 And our final speaker this morning is Dr. Adam Bourne, who is an associate professor at the Australian Research Center in Sex, Health, and Society at La Trobe University. Dr. Bourne's work examines patterns of drug use among LGBT populations and their specific harm reduction policy and service delivery needs. So among other things today he will discuss HIV exceptionalism and the fact that research on gay men only looks at drug use in relation to sex sexual risk rather than examining it as an important issue by itself. Dr. Bourne. Thank you very much, Monique. And I can assure you that when I stepped off the plane after 35 hours of travel through a foggy haze of jet lag, the first thing I did was reach for some poutine. I love Canadian cuisine, so. Okay, it was a great honour to be asked to give this talk, specifically on LGBT drug use. Also something of a challenge, I was just saying to Trevor, it's difficult for someone in my position to think of how to condense such a complexity of evidence and literature relating to a whole population of people into only 12 minutes. I've tried to keep it concise and I've tried to think of the four key things I'd really like you to go away knowing a little bit more about the four things I'd like you to remember. So first of all, diversity. One of the most crucial things to remember when you're thinking about LGBT populations that this is not a homogenous group of people. We share in common a marginalised identity, a member of a minority group. We might share in common the fact that we're attracted to someone of the same gender, but beyond that, we exhibit all the same kind of complexity and variation as you would see in any other population. There are lots of differences between lesbian, gay, bisexual and transgender people as well as among them. If you look at the ranking of different substances that are most popular for lesbian and bisexual women, then of course cannabis comes pretty close towards the top. Alcohol is most definitely the most popular substance as it would be with heterosexual women as well. But what's important is that studies from Canada, the US, from Australia, from the UK, the Netherlands, Germany, lots of places tell us that problematic alcohol use is significantly higher among lesbian women compared to their heterosexual counterparts. And it's a difference you actually don't observe in relation to gay men versus straight men. If we are talking about gay men though, cannabis of course comes near the top, but you also observe a much higher prevalence of so-called club drugs or party drugs. Cannabis, I'm sorry, ecstasy, cocaine, methamphetamine, GHB or GBL, and these are present for lesbian and bisexual women in lots of surveys, but they certainly nowhere near as high. When it comes to transgender populations, to be honest, it's astonishingly hard to say. There is extremely little data collected and published about transgender people. There are a handful of community surveys conducted around the world that tell us something, and there are a lot of other surveys that kind of quite awkwardly tack on transgender people onto surveys about gay and bisexual men. And what you see in all of those is that transgender people probably have the highest drug use of all within the LGBT populations. When we have samples that are large enough to look at the constituent parts of populations, if we're looking just at gay men, you see associations with ethnicity, with income, with education, all of the kind of usual axes of health inequalities. We know that problematic use is much more likely among gay men who are from poorer backgrounds, who are of minority ethnic status, sorry, minority ethnic origin, and who have lower levels of educational attainment. All LGBT people have more than one identity is the point I'm trying to make. Now the prevalence of drug use among LGBT populations isn't always very easy to establish because quite simply, in many countries, we don't ever ask the question. And at least a quarter of countries around the world, including most of Africa, most of the Middle East, most of Central Asia, and a lot of far Eastern Europe, we simply don't have any data whatsoever. And in a lot of other countries, we're reliant on one or two very small-scale community surveys that were often conducted quite a few years ago, and the data's very out of date. There are very few countries where in their national health or household surveys, they collect and disaggregate data by sexual orientation. And this is the ideal means, really, of establishing whether there are differences between different parts of the population, when you're using that same kind of methodology in the same sampling frame. But very often, questions about sexual orientation aren't asked, or inappropriate, or inadequate questions about gender identity are asked. And we know that a lack of evidence is very often used as an excuse for inaction. Trying to secure government or donor support for LGBT-specific interventions is challenging if we don't have the data to illustrate the prevalence of use and the extent of harm among these populations. But in nearly every survey that has been conducted that does disaggregate data by sexual orientation, we see significantly higher rates of use among lesbian, gay, and bisexual people than we do their heterosexual counterparts, significantly higher. So as two examples, from the data from the crime survey of England and Wales, established that the use of any illicit drug within the previous 12 months was five times higher among gay and bisexual men compared to heterosexually identifying men. The use of stimulant drugs was seven times higher, and the use of chrysanthomethamphetamine was 15 times higher among gay men compared to heterosexual men. In relation to lesbian and bisexual women, the use of any illicit drug was four times higher than among heterosexually identified women. If you look at data from Australia, from the National Drug Strategy Household Survey, it also shows significantly elevated rates of use among sexual minorities, and the use of any illicit drug within the previous 12 months was at least three times higher for both gay and bisexual men and lesbian and bisexual women. And there were a handful, a small number, of surveys from other countries that reinforce this same kind of pattern. But what about the harm that they're exposed to? Prevalence is one thing, but what harm are they exposed to or experiencing? Now, LGBT people are people. Many of the harms that they are exposed to when using drugs are exactly the same as would be the case for any other population, but they're much more concentrated given those significantly higher rates of use. And the harms may be amplified due to the additional marginalization that they often experience. At a population level where we have the data, opiates haven't often been the drug of choice for many LGBT people. So perhaps unsurprisingly, injection drug use had historically been relatively low. But as we heard in Katie Stone's opening yesterday, and as we heard again in the stimulant session in the afternoon, we are seeing significant rises in the injection of stimulants. And LGBT people are definitely a part of that picture. We're seeing increasing rates of injection of crystal meth and of methadone in several parts of the world now. And remember, this is a relatively naive population in terms of injection drug use. And I think we have to be very attentive to whether or not we're meeting their safe needle and syringe exchange harm reduction needs. But there are also harms that are a little more unique to LGBT populations, given their much high likelihood of using certain drugs. So GHB, for example, is really the one that I think in many countries we're most concerned about. It's a drug you take in very small, carefully timed doses. It makes it very easy to overdose. And earlier, just a few months ago, toxicologists at Imperial College in London found that the number of deaths from GHB in London had more than doubled between 2014 and 2015, with one person dying every 12 days of a G-related overdose. And as far as we're able to tell, the vast majority, if not all of those, were gay men. And crystal meth, obviously a drug used by multiple populations, but as I said, this significantly higher prevalence among gay men makes it a particular concern. And there's lots of data documenting ambulance submissions for people requiring medical assistance in dealing with panic attacks, with paranoia, hallucinations, and these mirror findings documented in London and North America and several other parts of the world. And there's also a fairly robust literature indicating that the adherence to antiretroviral therapy is significantly reduced, impeded, when using crystal meth among HIV positive men. Now I mentioned the association between drug use and HIV antiretroviral therapy with some degree of hesitation, actually, because I'm always very reluctant to reinforce the idea that the only drug-related harm for LGBT people, or for gay men specifically, is HIV. The vast majority of studies conducted worldwide among gay men and drug use are focused on understanding the relationship between drug use and sexual risk-taking behavior. The likelihood is this taking this drug, causing you to do something risky where you'll transmit HIV or another STI. We've been completely obsessed by it. This is the only time we paid attention to drug use among this population. And the answer, after those hundreds of different studies looking at that relationship, is that it's complex, it's quite complicated. Yes, there's definitely a correlation between the two, between using drugs and sexual risk-taking, but it isn't necessarily causal. Chemsex, the use of drugs or party and play, the use of drugs in sexual settings, has dominated media discourse and media coverage of gay men in lots of countries around the world over the last few years. But Chemsex is always treated as a sex problem. It's seeing, oh, if many using drugs in a sexual setting, the anxiety is about whether or not they're transmitting HIV or STIs. And far less attention is ever paid to overdose, to drug-related deaths, to injection site injuries, to the psychological harms and traumas that we know people are experiencing. Of course, sexual behavior and HIV is an important issue for gay men. There's a massively disproportionate burden of HIV among this population. I've spent the last 10 years of my working life on this topic, of course, I think it's important, but I think sometimes the obsession with HIV is to the detriment of other health concerns among gay and bisexual men. LGBT drug use is more than just gay men, and gay men are more than just HIV. And my fourth point then, service in terms of service provision, what is the current state of harm reduction for LGBT populations and what should it look like? Well, I think we can probably agree that the world over, the majority of drug services specialize in opiate addiction, and in opiate addiction, harm reduction, more so than it does in relation to stimulants and other drugs that are commonly more popular among LGBT people. And it's simply the case that many drug services don't necessarily have the skills or the capacity or the experience to work with the particular harm reduction needs of this population. Studies indicate that gay men often have higher rates of substance dependence and of psychological distress at the point of treatment entry into traditional drug services, but they also have worse treatment outcomes when compared to heterosexual men in traditional drug service settings. It's often a perception or indeed an unfortunate experience of discrimination by LGBT people from healthcare staff, and it's a very sad fact that LGBT people experience a great deal of discrimination at the hands of those people who they look to for help or support. And this causes reluctance in approaching harm reduction services who are often seen as part of that same healthcare system. And often this is especially because of fears that staff won't understand the world that they live in and the settings in which they use drugs, the gay bars and clubs that they frequent, the LGBT social scenes within which their drug use is very intertwined. The sexual contexts of use, if you are an LGBT person who engages in chem sex, trying to explain that highly sexual and adventurous environment to someone who has no conception of your world can be really challenging. And of course, the personal reality of being gay or being lesbian or being transgender. And I'm really reluctant to pathologize drug use, but it is a reality that for many people who have a problematic relationship with drugs, coming to terms with their sexual identity or their gender identity is often central to how and why they're using them. And this can be really hard to discuss with someone who doesn't understand or has no training on how to address these kinds of issues. There is a small but growing body of evidence to inform what good harm reduction for LGBT populations should look like. And it's not rocket science. It's the things that we should already all know that services need to be technically competent in the drugs that this population are using and the appropriate harm reduction techniques, that they recognize the role of drugs in LGBT communities and aren't judgmental of the settings or contexts of their use. And that their LGBT affirming, okay, some people may be struggling with their sexual agenda identity, but they should not be made to feel that they are abnormal or that there is anything wrong. They should be supported to make sense of their reality and to use drugs in a way that is safe for them. And then let's not kid ourselves. The biggest barrier to implementing such services for LGBT people is the ongoing criminalization of same-sex populations and the social exclusion of people who are transgender. More than 70 countries in the world still criminalize homosexuality. And it's these laws that stand in a way of making a difference. My four key points in 12 minutes. LGBT people are diverse. They use drugs significantly more than their heterosexual counterparts. They experience a range of harms. Some of them are very similar. Some of them are very unique and often overlooked in drug services. And they often struggle to access services that meet their needs. We should all think about what we're doing to address this. Thank you.