France – Different international studies have convergent results on Chemsex: it is a practice that concerns 20% to 30% of men who have sex with men and especially that is developing. In the infectious diseases department of the Saint-Louis hospital (Paris), where the number of patients practicing Chemsex is estimated at 1,000, dedicated consultations were launched in the fall of 2019. During the International Congress of Addictology of the’Albatross which took place in Paris last June, the Dr Alexander Aslan (doctor sexologist, psychotherapist-psychanalyst) who works there presented the results of a study carried out among Chemsexeurs who attend these consultations. This work allows us to better understand the phenomenon.
He agreed to answer questions from Medscape French edition to explain this problem linking sex, taking drugs and the telephone and which is still too little known to doctors.
Medscape: What exactly is Chemsex?
Dr. Alexander Aslan: Intuitively, one could think that it is about the consumption of molecules to have sex. It’s not really that. In the definition as it has been published in the scientific literature, it is a practice described in men having sex with men (MSM) who take certain very specific products in the context of their sexuality to increase the duration, the quality or the intensity of the experience but also to “manage” the questions around intimacy, performance and apprehension of STIs. The products are mainly a cocktail of three molecules including GHB, cathinones and crystal methamphetamine. In Chemsex, the smartphone via dating applications, that is to say geolocated apps that allow you to instantly find partners, also plays a central role.
The products are mainly a cocktail of three molecules including GHB, cathinones and crystal methamphetamine.
How does meeting via apps influence the sexual relationship and the taking of products?
Dr Aslan: The sexual encounter being mediated by the apps, it is often a commitment to have a sexual relationship even before the actual encounter. Let me explain: it is not an encounter or a person that will arouse the desire for sexuality, it is rather inside the person the sexual “drive” that will push to sexual consumption. However, finding yourself committing to having a sexual relationship with someone you do not know, to whom you have not yet spoken or not met physically, in an environment where you will potentially meet several people and where sexual moments are very marked by performance scripts linked to pornography, pushes to take products to “let go” and come to conform to the demands of this moment. In order to perform well and not be too inhibited, consumers have found in this cocktail of products something quite explosive that conveys a very great power of excitement and even that engenders new sexual practices.
Can we talk about augmented sexuality?
Dr Aslan: For the sexologist that I am, it is a very particular sexuality. Consumers feel a very rich sexuality with incredible experiences and greater connection with the partner. In fact, it is a sexuality where the very principles of sexual physiology – that is to say a desire followed by excitement, a sexual plateau and then an orgasm – are abolished by taking these products. Gradually, the sexual partner will no longer exist in the sexual scene in favor of a succession of partners whose only virtue is to maintain the fire of excitement, also reinforced by the products consumed. It is about “sex” by product rather than a sexual encounter linked to desire.
What are the health impacts?
Dr Aslan: This practice leads to many complications including STIs, but also physical injuries because these are scenes that can last from 24 to more than 48 hours. There are also psychic complications since the molecules can cause depression, paranoid attacks, mutilation or decompensation of psychosis. And then, it should be emphasized that sexuality, which is the pretext at the beginning, is then cannibalized by the taking of products: people will no longer be able to dissociate the sexual encounter from the taking of products, then, in a few years, there are no more sexual encounters but only the taking of products. In the United States, between 2021 and 2021, deaths from heroin and prescribed opioids have decreased. On the other hand, since 2020, the intoxications that explode are those due to fentanyl, non-prescribed opioids and stimulants – cocaine and methamphetamine, which can enter into practices in particular via the seemingly “playful” terrain of sexuality.
This practice leads to many complications including STIs, but also physical injuries because these are scenes that can last from 24 to more than 48 hours. There are also psychological complications.
How is the passage from a practice under control to a total addiction to products explained?
Dr Aslan: You always have people who manage to keep this practice under control. But the molecules consumed are very addictive and lead to taking more and more products. There’s a loop: the arousing sexual relationship itself, to which you add products that make you secrete even more dopamine, and you have phone screens with arousing pornographic-type images all the time. In all the patients that we see, we highlight a trajectory that resembles that of all drugs. When they are at the beginning, that is to say the first year, after a first experience which they describe as explosive, they may not go back there immediately then they come back. They realize that it may not be as wonderful as the first time, but they will try again. During this phase of newness, there is a coping strategy to regain the feeling they had the first time. After one or two years, there is disillusionment and a refocusing of all activities around product consumption. According to a survey carried out in our hospital department on more than 100 people whom we were able to question in detail, people perceive the negative consequences of Chemsex on their work (60%), on their sexual and intimate life (55 %) and on their friendly or family relationships (63%). This means that people are well aware of the negative effects of the practice on very important areas of their lives. But even if they perceive all of this, even if they are determined to have a number of reports without product, these molecules are so powerful in terms of dopamine secretion that it can sweep away all their decision-making power or their resolution, and they will practically be “forced” to consume. This is called craving.
You have phone screens with arousing porn-like images all the time.
How do you identify Chemsex consumers in your infectious disease department?
Dr Aslan: We systematically ask a few questions to all the patients seen in the service: do you use products to have a sexual relationship? What is your favorite product? How do you administer it? Are you having a good time? Is the experience good for you? Are you ok with your level of product consumption? They are also asked when the last sexual intercourse took place without any associated drugs. This is a very important question because if we identify someone who has about ten partners per month and who has not had sex without a product for more than a month, we try to bring out the idea that it would be not bad to talk about.
Should doctors be concerned about the use of Chemsex among their young patients?
Dr Aslan: Yes, but you have to be very careful. Often, we can tend to believe that, according to our personal representations or even our openness of mind, we are able to talk about sexuality at the right level with our patients. However, as with all areas of medicine, we must be trained first in sexual health, sometimes damage can be done even with good will. The representations we have of our own sexuality do not necessarily help to deal with people’s sexuality, particularly when they have a different sexuality. If one is interested in the question, one must be trained in all the answers that it may elicit. There are online training courses: on the site https://www.formaprep.org intended for doctors to help with the passage of PrEP in town, there is a module on sexual health and Chemsex. This is at least a base to start with. So that doctors know what questions they can ask and when to address a specialist such as a sex therapist trained in these specific questions.
The representations we have of our own sexuality do not necessarily help to deal with people’s sexuality.
What is the support based on?
Dr Aslan: The classic approach of addictologists may not be complete enough, in the same way the only sexological approach may also find a limit. It’s impossible to get away with thinking that only one discipline can have the solution. It is therefore a multidisciplinary sexual health care. It would take a psychiatrist or addictologist who knows the products and who is able to detect a field of psychiatric comorbidities (psychosis, ADHD).
You also need a sexologist to take care of sexual dysfunctions. In Saint-Louis, 60% of users revealed that consumption was linked to a sexual problem identified before the first doses but never addressed to a health professional. This still means that if these patients had been able to see a sexologist who would have taken care of the problem, the product might not have taken up all this space.
In Saint-Louis, 60% of users revealed that consumption was linked to a sexual problem identified before the first doses but never addressed to a health professional.
You also need a practitioner who deals with risk reduction, that is to say someone who can help them reach a desired level of consumption where the craving, the need for immediate consumption, is controlled.
In practice, we can sometimes have, in addition, recourse to medical treatments to manage craving or medical comorbidities, a sexological approach to take care of sexual dysfunction or even to relearn the sexual or erotic imagination without products, and an addictological approach or psychotherapeutic, some of our patients having experienced sexual abuse in childhood. In the end, Chemsex is a gateway, the problem which only seems sexual but which covers much more diffuse issues, not only sexual or so much related to products as that.
What are the results of this multidisciplinary care?
Dr Aslan: I must end by testifying that patients change these practices when we take care of them and provide them with appropriate care. Some of our patients, even very advanced in terms of product injection (every 30 minutes for 24 or 48 hours with complications such as thrombosis, sepsis, abscess, etc.), have completely stopped after several months of therapy. They are now leading a life that they say is better suited to them, so we have to organize ourselves as caregivers to take care of them.
Patients change these practices when they are cared for and provided with appropriate care.
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