Chemsex

The term "chemsex" comes from the fusion of two English words: "chems", a euphemism for drugs, and "sex". It refers to a set of practices, which has become particularly visible among men who have sex with men (MSM), involving the use of drugs in order to facilitate, prolong or intensify sexual experiences.

The phenomenon was recognised in professional circles from at least 2010 and reached the media after a paper in a prestigious scientific journal (BMJ) and a 2015 documentary that dwelt on its most lurid and sensational aspects.

Chemsex has been associated with certain characteristics and practices:

• Several people taking part in a single sexual encounter
• Use of phone apps to find sexual partners
• Encounters lasting a long time (many hours)
• Intravenous use of some drugs (methamphetamine, mephedrone)
• Low rates of condom use.

These associations have been shown consistently across different studies. But that does not mean every user systematically does all of these things. Intravenous use is particularly dangerous, although statistically very infrequent. Other associations need explaining: many users take PrEP (preventive medication against HIV infection) or are HIV positive and on treatment, and so do not transmit the virus. Many of these people accept the risk of other STIs (mostly bacterial and treatable with antibiotics) in choosing not to use condoms.

The consequences chemsex may have for people’s health and wellbeing are difficult to analyse. Using the biopsychosocial model, we can pick apart the elements that make up the phenomenon and arrive at a fuller picture.

1. The individual: myself and my circumstances

From this angle we find a diversity of histories, motivations and personal circumstances.

On one side there are adults with previous experience of recreational drug use, who come to these substances knowing their risks and dosing prudently. On the other we see young people in their first explorations of sex and of drugs — sometimes young people from rural areas or small provincial towns where they have not been able to express their sexuality freely. The impact of the almost infinite offer of sexual entertainment and drugs in large cities leaves them especially vulnerable to problematic patterns of use.

For some people the motivation is recreation and pleasure. Others use drugs as a way of coping with personal adversity: internalised homophobia, shyness, an HIV or STI diagnosis, or the lack of a solid support network. Chemsex can be a choice, or the reflection of inner struggles and complex personal circumstances.

2. The substances: three heavyweights

Sexual drug use need not be a problem in itself. But it is equally true that a significant proportion of regular chemsex users end up developing problems. That is explained in large part by the characteristics of the drugs most associated with chemsex.

• Methamphetamine is a very powerful stimulant lasting 6–8 hours. It has a high addictive potential and can be used intravenously. It is active at very small doses, and intoxication can produce very serious physical and psychiatric symptoms.

• GHB/GBL is a central nervous system depressant with effects relatively similar to alcohol: at low doses it produces disinhibition and euphoria, but at high doses a deep sleep that can lead to coma. With GHB/GBL the difference is a few millilitres. As with alcohol, daily use can produce dependence and a severe withdrawal syndrome if use stops abruptly.

• The effects of mephedrone (4-methylmethcathinone, 4-MMC) have been described as a mix of a stimulant (cocaine, amphetamine) and MDMA. It too can be used intravenously and can produce dependence. Unlike the previous two, it has barely been studied in humans. Its prohibition in 2001 was followed by the appearance of similar but technically legal substances such as 4-MEC and 3-MMC. Since then we have watched a macabre game of cat and mouse in which every ban is followed by new cathinones, structurally stranger each time and with ever less predictable effects. Most of the "meph" available on the black market today consists of mixtures of these compounds.

3. The context: between socialising and stigma

The social context plays a crucial part in shaping chemsex. The main aspects are:

• Users face double stigmatisation and discrimination: on one side the prejudice attached to drug use, on the other that attached to non-normative sexual practices.
• Being an immigrant, having a transgender identity, doing sex work, low socioeconomic status or mental health problems all multiply the risk of problems arising. They are also stigmas and grounds for further discrimination.
• All these factors get in the way of seeking help and support when problems appear. And the people at greatest risk are the ones who find it hardest.
• Social rejection of these practices, and the feelings of shame or guilt that come with it, can have a significant impact on psychological wellbeing. Some people withdraw or come to socialise exclusively with others who practise chemsex.
• Historically, the social identity of "the gay person" was forged around nightlife, one of the few spaces for expression and self-realisation free of prejudice. That connection partly explains a greater tolerance and normalisation of substance use in these settings, and highlights the intersection of culture, identity and drug use.
• In general, the media’s approach (occasionally backed by self-appointed "experts" and "community representatives") seeks only to scandalise and shock the viewer enough to hold their attention until the next commercial break. That distorted picture perpetuates stigma. It is also a subtle, twisted form of homophobia, infinitely more perverse than crude jokes.
• None of the above is incompatible with recognising that chemsex carries significant risks. Specific resources must be devoted to prevention and care, above all for the most vulnerable groups.

1. Professional clinical experience

Between January 2017 and December 2022 I saw a total of 97 patients who consulted in relation to chemsex. All of them were men.

32.98% were seen by video consultation, 27.83% in person, and 49.98% through a combination of both.

40.20% were seen on a single occasion. These were mostly one-off questions that could be resolved in one session.

21.68% of patients had between 2 and 10 therapy sessions.

12.37% of patients were in therapy for between 6 months and 2 years.

41 of the 58 patients completed their treatment as planned and agreed with the practitioner. 15 patients left treatment voluntarily but unilaterally. One referral was made to an inpatient setting because outpatient treatment was not viable, and another for severe psychiatric illness.

2. Community project

Between 2017 and 2020 I coordinated the launch and development of the CHEM-SAFE Project, within Energy Control and funded by ViiV Healthcare.

It was the first online information and prevention resource on chemsex from a harm-reduction perspective. Working with NGOs and activist groups for LGBT+ rights and people living with HIV, we built a website that remains a reference point today.

In 2018 the CHEM-SAFE Project was highlighted as a model of good practice in this international report.

3. Teaching, research and public communication

Between 2016 and 2021 I was a member of the Chemsex Working Group of the Spanish National AIDS Plan at the Ministry of Health. I have contributed to institutional reports, clinical guidelines and national and international conferences.

From 2015 to the present (eight editions up to 2023) I have taught on the online course "An integrated approach to sexual health and drug use problems in the context of chemsex", run by the National School of Public Health at the Carlos III Health Institute.

I was recently invited to take part in this podcast.