Drugs Used in “Chemsex”/Sexualized Drug Behaviour—Overview of the Related Clinical Psychopharmacological Issues
Psychopharmacology, Drug Misuse and Novel Psychoactive Substances Research Unit, School of Life and Medical Sciences, University of Hertfordshire, Hatfield AL10 9AB, UK; f.schifano@herts.ac.uk (F.S.); j.corkery@herts.ac.uk (J.M.C.); gducciopapantip@gmail.com (G.D.P.P.)
North Islington Core Team, Academic Secretary RCPsych, London N7 8US, UK; stefania.bonaccorso2@nhs.net
Department of Neurosciences, Psychology, Drug Research and Child Health, Section of Pharmacology and Toxicology, University of Florence, Viale G. Pieraccini, 6, 50139 Florence, Italy
Pharmacy, Medical School, The Grove, Swansea University, Swansea SA2 8PP, UK; amira.guirguis@swansea.ac.uk
Department of Drug and Health Sciences, University of Catania, 95124 Catania, Italy; giuseppe.floresta@unict.it
Tolmezzo Community Mental Health Centre, ASUFC Mental Health and Addiction Department, Via Bonanni 2, 33028 Tolmezzo, Italy
Department of Psychiatry and Psychotherapy, LVR-University Hospital Essen, Medical Faculty, University of Duisburg-Essen, 45147 Essen, Germany; norbert.scherbaum@lvr.de
Department of Urology, ASST Sette Laghi-Ospedale di Circolo di Varese, 21100 Varese, Italy; schifanonicolo90@gmail.com
*Correspondence: davide.arillotta@yahoo.itAbstract
Background: “Chemsex” involves the intake of a range of drugs (e.g., synthetic cathinones, gamma-hydroxybutyric acid/gamma-butyrolactone (GHB/GBL), ketamine, methamphetamine, “poppers”, type V phosphodiesterase (PDE) inhibitors, MDMA/ecstasy, cocaine, cannabis, and occasionally a few other molecules as well, to enhance and prolong sexual experiences. This paper aims to provide an overview of the clinical pharmacology of the vast range of drugs that are being used for chemsex with a focus on both the medical and psychopathological disturbances that they can produce. Methods: A narrative literature review was conducted using Pubmed, Scopus, and Web of Science databases. A total of 273 papers published up to January 2025 were screened; articles were selected based on relevance to chemsex/sexualized used behaviour and related substances. Both human and preclinical studies were considered. Results: The use of stimulants is likely related to the need to increase as much as possible both sexual arousal and performance but also to increase social interactions. Furthermore, the empathogenic/entactogenic activities of some MDMA-like “love drugs” facilitate the occurrence of “feeling closer/more intimate” emotional sensations, and GHB/GBL may provide the user with a subjective sensation of disinhibition, hence facilitating condomless meetings with a higher number of random partners. Conversely, ketamine may be used to both enjoy its psychotropic dissociative characteristics and facilitate the potentially painful receptive anal intercourse and/or fisting experiences. Most typically, these drugs are consumed in combination, with polydrug exposure possibly facilitating the occurrence of serotonergic syndrome, seizures, drug–drug pharmacokinetics’ interaction, and sympathomimetic overstimulation. Following these polydrug exposures, a range of psychopathological conditions have at times been reported. These issues may lead to misuse of opiates/opioids, gabapentinoids, and/or antipsychotics. Conclusions: Further actions should aim at reducing the stigma that prevents individuals from accessing necessary healthcare and support services. A multidisciplinary approach that combines medical, psychological, and social support remains key to managing the complex challenges posed by chemsex-related drug use.
1. Introduction
“Chemsex” has been defined as a voluntary intake of certain psychoactive and non-psychoactive drugs in the context of sex parties and sexual intercourse with the intention of enhancing, prolonging, and sustaining sexual experiences, hence facilitating the sexual encounter [1]. These sessions are mostly among men who have sex with men [2,3,4,5,6,7,8,9,10,11,12,13,14]. Conversely, one could argue that the use of drugs whilst being involved in intimate, sexual behavior may relate to a vast range of populations. From this point of view, similar concepts have been proposed, including perisexual drug use [15], sexualized drug behavior [16], “Sex on Chems” (Wilson and Williamson, 2024) [17], “Party-n-Play” [18], wired sex [19], and “Pampalibog” (in the Filipino language; [20]). Chemsex practices are becoming increasingly popular. Data from 55, 446 MSM subjects living in 44 urban centers were made available by Schmidt et al. [21]. In the European region, the past 4 weeks’ chemsex involvement was highest in Brighton (16.3%), Manchester (15.5%), London (13.2%), Amsterdam (11.2%), and Barcelona (7.9%). In 2018, 785 MSM were recruited at nine Dutch clinics, and 511 (65%) completed the online questionnaire. Chemsex, which was defined as using cocaine, crystal meth, designer drugs, gamma-hydroxybutyric acid/gamma-butyrolactone (GHB/GBL), ketamine, “speed” and/or 3,4-methylenedioxymethamphetamine (XTC; MDMA), was reported by 41% of interviewees during the previous 6 months [22].
At times, to enhance libido, potency, and sexual pleasure, a range of aphrodisiacs, which are often naturally occurring and traditionally used, are self-administered [23]; moreover, aphrodisiacs’ intake is frequently rooted in cultural beliefs and superstitions. The U.S. Food and Drug Administration (FDA) defines an aphrodisiac drug product as “any product that bears labeling claims that it will arouse or increase sexual desire, or that it will improve sexual performance”. Conversely, the European Medicines Agency (EMA) does not have specific definitions for aphrodisiac products but regulates drugs for sexual dysfunction [24]. As a result, a range of over-the-counter (OTC) herbal products and approved prescription drugs (for example, for erectile dysfunction) are legally available. From an anthropological perspective, chemsex cultures are multifaceted and shaped by a wide range of social and psychological factors [25], for example, geographical location, the use of apps and online platforms, and the availability of specific substances. Indeed, there is a lack of research as well on how sexual experience affects drug reward in animals [26]. Mating is clearly regarded as a basic reward activity. In fact, conventional reinforcers (e.g., food, sex) stimulate dopamine (DA) transmission in the nucleus accumbens shell [27]. Addictive drugs share with conventional reinforcers the property of stimulating DA transmission in the nucleus accumbens shell. This response, however, undergoes one-trial habituation in the case of conventional reinforcers. Resistance to habituation allows drugs to repetitively activate DA transmission in the shell upon repeated self-administration [27]. In sober sex, a clear post-ejaculation refractory time (PERT), e.g., the period after a single ejaculation when further erections and ejaculations are inhibited, has been documented [28]. Conversely, Schreck et al. [29] documented a 40-hour-long chemsex session. Further, a recent UK-based, mixed methods study surveyed some 123 subjects; 86% of respondents engaged in riskier sex during sessions and 35% no longer enjoyed sober sex [17]. Hence, one could argue that chemsex may respond to the perceived need to use a range of drugs to overcome resistance to habituation, synergistically increase sex-derived physiological pleasure, and facilitate voluntary self-exposure to idiosyncratic practices. To experience a more intense rush and longer sex, some drugs are being injected so that much higher bioavailability levels are being attained [30,31].
In considering the above, this paper aims to provide an overview of the clinical pharmacology of the vast range of drugs that are being used for chemsex, with a focus on both the medical and psychopathological disturbances that they can produce.
2. Methodology
For this narrative review, a literature search was performed using Pubmed, Scopus, and Web of Science databases from inception until January 2025 through the following search strategy: (“chemsex”, OR “perisexual drug use”, OR “sexualized drug behavior”, OR “sex on chems”, OR ”party-n-play”, OR ”wired sex”) AND (“GHB/GBL”, “synthetic cathinones”, “ketamine”, “amphetamine-type substances”, “MDMA”, “poppers”, “type V phosphodiesterase (PDE) inhibitors”, “cannabis”, “cocaine”, “alcohol”). Particular focus was here as well on the above substances’ associated medical and psychiatric manifestations. Evidence included in the review comprised both human data and preclinical data, if and when this was of interest. Each article’s title and abstract were reviewed for their appropriateness with regard to the relationship between chemsex/sexualized drug behavior and the specific classes of substances highlighted here, including alcohol. In this way, some 273 papers were initially scrutinized for relevance. Although the papers here quoted were published in the time frame 1986–2025, some 6 out of 10 of them were published in the period 2020–2025.
4. Discussion
An updated narrative overview of the pharmacological, clinical pharmacological, and toxicity issues related to the variety of psychoactive substances in use in chemsex sessions and sexualized drug behaviour has been provided here. Most psychoactive drugs mentioned are characterized by a stimulant (e.g., amphetamine-type substances, synthetic cathinones, and cocaine) and/or a psychedelic/dissociative (ketamine, MDMA) activity. However, GHB/GBL are very popular molecules as well, which are considered in the chemsex scenario.
4.1. Associated Risks
The use of stimulants is likely related to the need to increase as much as possible both sexual arousal and performance [15]. Furthermore, the empathogenic/entactogenic activities of some ATSs’ “love drugs” facilitate the occurrence of “feeling closer/more intimate’ sensations. All these drug-elicited properties may be perceived by chemsex enthusiasts as being useful since these sessions may be long/very long-lasting and involve intimate encounters with a range of strangers, e.g., people that have never met before the session itself. Furthermore, GHB/GBL may well provide the user with a subjective sensation of disinhibition, hence facilitating meeting with a higher number of sexual partners and involvement in both group sex and condomless anal intercourse with random partners [52]. The frequent mention of ketamine as a chemsex drug could be explained by its potent analgesic/anesthetic properties, facilitating the potentially painful receptive anal intercourse and/or fisting experiences [77].
Overall, however, sexual activity over protracted lengths of time under the influence of potent stimulant/dissociative/disinhibiting drugs can result in rectal trauma or penile abrasions and a significant increase in the risk of transmission of sexually transmitted diseases [55].
Another issue of real concern that emerged here related to the possible occurrence of intense, acute, and chronic medical and psychopathological consequences associated with the ingestion of these molecules, which are most typically consumed in combination (e.g., 3.5 drugs per session; [71]. Indeed, polydrug exposure can facilitate the occurrence of a serotonergic syndrome, with its relating life-threatening characteristics [122]; drug–drug pharmacokinetics’ interaction, which may be particularly relevant with HIV medication [29]; and sympathomimetic overstimulation, due to synergistic pharmacological interaction [46].
In association with the recent, possibly intense, chemsex-related polydrug exposure, a number of psychopathological disturbances, including mood disorders, suicidal ideation, and psychotic signs and symptoms, have been reported [64,114]. These disturbing subjective psychological experiences may lead to further levels of drug abuse, focusing on molecules with both strongly sedating (opiates/opioids; gabapentinoids) or antipsychotic activities.
4.2. Treatment Approaches
Given the serious health harms associated with the above stimulant/dissociative/disinhibiting polydrug ingestion, one would wonder about the best treatment and management approach to be considered. Unfortunately, however, for the treatment of withdrawal/cravings relating to most of the molecules discussed here, including stimulants and ketamine, no specific “ad hoc” medications have been approved [65]. In acute cases, intensive supportive care may be necessary; effective treatments may include adequate hydration, which helps manage dehydration, prevent rhabdomyolysis, and reduce the risk of renal failure; benzodiazepines, for example, diazepam or lorazepam, if properly dosed, due to their favorable pharmacokinetics, which can also be useful against hyperpyrexia and seizures; antipsychotics, for acute psychotic episodes not adequately managed with benzodiazepines [123] or other sedative agents. Conversely, for the inpatient treatment of GHB/GBL detoxification, high dosages of both benzodiazepines and baclofen may need to be administered [124]. Of note, routine screening tests often fail to detect most of these substances, making it essential to use validated analytical methods for their detection [32].
As with other drugs, the treatment of harmful drug use may need to include a psychosocial approach. For stimulant users, a 45–60 min clinical intervention/structured motivational discussion may need to include an exploration of the individual’s characteristics of use, desired and unwanted effects of stimulant ingestion, and plans for behavioral changes (for a comprehensive overview of these issues, see Abdulrahim and Bowden-Jones, 2015) [65]. Since, in most cases, users would be polydrug users, these interventions will, however, not need to focus on a single molecule in isolation.
4.3. Prevention
Clinical pharmacists may have a role as well in contributing to better monitoring the levels of sexual behavior-related drug intake. From this point of view, results of a national additional risk minimization measures program, implemented to train pharmacists for a safe supply of non-prescription sildenafil in the UK, have recently been made available. Within this program, some 86% of patients were advised on how to take sildenafil correctly, and about 70% of patients confirmed that they had received advice on lifestyle modifications to manage their erectile dysfunction-related health risks [125].
From the diagnostic point of view, there are gaps and potential risks of confusion among clinicians; the Diagnostic and Statistical Manual of Mental Disorders, latest edition (DSM-5) lacks, in fact, a specific category for sexual addiction, whereas the International Classification of Diseases (ICD-11) recognizes the possibility of a compulsive sexual behavior disorder [126]. Diagnostic difficulties can be further complicated by the potential of transitioning between disorders, such as substance use disorders, to behavioral addictions, with chemsex practices occurring intermittently or persistently during these transitions. Moreover, some authors suggest that certain personality traits and disorders, such as borderline personality disorder, may reflect a broader coping strategy where individuals prioritize reproductive traits and behavior as a way to deal with adversity [127].
Finally, the increasing application of computational modeling and AI-driven predictive tools has opened new avenues for identifying and monitoring emerging psychoactive substances, including those used in chemsex practices. As demonstrated in recent studies, structure-based and ligand-based approaches have successfully anticipated the appearance of novel substances before their formal identification in forensic or clinical settings [128]. These methodologies can be extended to a wide range of drug classes, including synthetic stimulants, hallucinogens, and dissociative agents. With AI-driven molecular design and screening, researchers can now explore vast chemical spaces with unprecedented speed and accuracy, potentially forecasting the next generation of designer drugs. This technological advancement underscores the need for regulatory agencies, toxicologists, and healthcare professionals to integrate AI-assisted tools into early warning systems.
4.4. Limitations
In order to fulfill the purpose of this review, presenting with a focus on a very specific topic, with most of the studies being relatively novel, a narrative approach has been preferred. This choice, which made making explicit the search strategy, has anyway provided broader literature coverage and more flexibility. We acknowledge, however, that this design has introduced a number of limitations. First, some of the studies included here did not disclose explicit criteria for article selection, which could lead to potential selection bias. Second, the review strategy employed led to the inclusion of studies with highly heterogeneous designs, methodological quality, and standardization of the methods used to characterize the impact of specific substances, including alcohol, on sexual behavior. Some of the included studies were small-sized, and, therefore, it remains unclear whether the findings could be generalized to the entire chemsex enthusiasts’ population.
5. Conclusions and Future Directions
Addressing the health harms associated with chemsex remains challenging due to the lack of updated and contextualized epidemiological data. Effective health policy interventions must be informed by comprehensive data on the patterns and consequences of chemsex-related drug use. Additionally, targeted media and social campaigns are essential to reduce the stigma that prevents individuals, particularly from the LGBTQIA+ community, from accessing necessary healthcare and support services [129,130]. Improving access to harm reduction programs, increasing awareness of chemsex-related risks, and integrating pharmacological and psychosocial treatment approaches are critical steps. Enhanced training for pharmacists and healthcare professionals, along with the use of AI-driven predictive tools for identifying emerging substances, can strengthen monitoring and early intervention efforts. A multidisciplinary approach that combines medical, psychological, and social support remains key to managing the complex challenges posed by chemsex-related drug use.
Data Availability Statement
No new data were created or analyzed in this study. Data sharing is not applicable to this article.
Conflicts of Interest
Part of these data were presented and discussed on the 24 January 2025 at the Royal College of Psychiatrists “Chemsex” webinar on the 20–22 February 2025 at the ESSM 2025 Congress, Vienna (A), and on the 26 March 2025 at the University of Swansea Substance Misuse Event (UK). F.S. is currently advising the European Drugs Agency (EUDA) NPS working group; A.G. is a formal member of the Advisory Council on the Misuse of Drugs (ACMD; UK). J.M.C. is a co-opted member of the ACMD’s NPS and Technical Committees. N.S. is a member of the Committee for Drugs and Narcotics (Ausschuss für Betäubungsmittel) at the German Federal Ministry of Health (Bundesministerium für Gesundheit) and of the Committee for Addiction and Drugs (Ausschuss für Sucht und Drogen) at the German Medical Association (Bundesärztekammer). Since 2021, he has been the chairperson of the German Head Office for Addiction Matters (Deutsche Hauptstelle für Suchtfragen e.V.).