Introduction

The public health response to chemsex, when understood objectively, is actually a simple model of multidisciplinary interventions. Just as opiate addiction requires behavioural therapies, medicine, community engagement, and an understanding of the motivations for use, chemsex requires – well, exactly the same. Many excellent models of chemsex support already exist internationally.1–3

Unfortunately, however, you can't remove the sex from chemsex; and where there is sex, there are moral and religious judgments and stigmas. Make that gay sex, include HIV, and chemsex becomes something that can require some untangling before an effective public health response can be mounted.

Defining chemsex

The untangling must, therefore, begin with a definition. Chemsex is a word invented on geo-sexual networking apps by gay men (and adopted by the gay men's health sector) that defines a syndemic of specific behaviours associated with specific recreational drugs, and is particular to a specific, high-risk population.

Though the media spotlight may have distorted the term to define the use of any drugs in sexual contexts by any population,4 chemsex actually refers to the use of any combination of drugs that includes crystal methamphetamine, mephedrone and/or gammahydroxybutyrate (GHB)/gammabutyrolactone (GBL), used before or during sex by men who have sex with men (MSM). These drugs provide users with a particular sexual disinhibition, appetite and duration that set them apart from previously favoured recreational drugs (such as ecstasy, cocaine, marijuana and alcohol), which never manifested the amount of sexual-related harm/infections, injecting harms, deaths, addictions or lifestyle deterioration as these modern-day drugs have amongst modern gay communities.

Chemsex is less of a traditional sex and drug issue than it is an issue related to the use of changing technologies, easy availability of certain recreational drugs via these technologies, and adopted by a small, international but very sexually active cohort of men who are considerably more likely to contract HIV through this behaviour than their non-MSM counterparts (due to high prevalence within that population and the higher number of partners that can be facilitated by the drugs and apps).

Chemsex is also defined by its association with some cultural idiosyncrasies unique to gay cultures that may complicate sex for gay men. These can include early experiences of gay sex and ‘coming out’ issues, sexualised gay scenes and media, definitions of gay sexual liberation, societal and internalised homophobia, and concepts of risk, fear and stigma born of a 30-year HIV epidemic. It is important that the health sector remains vigilant in providing care for anyone using drugs or alcohol for sex, but also that a particular focus is given to MSM using these drugs in this context as this represents a particular challenge to public health and communities, and some redesigning of the way in which support services function. It is this unique set of harms and motivations that led clinicians to call for chemsex to be considered a public health priority in 2015.5

The chemsex prevalence question

No emerging trend or epidemic can be adequately addressed if the prevalence can't be quantified. And therein lies the source of a great deal of the controversy surrounding chemsex. It is still an emerging phenomenon as far as the medical community is concerned, with a specific and complex definition that requires an intimate understanding of the drugs' characteristics and effects, and how they differ from other recreational drugs used in the same contexts. This challenges our research on this subject, and the question as to how many people are engaging in chemsex remains unanswerable, at least to date. Some frontline sexual health clinics are capturing some data,6 but it is still early days, and these data may lack context if they are attracting the highest-risk cohorts. Population-level surveys, conducted online or at gay Pride events for example, can also lack context if drug users – whose use is often associated with fear of disclosure, or denial – might be reluctant to participate or to disclose honestly.

So the prevalence question remains: are all gay men doing chemsex? Of course not, and no one thinks that. It is, however, important to remember that there is a generation of gay men who remember the stigmatising AIDS headlines from the 1980s, many of whom worked tirelessly to undo the stigma caused to gay communities by those headlines, and fought defiantly to define gay sexual liberation during those harrowing years. Many of these men would understandably be very fearful that chemsex headlines might set the movement back to 1985, be very resentful of news stories on the subject, and resent any evidence that chemsex may be more prevalent than they'd prefer. It may even manifest as chemsex denialism. It has been a harrowing few decades for a certain generation, and we must be sympathetic and mindful of this fact.