Understanding problematic versus non-problematic chemsex practices from a user's perspective: a qualitative study

Chemsex is predominantly reported among men who have sex with men (MSM) and plays an important role in HIV transmission and prevention, being associated with heightened vulnerability to HIV and other sexually transmitted infections. While often used recreationally, chemsex is linked to physical and mental health harms. This study explores how participants define problematic chemsex and perceive contributing and protective factors. Semi-structured, in-depth interviews were conducted among MSM who had used at least one chemsex substance defined in this study. Participants were recruited between January and September 2023 through the Public Health Service of Amsterdam, Centre for Sexual Health, the Netherlands. Among 27 participants (median age 37 years, range 20-62), problematic chemsex was characterised by loss of control affecting daily life, boundaries, emotional regulation, safety, health and reliance on drugs for sex. Contributing factors included coping with mental distress, lack of purpose, escalating use and injecting. Protective factors included self-imposed limits, fear of consequences, learning from experience and being in a steady relationship. Problematic chemsex appears influenced by interactions between psychological well-being, sense of purpose and substance use patterns. These indicators may inform quantifiable measures and improve chemsex-related support and interventions.