“Chemsex”: The Dark Side of the Dangerous Combination of Sex and Amphetamines
The phenomenon first emerged in the United States and in certain major European cities in the early 2000s. “Chemsex,” or chemical sex, uniquely combines sexual activity with the use of drugs such as cocaine, ketamine, or cathinones. It is now gaining traction in France, though it remains largely unknown—especially when it comes to its short- and long-term dangers.
Edouard TUAILLON, University of Montpellier
A synthetic derivative of a substance found in khat leaves, cathinones are becoming increasingly popular. As members of the broad family of amphetamines, they owe their popularity to the fact that they increase the release of dopamine, a key neurotransmitter in the reward system.
These synthetic drugs have only recently appeared in France: the first seizure dates back to 2007. Since then, their use—long limited to a small circle of experimenters who frequent specialized blogs (e-psychonauts) or former drug users—has quickly gained traction among MSM (men who have sex with men).
This success is due in part to the drug’s inherent properties, but also to the simultaneous emergence of several contributing factors: mobile dating apps, GHB (which we will discuss later), and the effectiveness of medications designed to prevent and treat human immunodeficiency virus (HIV).
The many factors behind its success
First, it should be noted that synthetic cathinones are relatively inexpensive due to their relatively simple production process, even though their effects are potent and do not lead to the development of tolerance with regular use. This is a notable difference from ecstasy, which requires users to space out doses to maintain maximum effectiveness.
We should also highlightthe impact of location-based mobile dating apps on behavior, the most famous of which (Grindr) was launched in 2009. These apps make it easier to meet partners who share the same sexual desires, but their widespread adoption has coincided with the closure of gay social venues. Paradoxically, the ease of meeting people has sometimes been accompanied by painful emotional isolation among individuals who nevertheless have numerous sexual partners.
Then, after decades marked by fear of AIDS, improved treatment made a new era of sexual liberation possible in the 2000s. While antiretroviral treatments still do not offer a cure, they are very safe, well-tolerated, and prevent HIV transmission. Furthermore, pre-exposure prophylaxis (PrEP), authorized in France since July 2017, effectively protects people who have unprotected sex with multiple partners from HIV.
Finally, GHB (4-hydroxybutyric acid or γ-hydroxybutyrate), another synthetic drug that gained popularity in the early 2010s, contributed to the rise of chemsex. This neurotransmitter is naturally synthesized by certain neurons and binds in the brain to GHB and GABA (γ-aminobutyric acid) receptors, just as alcohol and anxiolytics do. Its relaxing and sedative effects explain its medical use as an anesthetic.
Classified as a narcotic since 1999, GHB is, in theory, difficult to obtain… but this is far from the case with GBL (γ-butyrolactone). A solvent widely used in industry, GBL is rapidly metabolized into GHB after ingestion. Commonly referred to as the “date rape drug” because it is sometimes used as a chemical subjugation agent, many users deliberately combine it with cathinones in chemsex practices.
Powerless to intervene, the medical community has watched the combined use of cathinones and GBL/GHB emerge over the past decade through the lens of the treatment of sexually transmitted infections.
Related to sexually transmitted infections
Around the turn of the 2010s, issues related to drug use appeared to be secondary in the hospital care of people living with HIV. Most former drug users were either clean or undergoing substitution treatment with Subutex or methadone; the use of psychoactive substances involved the same products as in the general population, namely tobacco, alcohol, benzodiazepines, and cannabis.
It was nevertheless observed that a small number of patients surprisingly presented with multiple sexually transmitted infections: HIV, hepatitis A and C, as well as syphilis, gonorrhea, and chlamydia… In 2013, the outpatient clinic at Montpellier University Hospital, where I am one of the practitioners, reported cases of multiple sexually transmitted infections (STIs) linked to the use of cathinones. These patients exhibited particularly high-risk sexual behaviors, which appeared to be exacerbated by the use of drugs that were then little known.
A survey conducted that same year at the outpatient clinic among 1,000 HIV-positive patients revealed that 2.7% of them used cathinones and 7.1% used GBL.
A common practice
Since then, the use of PrEP has become much more widespread. Starting in 2017 with the introduction of PrEP, many hospital clinics have incorporated a preventive component aimed at people at risk of HIV infection. Whether the patients are young (exploring their sexuality in a less anxiety-inducing era) or older (enthusiastically embracing their return to single life after a period in a relationship), the freedom afforded by this prevention and dating apps also exposes the most vulnerable to the alienation of chemsex.
New terms have crept into the routine of consultations: “chem” for chemsex, “3-MMC” or “4-MEC” for 3-methylmethcathinone and 4-methylethcathinone (mephedrone), “G hole” for loss of consciousness due to a GBL/GHB overdose…
The consumer profile, meanwhile, has become more diverse, encompassing a wide range of individuals driven by equally varied motivations: shy thirty-somethings looking to let loose, fifty-somethings seeking to reignite their libido, gay men struggling with a homophobic upbringing or culture, or simply hedonists.
SElefant/Wikimedia/Pfizer, CC BY-SA
At the same time, it should be noted that requests for prescriptions for erectile dysfunction medication have become more common at the end of consultations for the prevention or treatment of sexually transmitted infections: cathinones do indeed stimulate libido… but inhibit erections. As a result, by the time they are barely 20 or 30 years old, regular users of these synthetic products are often already taking high doses of medications in the Viagra family.
The problem of "craving"
Many of the new users we now see coming in for counseling are unaware of these risks, such as the risk of addiction. However, once chemsex involving the use of cathinones becomes a regular practice, it is rare for use to stop afterward. The “craving,” or impulsive urge to use, is very pronounced with this amphetamine: 85% of users may experience it. The risk of addiction is estimated at 30%.
Craving is one of the main problems associated with the use of cathinones and is caused by the activation of the reward circuit. The urge to use the drug is thought to stem from the persistence of high dopamine levels while serotonin levels (another neurotransmitter that normally counterbalances the effects of dopamine) have returned to normal: this triggers a period of stimulation, and subsequently, an overwhelming craving for the drug.
In rodents, where craving has been confirmed by self-administration experiments with cathinones, it has been observed that, compared to other drugs such as methamphetamine, rats self-administer very high cumulative daily doses (31.3 mg/kg/day for cathinone versus 4 mg/kg/day for methamphetamine). Among currently used drugs, the risk of abuse associated with synthetic cathinones is thus one of the highest observed.
On the Slope of Addiction
Over the past four years, tragic stories involving cathinones have become all too common in hospitals and STI testing and counseling centers. The most vulnerable individuals are the most likely to see their drug use increase, their social integration unravel, and their mental health deteriorate into depression or paranoia.
The recent emergence of cathinone use in combination with GBL, along with the relative rarity of complete abstinence among regular users, suggests that health problems associated with prolonged use will become more pronounced in the medium term. What will become of this generation—which is experimenting with new practices combining PrEP, dating apps, and synthetic drugs—in ten years’ time?
The descent into addiction often involves a series of stages. The method of use is one such stage. Cathinones can be taken orally or even rectally. However, these routes of administration, which result in a slow rise in blood cathinone levels, are largely abandoned by most experienced users in favor of the nasal route, which allows for a rapid increase in blood levels. Finally, there is the injectable route, which produces an even more intense effect (known as a “slam”).
E. Tuaillon/Based on European Monitoring Centre for Drugs and Drug Addiction (2021), An analysis of drugs in used syringes from sentinel European cities: Results from the ESCAPE project, Provided by the author
This practice marks a transition—both symbolic and pharmacological—toward drug addiction, eventually leading some users to inject the drug compulsively several times a day. The frequency and context of use are further steps down the path to cathinone addiction.
From festive occasions to everyday life
Fortunately, there are still many occasional users who limit their chemsex activities to just a few parties throughout the year. However, others use it regularly, especially on weekends.
In such cases, drinking often begins on Friday evening and can continue through Saturday and sometimes into Sunday. It frequently becomes a regular habit, like a festive weekend ritual, which can disrupt one’s mood and work during the week, when the brain is running low on dopamine.
Many new regular users of chemsex have linkedthe increase in their use of cathinones to the health restrictions imposed by the COVID-19 pandemic.
The sexual context in which these substances are used is another indicator of the severity of addiction. For those with little or no dependence, sexual activity remains possible and desirable without cathinones. For others, sex is no longer appealing except within the context of chemsex. At the next stage, the very concept of chemsex fades away, replaced solely by drug use.
In the most severe cases of addiction, the substance is used two to three times a week, often by injection, and multiple times in a single day. It leads to periods of wakefulness lasting 48 to 72 hours, followed by periods of prolonged sleep.
As with other drugs, the risks associated with the use of cathinones and GHB stem from the inexperience of new users and the consequences of addiction among experienced users, including deaths resulting from accidents at home or on public roads, suicide, or cardiac arrest due to overdose.
It is difficult to determine the number of deaths directly or indirectly attributable to these substances, given the challenge of distinguishing between accidents and suicides linked to their use. In 2017, approximately 20 deaths likely related to chemsex were reported by the Lyon Regional HIV Coordination Committee (COREVIH Lyon-Vallée du Rhône).
Prevention: A Top Priority
Many people who engage in chemsex do not consider themselves drug users. Those who are aware of their addiction often refuse treatment that is difficult to access and does not offer substitution therapy.
Prevention must therefore become a priority. We need to explain the neurological mechanisms of addiction and encourage regular, occasional, and potential users to stop denying the problem and recognize the difficulties faced by those in their lives who have become addicted.
Raising awareness helps prevent or reduce the risks associated with the use of cathinones and GBL.
Beyond specialized hospital consultations, society as a whole must become aware of the problem of cathinones.
For now, chemsex is making headlines in the press, on radio shows, and in literature. Yet there is no public health campaign from the government, even as law enforcement crackdowns are being implemented.
For a long time, dealers—who were themselves consumers and well-integrated into society—were largely left alone by the police and the courts. That is no longer the case. Consumers are being summoned for legal proceedings, and prison sentences are being handed down to sellers. In early 2021, a doctor from the Montpellier area, who was both a consumer and a supplier, was convicted and barred from practicing medicine.
In this context, the lack of a ban on the sale of GBL-containing solvents is paradoxical. In 2011, France issued a decree prohibiting its sale to the general public, but not its sale to professionals.
United States Department of Justice/DEA/Wikimedia
GBL therefore remains available, and its use has increased in recent years. The French National Agency for Medicines and Health Products Safety (ANSM) expressed concern about this in December 2018. The ANSM’s recommendations, which were intended to tighten restrictions on the sale of GBL, appear to have gone unheeded so far.
While prevention campaigns should be a priority, they remain very rare. One example is the campaign launched in 2018 by COREVIH Lyon-Vallée du Rhône, which includes a website, conferences, and videos. It is also worth noting that in March 2021, the Paris City Council voted in favor of an “information and harm reduction plan on chemsex” and aims to implement tools by the end of February 2022. One of the project’s leaders, Paris Deputy Mayor and activist Jean-Luc Romero-Michel, lost his husband in 2018 to an overdose.
Let us hope that these initiatives mark the beginning of a new era, one in which public authorities take action to address the challenges of preventing risks associated with synthetic amphetamines.
Edouard TUAILLON, University Professor and Hospital Physician. Areas of expertise: infectious diseases, virology, sexual health, University of Montpellier
This article is republished from The Conversation under a Creative Commons license. Readthe original article.