Compiled by Florian Vock (Swiss AIDS Federation) and Adrian Knecht (St. Gallen-Appenzell AIDS Federation)

The phenomenon of chemsex (Heide Mutter)

Chemsex has become a widespread phenomenon due to the easier availability of synthetic substances and the easier search for sexual partners through dating apps. We have to work in a differentiated, sensitive and committed way:

• knowing, not believing
• listening, not judging
• empowering, not lecturing.

Chemsex is the simultaneity of ‘sex on drugs’ and ‘drugs on sex’.

Intoxication and sexuality (Dr Dr Stefan Nagel)

Alcohol is part of ‘socially acceptable’ sex (e.g. a glass of Prosecco beforehand). The connection between sex and substances is extremely closely connoted and culturally established. Chemsex is a variant of this. From a psychoanalytical point of view, desire fights against the pain (the deep pain of living in this world): we experience a loss of values and meaning, a loss of orientation and limitation, normative disorientation (one's own truth). Sexual desire seeks eternity and suspends the principle of life: desire dominates survival. Escatological states of emergency are highly ambivalent: on the one hand, they threaten the norms of social order, but on the other hand, they stabilise precisely these norms thanks to a temporary relief (carnivalisation of society). Sex is also socially regulated and at the same time a place of escape: ‘Discomfort can be a source of sexual pleasure.’

The problem with sexualised substance use: satisfying pleasure is in short supply, which is frustrating. So a substitute is needed: substances serve to compensate for the lack of pleasure. The drug changes the experience of sexuality in many ways:

• substances create desired states such as alertness, lack of inhibition and openness, and strengthen the physical experience and willingness to communicate.
• Thanks to mixed consumption (e.g. with Viagra or alcohol), unwanted side effects can be compensated.
• Substances regulate the body's rhythm at will, a day-night reversal is possible, shame, tensions and fears can be reduced.
• Substances make it possible to fulfil sexual desires.

The problem is that substances are purely functional; they fit into an ideology of usefulness and purpose. Sensual references are lost. For humans, this is fatal.

State of research on chemsex (Prof. Dr. Daniel Deimel)

Chemsex is a gay, urban cultural phenomenon, not just a behaviour or a form of consumption. Chemsex is a specific form of sexualised substance use. Polysubstance use and mixed use are the rule, not the exception: different substances are used both simultaneously and serially. This makes it all the more important to focus not on the substance, but on the sexual context of use as a whole when it comes to prevention and treatment. The most important motives for use are ‘forgetting problems’; ‘partying, relaxing, having fun’ or ‘enhancing sexual performance and experience’.

It is all too easy to assume that chemsex is an expression of minority stress and other psychological stresses. This is not necessarily the case, and the picture regarding mental health is not clear. Overall, gay MSM are under a great deal of stress. But gay chemsex users have even lower levels of internalised homophobia than non-using gays. This is because minority stress is based not only on real, but also on expected exclusion. In the chemsex context, as a sub-phenomenon of gay subculture, there are strong feelings of belonging, which is a protective factor against minority stress (so-called interceding factors). So a decrease in homophobia is not an automatic guarantee of a decrease in substance use, even if there are correlations.

Chemsex brings with it physical, psychological and social problems. In chemsex settings, there are more non-consensual acts and experiences of violence. The majority of chemsex users do not want to change their behaviour. Abstinence orientation is not effective. Consumption reduction and harm reduction are the order of the day!

Problem child GHB (Antonia Bendau, Twyla Michnevich)

In addition to monkeydust (synthetic cathinones), GHB (and its precursor products GBL and BDO) is one of the problem children for prevention. It is taken orally (drunk diluted) and feels less invasive. GHB has an extremely satisfying effect, somewhere between sedative and stimulant, and can thus fulfil many needs in the context of sexualised substance use. The motivation for use is also to intensify feelings.

Sometimes GHB is also used to help people fall asleep after a party weekend and the use of amphetamines. In biological terms, GHB takes on a similar function to alcohol or benzodiazepines (blockade of neurotransmitters). Therefore, mixing GHB with alcohol and benzodiazepines, but also with allergy medication, is life-threatening, as it can cause fainting and respiratory arrest.

However, studies also show that users have a very high level of competence. 95% use safer use techniques such as dosing aids or timers. Nevertheless, over 50% of regular users have already experienced loss of consciousness as a result of overdosing or mixed use. This shows how challenging GHB is to use. Dosing aids or timers also give a false sense of security: the body is not a machine and the same dose can have very different effects on two different days. Repeated use also increases the effect.

GHB is not only a challenge for prevention, but also for therapy. Both a psychological and a physical dependency develop relatively quickly. The withdrawal symptoms are life-threatening: 70% develop delirium; a life-threatening state of emergency with symptoms such as epileptic seizures, motor disorders, anxiety and panic, and complete confusion. Withdrawal from GHB use is extremely demanding and must be carried out in a hospital setting with close supervision and a gradual reduction in dosage.

In terms of everyday prevention, the motivation to use must be the main focus. We have to recognise how closely GHB is linked to sexuality and sexual spaces and take this into account in counselling: What alternative functional strategies can I develop?

Therapy (Anne Iking, Marcus Pfliegensdörfer, Urs Gamsavar, Tim Niebuhr)

If the motive for consuming chemsex is to enhance pleasure and performance, this is a strong predictor of relapse. It has also been shown that HIV infection can have a strong influence on consumption. Chemsex can be used to cope with negative feelings such as shame or fear.

The substance is always the most effective way of achieving a reward, while all the alternatives are more elaborate. Changing consumption behaviour requires the creation of a more diverse identity and a new way of forming relationships. Therapy can help people with this. Users need to learn to diversify pleasure and leisure activities. The central task in therapy is: how can basic needs be fulfilled differently? How can I reward myself differently?

Beyond Harm Reduction (Mati Klitgard, Lyu Azbel, Juliana Gleeson, Fouad Marei)

Like every paradigm, the idea of harm reduction means that we can see certain things better, but we can no longer perceive others. This makes it all the more important to always examine our own measures in terms of a social-theoretical question: does our work contribute to the ideal of individuals and collectives that we have? Work must remain iterative, flexible and experimental.

The media coverage of chemsex is harmful to those affected and to the work of professionals. It fuels a moral sex panic and claims to have discovered a phenomenon. Experts respond by taking a problem-oriented approach. However, this approach overlooks the fact that chemsex is not simply destructive (‘Flirthing With Death’), but also has a productive effect (‘Life Affirming Practices’). This ‘gay infrastructure’ of chemsex provides answers to isolation, loneliness, pressure to perform and the privatisation of social spaces.

‘Yes, I can live without drugs. But is it fun?’ We also have to find social answers to this. Chemsex drowns out loneliness with fun, but all too often chemsex parties are left even lonelier than when they arrived. The indifference of people to passion, lust, connection and friendship, which is promoted by our society but also by substances like cocaine, makes the damage greater than what we generally understand by harm reduction.

We need to not only minimise the damage, but also maximise the opportunities. To do this, we need to recontextualise chemsex. In doing so, we quickly see how great the challenges are in terms of loneliness, poverty and consumerism, and where our task lies (also).