"Chemsex": behind the scenes of the dangerous alliance between sex and amphetamines

The phenomenon emerged in the United States and some major European cities in the early 2000s. Chemsex", or chemical sex, combines sexual intercourse with drugs such as cocaine, ketamine or cathinones. Today, it's on the rise in France, but remains largely unknown - especially when it comes to its short- and long-term dangers.

Edouard TUAILLON, University of Montpellier

Synthesized from a substance found in khat leaves, cathinones are enjoying growing success. A member of the vast amphetamine family, they owe their popularity to the fact that they increase the release of dopamine, the central neurotransmitter in the reward circuit.

The arrival of these synthetic molecules in France is recent: the first seizure dates back to 2007. Since then, their use, long restricted to a narrow circle of experimenters frequenting specialized blogs (e-psychonauts) or former drug addicts, has rapidly gained ground among MSM (men who have sex with men).

This success is partly due to the characteristics of the drug itself, but also to the simultaneous emergence of several factors favoring it: mobile dating applications, GHB (which we'll talk about later) and the effectiveness of drugs designed to prevent and treat the human immunodeficiency virus (HIV).

The many factors behind its success

It's worth noting that synthetic cathinones are relatively inexpensive to produce, yet their effects are powerful, with no tolerance developing with regular use. This is a notable difference from ecstasy, which requires more frequent doses to maintain maximum effect.

We should also mention theimpact of geolocation-based mobile dating apps on behavior, the most famous of which (Grindr) was launched in 2009. These applications make it easier to meet partners with similar sexual desires, but their spread has been accompanied by the closure of gay-friendly venues. Paradoxically, the ease of dating has sometimes been accompanied by painful emotional isolation for people with numerous sexual partners.

Secondly, after decades marked by the fear of AIDS, better treatment in the 2000s enabled a new period of sexual liberation. While antiretroviral treatments still do not provide a cure, they are very safe, well tolerated and prevent HIV transmission. What's more, pre-exposure prophylaxis(PrEP), authorized in France since July 2017, effectively protects people having unprotected sex with multiple partners from HIV.

Finally, GHB (4-hydroxybutanoic acid or γ-hydroxybutyrate), another designer drug popularized in the early 2010s, has contributed to the success of chemsex. This neurotransmitter is naturally synthesized by certain neurons and binds to GHB and GABA (γ-aminobutyric acid) receptors in the brain, as do alcohol and anxiolytics. Its relaxing and sedative effects explain its medical use as an anaesthetic.

Classified as a narcotic since 1999, GHB is theoretically difficult to obtain... but this is far from being the case for GBL (γ-butyrolactone). A solvent widely used in industry, GBL is rapidly metabolized to GBH after ingestion. Commonly referred to as the "rapist's drug", as it is sometimes used as a chemical submission agent, it is voluntarily associated by many users with cathinones in the practice of chemsex.

Powerless, the medical world has seen the emergence of the combined use of cathinones and GBL/GHB over the past 10 years, through the prism of the management of sexually transmitted infections.

In connection with sexually transmitted infections

At the turn of the 2010s, drug-related issues seemed secondary in the hospital care of people living with HIV. Former drug addicts were for the most part weaned off drugs, or on Subutex or methadone substitution therapy; psychotropic drug use involved the same products as in the general population, i.e. tobacco, alcohol, benzodiazepines and cannabis.

Nevertheless, it was surprising to find that a small number of patients had multiple sexually transmitted infections: HIV, hepatitis A and C, but also syphilis, gonorrhea, chlamydia... In 2013, the consultation service at Montpellier University Hospital, of which I am one of the practitioners, reported cases of multiple sexually transmitted infections (STIs) linked to cathinone use. These patients presented particularly high-risk sexual behaviors, which seemed to be favored by the use of drugs that were unknown at the time.

A survey of 1,000 HIV-infected patients carried out in the consultation department the same year revealed that 2.7% of them used cathinones and 7.1% GBL.

Commonplace use

Since then, consumption has become considerably more commonplace. Since 2017 and the arrival of PrEP, many hospital consultations have included a preventive component aimed at people at risk of HIV infection. Whether they are young consultants (starting their sexuality in a less anxiety-provoking era) or older (enthusiastically approaching their return to celibacy after a period in a relationship), the freedom provided by this prevention and dating apps also exposes the most fragile to the alienation of chemsex.

New terms have entered the consultation routine: "chem" for chemsex, "3-MMC" or "4-MEC" for 3-Methylmethcathinone and 4-Methylethcathinone (mephedrone), "G hole" for loss of consciousness linked to GBL/GHB overdose...

The consumer profile, for its part, has been enriched by a multitude of faces and motivations: shy thirty-somethings looking to let go, fifty-somethings in search of a renewed libido, homosexuals in conflict with a homophobic upbringing or culture, or simple hedonists.

At the same time, it should be noted that requests for prescriptions for erectile dysfunction drugs have become more frequent at the end of consultations for the prevention or treatment of sexually transmitted infections: cathinones stimulate libido... but inhibit erection. As a result, by the age of 20 or 30, regular users of these synthetic products are often already taking high doses of Viagra-type drugs.

The problem of craving

The many new users we now see coming into our clinics are unaware of these risks, as well as the risk of dependence. And yet, once the practice of chemsex with cathinones becomes regular, it's rare for consumption to cease. Craving", or the impulsive need to consume, is very pronounced with this amphetamine: 85% of users may experience it. The risk of dependence is estimated at 30%.

Craving is one of the main problems associated with the use of cathinones, and is explained by the activation of the reward circuit. The urge to use the drug is due to the persistence of a high concentration of dopamine, while serotonin levels (another neurotransmitter which normally counterbalances the effect of dopamine) have returned to normal: this provokes a period of stimulation, and subsequently the craving for the product.

In rodents, where craving has been confirmed by cathinone self-administration experiments, it was found that, compared with other drugs such as methamphetamine, rats self-administer very high cumulative daily quantities(31.3 mg/kg/day for cathinone versus 4 mg/kg/day for methamphetamine). Among the drugs currently in use, the risk of abuse associated with synthetic cathinones is thus one of the highest observed.

On the road to addiction

Over the past four years, tragic stories about cathinones have become commonplace in hospitals and STI information and testing centers. The most vulnerable people are the most likely to see their consumption increase, their social integration fragment and their psyches tip towards depression or paranoia.

The recent nature of the use of cathinones combined with GBL, and the relative rarity of complete withdrawal among regular users, suggest that in the medium term the health problems associated with prolonged use will increase. In ten years' time, what will become of this generation experimenting with new practices combining PrEP, mobile dating apps and synthetic drugs?

Falling into addiction often involves a succession of stages. The way in which they are taken is one of them. Cathinones can be taken orally, or even rectally. But these digestive routes are associated with a slow rise in blood levels of cathinones, and are abandoned by the majority of experienced users in favor of the nasal route, which enables a rapid rise in blood levels. Finally, there's the injectable route, giving access to an even more violent effect (the slam).

This latter practice marks a symbolic and pharmacological transition to drug addiction, leading some users to compulsive injections several times a day. Frequency and context of use are further steps on the road to cathinone addiction.

From festive event to everyday practice

Fortunately, there are still many occasional users, who limit their chemsex to a few festive events a year. But others use it regularly, especially at weekends.

In this case, consumption frequently begins on Friday evening and can extend into Saturday and sometimes Sunday. It often becomes regular, like a festive weekend ritual, more or less disrupting mood and work during the week, when the brain is starved of dopamine.

Many new regular chemsex users have linked theincrease in their cathinone consumption to the health restrictions imposed by the Covid-19 pandemic.

The sexual context of product use is another indicator of the severity of addiction. For people with little or no addiction, the sexual act remains possible and desirable without cathinones. For others, sexuality is only attractive in the context of chemsex. In the next stage, the very notion of chemsex fades away in favor of drug use alone.

In the most severe cases of addiction, the product is taken two or three times a week, often by injection, and several times a day. It leads to phases of wakefulness lasting 48 to 72 hours, followed by phases of prolonged sleep.

As with other drugs, the risks of using cathinones and GHB lie in the inexperience of new users and the consequences of addiction for experienced users, with deaths from domestic or public accidents, suicide or cardiorespiratory arrest due to overdose.

The number of deaths directly or indirectly attributable to these products is tricky to establish due to the difficulty of distinguishing the share of accidents and suicides linked to their use. In 2017, around 20 deaths likely linked to chemsex were reported by the Lyon Regional HIV Coordination Committee (COREVIH Lyon-Vallée du Rhône).

Prevention: a real priority

Many chemsex users do not consider themselves to be drug users. Those who are aware that they are addicts often refuse to accept difficult care that does not offer substitution treatment.

Prevention must therefore become a priority. We need to explain the neurological mechanisms of addiction, and encourage regular, occasional and potential users to come out of denial and see the difficulties faced by those around them who have become addicted.

Awareness helps to prevent or reduce the risks associated with the use of cathinones and GBL.

Beyond specialized hospital consultations, the whole of society is called upon to become aware of the cathinone problem.

For the time being, chemsex is the talk of the town in the press, on the radio and in literature. But this is happening without any preventive discourse from the public authorities, while at the same time repression is being put in place.

For a long time, sellers, who were themselves consumers and socially well-integrated, were not bothered by the police or the justice system. This is no longer the case. Consumers are summoned for reminders of the law, and firm prison sentences are handed down to sellers. In early 2021, a doctor in the Montpellier region, who was both a consumer and a supplier, was sentenced and banned from practicing.

Against this backdrop, the absence of a marketing ban on solvent containing GBL is a paradox. In 2011, France issued a decree banning its sale to the public, but not its marketing to professionals.

GBL therefore remains available, and its consumption has increased in recent years. The French National Agency for the Safety of Medicines and Health Products (ANSM) was alarmed by this in December 2018. The ANSM's recommendations, aimed at tightening GBL marketing limits, appear for the time being to have gone unheeded.

While prevention campaigns should be the priority, they remain very rare. One example is the one set up back in 2018 by COREVIH Lyon-Vallée du Rhône, including a website, conferences, videos. It's also worth noting that in March 2021 the Paris Council voted in favor of a "chemsex information and risk reduction plan", and wants to put tools in place by the end of February 2022. One of the project's promoters, Paris deputy mayor and activist Jean-Luc Romero-Michel, himself lost his husband to an overdose in 2018.

It is to be hoped that these initiatives mark the start of a new period, one in which public authorities will react to the challenges of preventing the risks associated with synthetic amphetamines.

Edouard TUAILLON, University Professor - Hospital Practitioner. Areas of expertise: infectious diseases, virology, sexual health, University of Montpellier

This article is republished from The Conversation under a Creative Commons license. Read theoriginal article.