When it comes to chemsex, the findings of various international studies all agree: 20% to 30% of men who have sex with men (MSM) engage in this practice, which is becoming more and more prevalent. Chemsex combines sex, drugs, and smartphones, and physicians know very little about it. Dedicated consultations were instituted in the fall of 2019 at the Infectious Diseases Department at the Saint-Louis Hospital in Paris. It's estimated that 1000 persons who were patients there practice chemsex.
Alexandre Aslan, MD, is one of the department's physicians; he is also a sexologist and psychotherapist-psychoanalyst. At the ALBATROS International Congress of Addiction, which took place in the French capital in June, he presented the results of a study of patients who engage in chemsex and who regularly attend those consultations. Through this research, light is being shed on the phenomenon.
Medscape French Edition invited Aslan to discuss the issues connected with this practice.
Medscape: What exactly is chemsex, also known as party 'n' play (PnP)?
Aslan: Hearing the word "chemsex," one would automatically think that it is what it sounds like it is: having sex while on drugs. That's not really what it is. According to the definition that's been published in the scientific literature, chemsex is a practice seen among men who have sex with men (MSM), where they take some very specific substances during sexual activity to sustain, enhance, or intensify the sexual experience, but also to "manage" issues related to intimacy, performance, and concerns about sexually transmitted infections (STIs). The substances are most commonly a cocktail of three drugs: GHB [gamma-hydroxybutyrate], cathinones, and crystal meth. In chemsex, smartphones play a central role as well, through the use of social networking and dating applications — those location-based apps that allow users to instantly find partners.
Medscape: In what ways does meeting through apps influence the sexual relationship and the use of substances?
Aslan: Because the plan to meet up for sex is being made through these kinds of apps, the promise to have sex is often implied — and this is before the individuals even meet up in real life. Let me explain. It's not an encounter or a person that's going to trigger sexual desire. Instead, it's something within — the sexual "urge" inside of the individual — that's going to drive them toward sexual activity. Now, finding yourself promising to have sex with someone — someone you don't know, haven't spoken to, and haven't actually met — in an environment where it's possible that you'll meet several people and where the moments in which the sexual acts take place are predominantly characterized by pornography-related performance scripts: this can push you to take substances so you can "let go" and get to the point where you're able to adapt to the requirements of the situation. Seeking to perform well and to not be overly inhibited, these individuals have found that this drug cocktail proves to be quite explosive, imparting a very strong capacity for experiencing excitement and even bringing about new sexual practices.
Medscape: Can you speak a bit about drug-enhanced sex?
Aslan: We sexologists consider it to be a very particular type of sex. People who engage in it feel that the sex is very intense, with unbelievable experiences, and that they have a deeper connection with their partner. In fact, it's a type of sex where taking these substances does away with the very principles of sexual physiology — in other words, desire followed by excitement, plateau, orgasm, and resolution. Little by little, one's sexual partner is no longer going to exist in the sex session, and the benefit is a succession of partners whose sole purpose is to keep the fire of excitement burning, an excitement that's also reinforced by the substances taken. It's "sex" under the influence rather than a sexual encounter linked to desire.
Medscape: What impact does it have on health?
Aslan: This practice brings with it numerous complications, such as STIs, but also physical injuries, as these sessions can last for 24 to more than 48 hours. There are also psychological complications, because these drugs can bring about depression, paranoia, self-harm, and even episodes of decompensation. And then, it should be noted that later on, the spotlight gets pulled away from the sex — the pretext from the very beginning — and shifts toward the taking of drugs: the individuals will no longer be able to separate the sexual encounter from the taking of drugs. Then, in a few years, there's no longer the sexual encounter, only the taking of drugs. In the United States, between 2021 and 2022, there was a decrease in the number of deaths caused by heroin and prescription opioids. On the other hand, since 2020, the overdoses that have exploded in number are those related to fentanyl, nonprescription opioids, and stimulants — cocaine and methamphetamine, which can come back into the practices particularly through the seemingly "playful" arena of sex.
Medscape: How is it that things have gone from being a practice that's under control to full-on drug addiction?
Aslan: You still have people who manage to keep things under control. But the kinds of drugs that are taken are highly addictive and compel the individual to take even more. It's one big circle: the exciting sexual relationship itself, to which you add substances that cause even more dopamine to be released, and a smartphone screen with excitatory pornographic images on it all the time. In all the patients we see, we notice a trajectory that looks like the trajectory of every drug. When they're at the beginning — in other words, the first year — after a first experience that they consider to be explosive, they may not return to the scene right away, and then they do return to it. They realize that it's perhaps not as marvelous as the first time, but they're going to give it another try. During this novelty phase, a strategy is pursued whereby they adapt and make adjustments in an attempt to feel again what they felt the first time. At the end of a year or two, they become disillusioned and they refocus on all activities having to do with drug use. Our hospital department conducted a survey where we asked detailed questions to over 100 individuals. It showed that people noticed the negative consequences that chemsex had on their work (60%), on their private lives and sex lives (55%), and on their relationships with friends and family (63%). This means that people are well aware of the negative effects that this practice has in very important areas of their lives. But even if they notice all of that, even if they resolve to have a certain number of sexual relations without drugs involved, these substances are so powerful in releasing a rush of dopamine that that very fact can sweep away any capacity the individual may have had to make a decision and stick to it, and they're going to feel practically "compelled" to use. This is what's called a craving.
Medscape: How do you identify patients who engage in chemsex among the patients in your infectious diseases department?
Aslan: As a rule, all patients admitted to our department are asked a series of questions. Do you use drugs to engage in sexual relations? Which drug do you prefer? How do you take it? Do you have a good time? Do you find that it's good for you? Are you okay with how much you're using? We also ask patients to tell us when they last had drug-free sex. It's a very important question, because if we can identify someone who has had 10 or so partners a month but hasn't had drug-free sex for over a month, we'll try to steer the conversation to where they'll come to think that it might not be such a bad idea to talk about it.
Medscape: Should a physician be asking younger patients whether they're engaging in chemsex?
Aslan: Yes, but the physician has to be very careful. We often have a tendency to believe that we're capable of speaking with our patients about relevant matters related to sex. We see ourselves as that kind of person, not to mention we're open-minded. Now, as in all fields of medicine, we have to educate ourselves about how best to approach patients — in this case, about their sexual health. Because sometimes, despite our best intentions, we can do harm. The idea that we have of our own sexual behavior does not necessarily help provide counsel regarding another person's sexual behavior, particularly when there are differences between the two. If you're interested in the issue, you need to be trained on all the answers that could come up. There are training courses online. There's a module on sexual health and chemsex at a site designed to give private practice physicians guidance about PrEP. It's at least a place to start. This way, physicians will know what questions they can ask and when they should reach out to a specialist, such as a sexologist with training in these specific issues.
Medscape: What is the treatment based on?
Aslan: The traditional approach taken by addiction medicine physicians may not be comprehensive enough. Likewise, a sexologist's approach alone can only go so far. It's impossible to get by thinking that a single discipline can hold the solution, all the answers. So, it's a multidisciplinary sexual health treatment. There should be a psychiatrist or addiction medicine physician who knows the drugs and is capable of navigating through this landscape of psychiatric comorbidities (such as psychoses and ADHD).
There also has to be a sexologist for the treatment of any sexual dysfunctions there may be. At Saint-Louis Hospital, 60% of patients who engage in chemsex said that engaging in the practice was related to a sexual problem that they noted — but never went to see a doctor about — before the first time they used. Be that as it may, it's still the case that if these patients had been able to see a sexologist — who would have treated the problem — the drug may perhaps not have taken hold.
There also has to be a practitioner who can focus on risk reduction. In other words, someone capable of helping the patient get to the desired level of use where the craving, the need for instant gratification, can be kept in check.
In practice, one can sometimes, in addition to all of that, turn to medical treatments to manage the craving or medical comorbidities, an approach based on sexology to provide care for the sexual dysfunction or even to help the person learn how to evoke sexual or erotic fantasies without drugs, and an approach based on addiction medicine or psychotherapy, as some of our patients experienced sexual abuse in childhood. In the end, chemsex is just the outer layer — a problem that only seems to pertain to sex but that, in reality, covers up a wide range of issues. And not only sexual issues or issues that are related to drugs like chemsex is.
Medscape: What are the outcomes of this multidisciplinary treatment?
Aslan: Before we finish, I must point out and just state that the patients, when they're cared for and when they're provided with the appropriate treatment, change their practices. Some of our patients, even those with more advanced cases in terms of frequency, how often they're injecting drugs — every 30 minutes over the course of 24 or 48 hours, with complications such as thrombosis, sepsis, and abscesses — they've completely stopped after several months of treatment. They now lead lives that, as they've told us, work better for them. So, those of us in the healthcare industry, we have to get organized and set things up in a way that will allow us to focus our efforts on treating these patients.
https://www.medscape.com/viewarticle/978929
