and conflicts with multiple agents. Attention was also paid to the paths, chains, conjunctions and juxtapositions of objects. Interviews were transcribed verbatim and analysed using an inductive approach (Braun and Clarke 2006). The authors read the transcripts, coded them thematically and organised them into topics related to the chemsex environment. To protect the participants’ confidentiality, we have changed their names in the manuscript.

Findings

Digital traces and social networking apps

The use of crystal meth in sexual encounters, commonly referred to as ‘PNP’ or ‘Tina’ in Western contexts, is known colloquially in Taiwan as doing ‘ice’, a term used more generally in East and Southeast Asian to refer to the crystalised form of meth (Guadamuz and Boonmongkon 2018; Lim et al. 2018; Tan et al. 2018). Slamming is referred to using coded language, as the word ‘slam’ is a highly stigmatised term in Taiwan. Instead, the social media profiles that participants encountered used more strategic and—according to some—respectable methods of coded communication that involved abbreviations, leetspeak, symbols and other forms of simple encryption. Examples included referring to ‘slam’ as ‘SL’, using the number 51, presenting mathematical problems such as ‘2070–2019?’ (the answer is 51) and requesting to borrow a pen (an object that, to some, symbolises a syringe).

In addition, emojis were used by nearly every participant to locate potential sexual opportunities and to navigate potential miscommunications and embarrassment. In our study, common symbols used on social apps to connote chemsex included use of the cigarette (🚬) and ice cream (🍨) emojis to mean crystal meth, candy (🍬) to mean ecstasy, the shamrock () to mean marijuana, and the syringe (💉) to mean slamming. This symbolic language overlaps with what has been reported in Thailand, where the cigarette emoji is associated with crystal meth and the syringe is understood as slamming (Guadamuz and Boonmongkon 2018). Taiwan’s emojis for chemsex differ, however, from those used in Western contexts, where, for example, the diamond (💎) and rocket (🚀) respectively symbolise crystal meth and getting high. Neither of these emojis are commonly used to connote chemsex in Taiwan and were not mentioned by our participants.

Strategic opacity

This coded language served as a filter and a protective mechanism that not only enabled convenient identification of others interested in chemsex, but also prevented unintended miscommunication. The coded nature of the text, which was apparent even to those who did not understand the code itself, deterred approach or further inquiry by individuals not in the know (see Frederick and Perrone (2014) analysis of PnP ads on Craigslist). Coded language enabled users to evade potential moral condemnation from others. This is significant because social perceptions of slamming have remained problematic even among participants using crystal meth. For the many participants who reported using ecstasy prior to using crystal meth, their journey of drug use—from casually consuming recreational club drugs to inhaling them and then to injecting them—felt like a road of ‘no return’, as one of them characterised it. This framing of their progression of drug use suggests that chemsex drug users see the act of injecting drugs as signifying a loss of control over the substance; for them, intravenously injecting crystal meth turns their drug practice into something socially and morally reprehensible. As such, drug users regularly face the threat of outgroup discrimination by other drug users who may use drugs differently, and so they find coded language useful for drawing distinctions between different ingroups according to the types of drugs used and how they are introduced into the body. One participant explained:

Although many might specify ‘No agenda’ on Grindr, it’s clear that ‘No agenda’ means solo agenda: hi fun. It’s just the norms in the community where many people are doing hi fun, but they’d be concerned that their identity would be found by others. All of those [coded] terms help us find similar others.

Besides helping to manage the stigmatisation of drug use, these digital textual practices help practitioners navigate state surveillance and phishing. Presenting the word ‘slam’ as ‘SL’ or ‘51′, using the pen emoji and posing math problems are examples of drug users’ efforts—their creative tactics—for navigating social barriers, stigmatisation and law enforcement. Moreover, the coded languages they use are highly contextualised, fluid, subject to constant modification and open to interpretation. Another participant elaborated on that point:

People put ‘Everything is possible’ [in their online profiles]. For me, that’s equivalent to looking for hi fun. They’re intentionally vague—so vague that they could only mean one thing. By doing that, they won’t be targeted by the police. But for me, ‘Everything is possible’ is like a lively invitation: very playful and flirtatious.

As our analysis suggests, the rule of thumb in navigating the digital setting of chemsex is strategic opacity, where intentional ambiguity in the use of words, language, text and symbols is a useful tool for communication. Such ambiguity offers protection and affords a form of care that allows gay and bisexual men who engage in slamming to avoid discrimination and police surveillance.

Syringes and the labour of slamming

Our participants shared two aspects of their slamming experiences that were entangled with their digital interactions with chemsex: their preparations for their first slamming encounters, and how delivering injections has become outsourced as a form of labour.

Getting involved

Among participants, a shared motivation for switching from smoking to injecting meth was to maximise sexual pleasure. Most of them, however, engaged in slamming for the first time under peer encouragement. Many participants’ first injections were unplanned and requested by sexual partners in a group setting. Some participants reported a sense of coercion to ‘go a bit further’ and ‘keep the night going’. Many participants, feeling a diminished capacity to negotiate for the sex they wanted, became caught in the dilemma between choosing pleasure and confronting the potential harm of injection.

In addition, quite a few participants mentioned that rising drug costs had become their primary reason for continuing to inject drugs. This rationale needs to be understood in the broader context of the crystal meth market in Taiwan, where many have reported scarcity of the drug due to escalating state surveillance and law enforcement. One participant shared:

In the past, I could purchase a unit [gram] of ice for TW $3,000 (US $100), but now I spend two to three times more on the same quantity. The drug price was even higher during holidays. When the drug becomes more expensive, you become more calculating in how to use it. You end up taking more risks. When you smoke it, 40% of the drug is diluted into water and air, but 100% of ice goes into your body if you inject it.

More than half of the participants reported performing similar cost-benefit analyses to justify slamming. Nonetheless, some acknowledged that slamming caused more significant harm than smoking. Some even devised unconventional methods of drug intake, such as dissolving crystal meth into lubricant to enhance sexual pleasure. Participants learned how to use drugs effectively through trial and error in social settings where chemsex was taking place. During these encounters, communication about slamming occurred nonverbally.

The nurse

A successful slamming event requires many resources and skills that not everyone has, such as a safe space, clean syringes, affordable and accessible drugs, skilful and steady hands, and competence. As such, participants reported that slamming often involved ‘following the syringe’. Some learned to inject drugs from YouTube videos or Twitter, and some indicated that they and their sexual partners injected each other. Notably, these approaches cause physical harm, such as injection site bruising (Strong et al. 2022).

In one of Taipei’s most vibrantly LGBTQ commercial districts, the act of injection has become available as a delivery service. Jong (36 years old, HIV positive) shared their experiences with requesting such services from ‘nurses’.

A ‘nurse’ is a person who offers injection services. Similar to ordering Uber Eats, you can find nurses on Grindr and request them to stop by your hotel. They arrive at our room when most of us are high and almost naked with only underwear. The cost of a single injection ranges from NT $300–600 [US $10–20], and you need to prepare your drugs and syringes. Sometimes if they are hot, they’ll stay and play with you. It all depends on chemistry.

It is unclear if the ‘nurse’ in the described context is a certified medical practitioner or a staff member of an AIDS-related nongovernmental organisation. There are also times when ‘nurses’ are enterprising laypeople with learned skills and knowledge about drugs whose injection services can be found on social apps using coded language (e.g. ‘nurse’, ‘pen’, ‘Help you with 51′, ‘I can help’ or other equivalent remarks that signal an openness to facilitating drug use). In the evenings and on weekends, nurses travel from hotel room to hotel room in Taipei’s commercial districts, where they provide gay and bisexual men with requested erotic harm-reduction services for a fee. The nurses’ online profiles, like a menu or business website, often clearly state the scope of their services and the ethical boundaries of their work (e.g. only injection, and no strings attached).

Taiwan’s situation of labour outsourcing is reminiscent of the ‘folk pharmacology’ of gay drug networks in Sydney (Southgate and Hopwood 2001), where ‘knowledge about perceived and expected pharmacological effects of drug on sexual behaviours is socially and culturally organised’. The ‘nurse’ in Taiwan’s chemsex scene is similar to Sydney’s ‘network nannies’ in that both are lay experts who are not only willing to experiment with new drugs, but also share their knowledge of how to minimise drug-related harm. There is a difference, however, in that network nannies are ingroup members. The work of network nannies therefore entails a sense of altruism in providing care and support to their friends and ‘sharing their personal experiences of drug use, teaching each other about safe modes of administration and demonstrating safe and controlled drug use through their actions’ (Southgate and Hopwood 2001, 330).

The chemsex services that ‘nurses’ provide in Taiwan are distinct from those of network nannies because nurses perform professional work that is, based on our observation, an opportunistic, transitional way to fit into the larger context of the on-demand economy. Chemsex nurses can therefore be interpreted as an outsourced labour force for gay men’s chemsex care, and new health services like these are made possible in urban Taiwan primarily by the density of LGBTQ-related businesses (e.g. hotels, saunas and bars) and sexual health services (e.g. HIV testing sites and health clinics). The assemblage of these online and offline infrastructures in northern Taipei, with their further links to the gay-friendly commercial district, enables these male nurses to be relatively mobile as personal workers traveling between hotels during nightime hours. But, given the secretive nature of chemsex, it remains unclear how trust is established and maintained in the in-person encounters with the nurses once they arrive on the scene, especially in any verbal or nonverbal communication that occurs, and how community-based health interventions can be better tailored to support harm reduction in these contexts.

Acts of (non)disclosure statement and antiretroviral therapy (ART)

This section considers how biomedical interventions for HIV—that is, physical medicine and biomedically informed understandings about HIV prevention—find their way into contexts where chemsex is practiced.

Acts of (non)disclosure statement

All participants recounted experiences with condomless anal sex in chemsex. Most participants explained their practice of going condomless in terms of sexual sensation, emphasising that condoms reduced pleasure and intimacy. At the same time, all participants reported implicitly assuming that condomless sex was risk-equivalent to having sex with an HIV-positive person. Some saw this assumption as a sign of the rampant stigmatisation of HIV in the community. Fred (30 years old, HIV positive) explained:

When it comes to condoms, everyone I’ve met would say the same thing: ‘Since we’re doing hi fun already, what are you afraid of?’ No one I’ve ever had sex with has used condoms. You don’t ask about their HIV status or willingness to use condoms. But I guess we’ve all assumed that at least 70% of us, or more, are HIV positive. But, if you bring up the topic (e.g. serostatus) afterward, my experience has been that most people are willing to tell you they’re positive, too.

Many participants’ hesitations to inquire further into their partners’ HIV status were closely linked to an assumption that those engaging in chemsex were already HIV-positive, and that asking them thorny questions might hinder the progress of the sexual encounter. Fred’s experiences resonate with our provisional findings on the digital setting of chemsex, where communication occurred on social apps in such a way that questions about the risk of HIV and safety were rarely expressed, whether before or during sex. Many participants’ assumption that those who engage in chemsex are HIV positive—assumptions made to prevent risk of social ostracisation—suggests that, in this context, risk management is not about obtaining ‘safer sex’ in the biomedical sense, but rather about how to make sex socially safer (Bourne and Robson 2009; Bourne et al. 2015). Like many other types of sexual practices, chemsex is not always planned in advance or executed well. In the heat of the moment, initiating a discussion that carefully elicits a partner’s sexual history and STI status—a strategy suggested by the concepts of biomed-matching and serosorting behaviours—becomes challenging. As Fred’s remarks illustrate, participants reported tending to minimise discussion of sexual safety in order to avoid unnecessary embarrassment or trouble.

The lack of verbal conversation does not mean, however, that gay men are not taking steps to protect their health. As was the case for many others, Hank (39 years old, HIV positive) developed his own protocol for sex that he felt could be understood by both parties as safe:

My profile clearly states, ‘Make out, cum play, and BB [barebacking sex]’. I don’t specify that I’m looking for hi fun, but the hidden message is clear enough. If you recognise those keywords, you’d know my intention.

In addition, Hank relied upon communication of his undetectable viral load level as a means to regulate his safer-sex practice, underscoring a shared responsibility for harm reduction:

Having suggested that I’m looking for ‘BB hi fun’ and that I’m aware of my viral load count, I think that if you’re still interested in meeting up, it’s also your responsibility to use PrEP or whatever safety measure you feel comfortable with. Otherwise, I assume that you’re like me [HIV-positive, undetectable].

Health interventions could look to these indirect means of conversing about safer sex for ideas of the kinds of safety that those using drugs already gravitate toward, and consider how they could move them into the realm of direct conversation.

ART as vicarious sociality

Some participants shared that, in some circumstances, if people did not ask about each other’s HIV status, ‘HIV medicine will do the talking’. That is, instead of ignoring the conversational point of HIV-status disclosure altogether, they developed situated methods of letting the medicine talk—using ART, the medicine taken in HIV treatment, to disclose their HIV status. Because people living with HIV need to follow a daily ART regimen, and because chemsex encounters sometimes last an entire night or weekend, chemsex practitioners are likely to need to take their medication sometime during such prolonged sexual activities. Some participants reported intentionally placing their ART in an open, conspicuous space in such cases, where it served as a visual, nonverbal cue both for themselves to take the medication and for others to inquire after relevant information. Dong (31 years old, HIV positive) shared his experience:

I never hide those bottles. I always put my medicine on top of my desk. My intention is to let my sexual partners know that I’m HIV positive. If they ask what the medicine is for, I’d explain. There have been times when people have told me directly that they’re taking the same or other types of medication.

By intentionally displaying his medication, Dong’s gesture piqued his sexual partners’ curiosity, which in turn sparked a conversation about sero-disclosure. Here, ART functioned as a material extension of his HIV status that helped him to navigate sero-disclosure and broach the thorny topic of his HIV-positive status, a condition that he reported being otherwise reluctant to voice explicitly to partners prior to sexual encounters.

As objects, ARTs functioned as resources within a drug-informed sociality, allowing chemsex practitioners to engage in extended dialogue about self-care and care for each other without confronting the loaded meanings of HIV head-on. Drug-informed sociality builds on the concept of ‘sex-based sociality,’ defined by Bryant et al. (2018) in a context where Australian gay and bisexual men use drugs and sex as social resources to establish relationships, build identities, and participate in gay communities. Our data suggests that, in a drug-informed sociality, social relationship management centres around the politics of visibility. The intentional displaying of ART affords an opportunity for gay and bisexual men who have sex with men to reveal their own and inquire about others’ sexual health conditions. Furthermore, the intentional displaying of ART visually, physically and spatially extends sex-based sociality beyond the boundaries of the human by allowing individuals to manage their HIV-related identities and desire through biomedical objects. Derek (30 years old, HIV positive) described navigating relationship intimacy using ART due to his discomfort with stating outright that he was HIV positive:

I’d never reveal my HIV status if it [sex] was just a random hook-up. However, if I’ve developed a strong feeling for the person, then I’d tell him, ‘I take my med regularly, and I’m undetectable.’

As a result of making that particular gesture, Derek has established several long-term relationships: ‘When the other person also tells me that he’s taking the same or a different medicine in the heat of the moment, you definitely feel a strong sense of connection.’ As Derek admits, however, whether or not he discloses his serostatus depends upon the intensity of his feelings for a partner.

Even though ART can extend chemsex practitioners’ capacities for engaging in less oppressive communication, it can also impose new communicative barriers. To compare the intentional displaying of ART in a physical setting to how ART functioned in its biomedical setting, we looked at how HIV-positive participants perceived PrEP as a tool for safer-sex practice. Most interviewees, due to either their positive serostatus (71%) or prolonged history of using recreational drugs (78%), were familiar with, or had at least heard of, PrEP and the concept of U = U. Lawrence (39 years old, HIV positive) described his dilemma of choosing between ‘POZ’ and ‘HIV Negative, on PrEP’ as labels for conveying his U = U status:

For me, U = U and PrEP are the same things. I tell my sexual partners that I’m on PrEP because I’m undetectable and not infectious to others. I also prepare a bottle of PrEP to show my guests that I’m taking Truvada. If my sexual partner has no idea what Truvada for PrEP is, then I sometimes explain and possibly offer him some pills.

Lawrence’s experience illustrates how gay men navigate between different biomedical treatment regimens to find a compromise approach to achieving their sexual goals. Lawrence clearly understood the benefit of U = U. But his experiences also illustrated the need he felt to navigate around the lower acceptance of U = U among HIV-negative individuals as a safer-sex practice compared to their acceptance of using Truvada for PrEP.

Discussion

This qualitative study examined gay Taiwanese men’s chemsex practices. Public health scholarship on chemsex often prioritises an individualised understanding of meth use, assuming a correlation between risk-taking behaviours and drug use, and therefore producing individualised, behaviourally-based health interventions (Maxwell, Shahmanesh, and Gafos 2019; Race et al. 2017). Adopting an object-oriented perspective, the study paid closer attention to sexual behaviours and the use of objects (drugs, social apps, syringes and ARTs). It also revealed how those objects afforded gay and bisexual men opportunities to manage both health and social risks and thereby sustain their sociosexual relationships. The seemingly straightforward, one-size-fits-all interventions in public health should be re-assessed and modified. A situated intervention grounded in the community that can engage the digital, sociosexual complexities of drug use should be implemented.

Our object-oriented account resonates with Race’s (2019) discussion of ‘Queer ANT’ insofar as non-human factors—such as coded language, emojis, slamming, syringes and ARTs—were brought together in gay and bisexual men’s erotic experiments and sexual play. By tracing how these objects were used, displayed, interpreted and represented, we were able to better understand gay and bisexual men’s encounters of risk, pleasure and identity in chemsex, and make sense of their relationship with stigma management, state surveillance and HIV science. Our analytical focus on digital, coded texts also afforded insight into the politics of visibility. The digital materiality of the coded texts manifested the productive secrecy of chemsex play, revealing an ingroup-based sense of shared knowledge among those who used drugs and utilised similar coded languages. These digital practices allowed individuals to negotiate their drug/HIV identities while creating opportunities for slamming and the delivery of harm-reduction services on demand. At the same time, however, these digital practices manifested the power of surveillance, whereby gay and bisexual men continue to be subjected to state oppression and outgroup discrimination. Participants’ admissions to tacitly assuming all their chemsex partners were HIV positive—preferring risk to their own health over the social risk of frank and open discussion—was further evidence of such oppression. Our findings about secrecy corroborate research findings from studies conducted in nearby Asian countries, where chemsex takes place via coded languages, secret gatherings and underground transactions (Guadamuz and Boonmongkon 2018; Tan et al. 2018; Lim et al. 2018). The textual practices shared across chemsex scenes offer a broader backdrop against which to explain why and how certain sexual practices and harms unfold. Future research could potentially compare how cyber arrangements of chemsex in geographically proximate countries respond to rapidly changing HIV science and increases in global travel and interaction among gay and bisexual men.

Our study of slamming also revealed that the act of injection has become outsourced as a delivery service in Taiwan’s urban areas. This finding resonates with studies conducted in Australia (Southgate and Hopwood 2001; Race et al. 2021) and Thailand (Guadamuz and Boonmongkon 2018) in a particular way: the observation that the administration of drugs tends to operate along social hierarchies and sexual identities. Our study adds to this area of research by discussing the outsourcing of labour and the online-delivery aspect of injection services, investigating how the factors of desire, drug access, lay knowledge and HIV risk intersect in the cost-effectiveness mindset of drug users. Given the new harms made possible in a climate of loosely regulated drugs and cost-induced drug scarcity, future research and health interventions should further explore the economics of chemsex and identify opportunities for intervention.

Finally, the field of public health often views ARTs as a means of biomedical rather than social or cultural intervention. Research on chemsex and intimacy has also contended that chemsex settings offer superficial social contact while limiting opportunities for deeper emotional attachment (Pollard, Nadarzynski, and Llewellyn 2018). By scrutinising the social use of ARTs, this paper reveals that ARTs function in both digital and spatial settings as part of drug users’ strategies for navigating social stigmas and a complex array of HIV-related sexual identities. These strategies manifest in three ways: (1) the implicit assumption in chemsex encounters that one should not disclose one’s HIV status, (2) letting the medicine ‘do the talking’ and (3) using ARTs in a physical environment or in digital communication to display one’s HIV-related status. These strategies are notable for how they make ARTs visible while rendering HIV stigma in/visible. They also show how drug users engage thoughtfully with these medicines to navigate everyday dilemmas of weighing the priority of sexual pleasure against the social harms of HIV disclosure and surveillance. While the predominant mode of sexual education attempts to enhance individual capacities for decision-making and negotiation, our analysis shifts attention away from individualised harm- and risk-driven concerns to care- and relationship-based sociality. Sexual communication and education interventions might need to adopt a situated approach for considering the biomedical setting of chemsex. Future research could investigate how HIV medicine and the notion of U = U can serve as environmental-emotional supports in drug-related health interventions.

The current study is limited in its scope and sample size. Recruiting and eliciting information from sexually marginalised populations has been challenging in many Asian contexts, and our study was no exception. Having a larger number of informants who are intentionally recruited for demographic and regional diversity, different life experiences with a greater variety of drugs, or long-term observation would shed further light on the material interpretation of chemsex. Using a lens that emphasises objects and other relations to sexual practices, we contend, offers a more nuanced way of considering how risk, pleasure and identities are contingent on human as well as nonhuman actants. It suggests how we can consider sexual health interventions along more expansive lines. Ultimately, this study calls for the need to ‘think with’ relationships in assemblages of the human and nonhuman, paying attention to the paths and trajectories of objects’ use so that we can gain a more nuanced understanding of less visible real-life struggles in the rapidly changing chemsex epidemic.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

The publication of this manuscript is supported by the National Science and Technology Council, Taiwan (grant number: MOST111-2410-H-002-261-MY2).