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Background: The prevalence of chemsex and sexualized substance use is increasing in several European countries, particularly among men who have sex with men. In this subgroup, illegal substance use is associated with increased sexual risk behavior, which can result in severe physical and psychological impairments. The present study examined the incidence and prevalence of chemsex in German-speaking countries. Whether Chemsex has negative effects on well-being was measured with the WHO well-being index. Of additional interest was how informed Chemsex users are about the topic and what needs are placed on the practitioners. The online questionnaire consisted of items, and data was collected from March to May Results: There were no significant differences in well-being between chemsex users and non-users. All participants protected themselves against sexually transmitted diseases irregularly or not at all. They viewed their sexual and substance use behavior as problematic, but few showed motivation for behavior change. Chemsex users clearly expressed a need for more information and advice centers. Conclusion: The results provide information on chemsex users that can be used for the future development of a therapy manual and thus contribute to improving health care for this group. The prevalence of chemsex is increasing and urgently needs more research to protect clients from health impairments and stigmatization. The use of mind-altering substances is a well-known social phenomenon, and population-wide substance use remains a matter of concern. In the 15 to 64 age group, problematic use is described in this context; of the According to the United Nations Office on Drugs and Crime, around 35 million people suffer from health disorders caused by drug use and require treatment services 1. Two specific types of substance use are chemsex and sexual motivated substance use, whereby the former describes the extent of and motivation for substance use more explicitly than the latter 4. The literature differentiates between the 2 terms because of the higher risk potential of chemsex 5. Chemsex is used to initiate sexual acts and increase or disinhibit the pleasure, duration, and intensity of the sexual experience 4 , 6 , 7. Chemsex users take one or more illegal psychoactive substances to influence sexual perception and behavior and enable long-lasting sex sessions, sometimes over several days, or sex with several partners simultaneously 5 , 6 , 8 , 10 , The four chems have an increased addiction potential and can also cause lasting damage. Ketamine use can lead to near-death experiences and trigger drug-induced psychosis Overdoses of mephedrone may cause thought disorders, anxiety states, panic attacks, acoustic hallucinations, palpitations, nausea, and vomiting 17 — The negative effects of methamphetamine include motor restlessness, aggressiveness, panic attacks, concentration disorders, and long-term effects on the brain. In addition, there is the danger of unconscious mixed use, which is caused by contaminated substances. For example, the case report by Pichini et al. Besides these negative effects of drug use among chemsex users, other problematic aspects include criminalization through illegal procurement of the substances and the risk of social decline Generally, substance use is higher among lesbian, gay, bisexual, and transgender LGBTQ people than among purely heterosexual people 24 , partly because of sexual substance use Chemsex occurs predominantly among men who have sex with men MSM 6. Peer groups have been shown to have a stronger influence on sexual behavior than family members 26 , particularly in the MSM community In a qualitative study on the experiences of 30 MSM, the interviewees reported that drug use and in particular chemsex is now perceived as being ubiquitous in the MSM community 7. Often, sex dates are arranged through mobile dating apps such as Grindr. Before they meet, the parties not only arrange the location but also exchange information including the type of substance use, HIV status, and number of participants. This virtual communication allows like-minded people to meet each other without having to visit bars, clubs, or similar locations and allows them to meet their sexual needs more quickly and effectively 5 , Chemsex is associated with increased health risk behavior, which can lead to increased rates of sexually transmitted diseases STDs and even to death from drug intoxication 11 , 28 — Safer sex practices are often neglected during group sex sessions with substance use, and needles may also be shared The disinhibition resulting from substance use means that chemsex users often consume more psychoactive substances than planned, and a lack of knowledge about the dosage can lead to severe intoxications and even to fatal overdoses The European MSM Internet Survey, the first study to examine the extent and spread of chemsex in Germany 35 , 36 , found a significant association between psychotropic substance use and risky sexual behavior The study also showed a positive association between positive HIV status and increased risky health behavior, such as promiscuity and unprotected sexual intercourse In spring , the Ludwig-Maximilians-University Hospital Munich, department of psychiatry opened a special outpatient clinic to provide support to chemsex users, and the clinic is seeing increasing numbers of people. The counseling and treatment of people with sexual motivated substance use is problematic mainly because of the combination of harmful use of psychotropic substances and sexual risk behavior. Compared with data on other psychiatric phenomena, data on the prevalence of chemsex and characteristics of chemsex users is still lacking 6 , especially in German-speaking countries. Furthermore to our knowledge, no standardized guidelines or therapy programs exists. Therefore, the present study aimed to better define the group of people that engages in chemsex, obtain data on their use of chemsex and needs for advice and information, and assess their well-being. The specific research questions were as follows:. Can demographic variables be used to identify a high-risk group for chemsex? What are the main characteristics of the sexual and health behavior and frequency of use of psychotropic substances, in particular the 4 chems? Does chemsex affect the well-being of users? What do users know and need from clinics on the topic of chemsex? This project has been approved by the ethical committee by the Ludwig-Maximilians-University Hospital Munich, department of psychiatry and was registered bay the number: 18— KB. Participation in this field study was limited to people in German-speaking countries. Persons of all gender and legal age and who had functioning online access could participate in the survey. Due to the exploratory character of this study and the aspects that chemsex users belong to a group that is difficult to identify and locate, the method of snowball sampling was chosen for statistical purposes. They were recruited by flyers in the psychiatric outpatient clinic at the Ludwig-Maximilians-University Hospital Munich, department of psychiatry, at regional scientific congresses, and nationwide via AIDS and addiction advice centers, LGBTQ contact and advice centers, specialist hospitals for the treatment of addiction disorders, and relevant bars in large German cities. People on the email distribution list of the Ludwig Maximilian University Munich were also invited to participate. The study was also publicized on social media such as Planet Romeo a dating app for homosexual and bisexual men , the homepage of the chemsex outpatient Ludwig-Maximilians-University Hospital Munich, department of psychiatry, the Facebook page of the interdisciplinary HIV Center IZAR of the Technical University Munich, and via the personal Facebook and Instagram accounts of the authors. Participants anonymously completed an online questionnaire between March 2 and May 31, The questionnaire inquired about sociodemographics, sexual and health behavior, frequency of psychotropic substance use, and well-being. It included a list of legal and illegal controlled substances in Germany that was based on the medical guidelines on health care for methamphetamine-related disorders The order, content, and number of items in the questionnaire are shown in Table 1. At the end of the questionnaire, all participants were able to leave personal comments as free text. To assess substance use, participants were asked about their use of 23 psychotropic substances in the past 12 months options: never, about once every 3 months, about once a month, about once a week, several times a week, daily. Sexual behavior was assessed on a 7-point Likert scale ranging from 1 strongly disagree to 7 strongly agree. Participants used the scale to rate how strongly they agreed that in the past 12 months they had had sex while under the influence of substances, had participated in group sex, or had attended private sex parties. Additional questions inquired whether participants saw themselves as chemsex users, viewed their own chemsex behavior as problematic and wanted to change their behavior. The topic of safer sex practices was also assessed with a 7-point Likert scale ranging from 1 strongly disagree to 7 strongly agree ; questions concerned the use of condoms, drugs for HIV pre- and post-exposure prophylaxis, and hepatitis A and B immunization status. Participants were also asked to provide information as free text about safer sex practices not included in the list and to specify whether they used any safer sex practices at all. We were also interested to find out whether participants took measures to protect themselves from STDs depending on whether they were having sex inside or outside a partnership. Study participants were asked when they last had sex while not under the influence of alcohol or illegal substances response options: in the past week, month, 3 months, 6 months, 12 months, and longer than 12 months. They were also asked whether they drank alcohol before and during sex, which was assessed on a 7-point Likert scale ranging from 1 never to 7 always. To assess participant health status, the questionnaire asked about current or past STDs and the time of the last test for such diseases. Participants were also asked about their knowledge of contact points and advice centers and about current and past psychotherapy and psychiatric treatment. When responding to the questions, participants were asked to consider the past 12 months because the study aimed to obtain an overview of the current epidemiology of chemsex. The participant's current level of well-being was assessed with the WHO-5 This scale is a brief psychometric questionnaire that uses five items to inquire about subjective well-being in the past 2 weeks A sum score of 0 to 13 indicates a low or negative well-being. Data were analyzed with R, version 3. Participants were categorized as chemsex users and non-users on the basis of their response on a 7-point Likert scale ranging from 1 strongly disagree to 7 strongly agree to the question whether in the past 12 months they had used illegal controlled substances to influence their sexual behavior. A t test was used to calculate whether differences existed in the mean well-being of chemsex users and non-users. At the end of data collection, 1, data records were available. The mean SD age of all participants was Figure 1. Most of the participants described themselves as male, and almost half belonged to the MSM group. The majority of the sample were living in a partnership, had a college degree and were employed. The mean SD well-being score was Thus, both groups were above the cut-off score of 13 see 2. A Cohen's d of 0. Table 2 shows the sociodemographic characteristics of the participants. Table 2. Sociodemographic characteristics of participants in an online survey of chemsex use. The current intoxication when answering the questionnaire was not recorded. Use of the 4 chems by the chemsex users is shown in Figure 2. Figure 2. An overview of sexual behavior in the past 12 months is shown in Figure 3. Figure 4. In this study, one in three participants stated that they had used illegal drugs in the past 12 months to influence their sexual behavior. The group of chemsex users consisted mainly of homosexual middle-aged men, most of whom were living in a partnership. The majority had an average income and were employed. Most used the 4 chems sporadically, but we did not obtain information on the exact amount of use. The average number of sexual partners, participation in group sex sessions, and lack of protective measures against STDs indicate that participants engaged in risky health behavior. The majority of chemsex users were not aware of contact or advice centers specializing in chemsex, and few of them had previously obtained information or offers of help via public or private contact points. Almost half of the chemsex users had moderate to significant insight into the issues associated with their own chemsex behavior, and almost a quarter of chemsex users had no desire to refrain from chemsex in the future. Our findings indicate that overall the chemsex user group has a positive sense of well-being. The predominantly positive well-being can be explained on the one hand by the mostly sporadic substance use and on the other hand by demographic characteristics. Controlled and socially ritualized substance use can reduce undesirable side effects, such as overdoses 41 , and therefore has a less negative influence on well-being. Furthermore, this study used the WHO-5, which only examines current well-being and does not record possible past depressive phases. We can also assume that the study sample had social support from a partner and a high socio-economic status through their employment and salary, which in turn has a positive influence on subjectively perceived well-being Findings on the participants' insight into their own chemsex behavior and the corresponding lack of a desire for change indicate that they had only a low level of suffering. This might be one explanation for the low number of participants who had contacted contact points and advice centers on chemsex. The findings can be further interpreted as showing that some chemsex users are ambivalent about the thought of abstaining from sexual motivated substance use. Noteworthy here is that ambivalence should not be seen as an expression of resistance toward counseling and treatment but as a starting point that can be used to promote motivation and thus to improve one's own health behavior Motivational interviewing may be such a therapeutic starting point 44 , We can also assume that chemsex users are a high-risk group with regard to sexual and health behavior and that they are poorly informed about options for advice on chemsex and treatment. This assumption is supported by the findings that chemsex users frequently changed sexual partners and did not always protect themselves against STDs or be tested for them. The low number of contacts with contact and advice centers supports this assumption. Shame and concern about stigma might act as barriers to seeking help and support The study has some limitations that should be considered when drawing possible conclusions. First, participants were recruited specifically in the LGBTQ community and included an above average number of MSM, especially in the group of chemsex users which can be explained by the snowball sampling. Second, although the WHO-5 has good psychometric properties 39 it records self-reported, subjectively perceived well-being over the past 2 weeks Third, this study was an online survey, so it could not control for the conditions of the participants. The participants' responses may therefore have been distorted because they were distracted or influenced by third parties or because they provided incorrect information because they want to give socially desirable responses. Limitations of this study also include the aspect that biomarkers for the use of clinical evaluation substances were not obtained in the process of data collection. Fourth, IP addresses were not saved because of data protection guidelines, so we cannot exclude that one person answered the questionnaire several times. Last, a large proportion of questionnaires were not completed, which may be because the questions about sexual behavior and substance use were perceived as being too intimate or the participants had doubts about data protection. Chemsex is becoming more widespread, so we need to understand which interpersonal relationships and influences exist in sexual motivated substance use, taking into account the characteristics of users and their lives. The results of the present study confirmed that chemsex is most common among MSM, although other groups also practice it. In this sample, chemsex users point out that they belong to a special risk group due to lack of protection against sexually transmitted infectious diseases, lack of education about chemsex and little motivation to change. Future research should further investigate the complexity of sexual orientation, sexual behavior, drug use patterns, and motivation for chemsex. A uniform definition of chemsex would improve comparability of studies, and research on this topic would improve the knowledge base. Additional studies on chemsex are urgently needed because chemsex users are known to represent a high-risk group that takes few precautions with regard to STDs and because information on the topic and treatment options are lacking. The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation. The studies involving human participants were reviewed and approved by the ethical committee by the LMU and was registered by the number: KB. CR: conceptualization, methodology, software, validation, formal analysis, investigation, data curation, writing—original draft, visualization, and project administration. MG: conceptualization, methodology, writing—review, editing, and investigation. MS: investigation, visualization, writing—review, and editing. EL: methodology, supervision, writing—review, and editing. TR: resources, writing—review, editing, and supervision. All authors contributed to the article and approved the submitted version. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. We thank the participants for their time and their interest in the study. A special thanks goes to our translator Jacquie Klesing. Nations U. World Drug Report United Nations Publication Google Scholar. European Drug Report Trends and Developments. Luxemburg: Publications Office of the European Union Radtke R. 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Measuring the dimension of psychological general well-being by the WHO Qual life Newsl. Zinberg NE. Drug, set, and setting: The basis for controlled intoxicant use. Layard R. Frankfurt am Main A multi-site comparison of psychosocial approaches for the treatment of methamphetamine dependence. Drug use and health behaviour among German men who have sex with men: Results of a qualitative, multi-centre study. Harm Reduct J. Miller WR, Rollnick S. Meeting in the middle: motivational interviewing and self-determination theory. Macfarlane A. Sex, drugs and self-control: why chemsex is fast becoming a public health concern. Psychiatry The use, distribution or reproduction in other forums is permitted, provided the original author s and the copyright owner s are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms. Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. Top bar navigation. About us About us. Sections Sections. About journal About journal. Article types Author guidelines Editor guidelines Publishing fees Submission checklist Contact editorial office. Psychiatry , 31 May Introduction The use of mind-altering substances is a well-known social phenomenon, and population-wide substance use remains a matter of concern. The specific research questions were as follows: A. Materials and Methods Recruitment and Sample Participation in this field study was limited to people in German-speaking countries. Assessment Participants anonymously completed an online questionnaire between March 2 and May 31, Table 1. Content of the questionnaire. Figure 3. Sexual behavior. Figure 5. Current and past sexually transmitted diseases among chemsex users.

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