Community experiences and strategies of risk management within chemsex practices: a qualitative study

The rise in the study of sexualised drug use among gay, bisexual and other men who have sex with men (MSM), known as chemsex, has generated a multiplicity of data that contribute to its problematisation as a public health issue through the link with HIV and addictions. The study of these practices, from a biomedical paradigm, has focused on risk and has contributed to its reduction as a unique and quantifiable phenomenon. This study aims to explore the experience of risk in the course of the practices, to find out what management strategies they employ in the face of risk and how they are generated. Semi-structured interviews were conducted with five chemsex practitioners in the Metropolitan Area of Barcelona and, subsequently, a thematic analysis was applied. The findings show how these men detect, assume and confront the risks present in these practices, where the type of relationships that take place and the social circle available to them are relevant. This study also highlights the creation of strategies based on experience and how the transmission of this knowledge among participants facilitates decision-making and risk management.


Introduction
The term chemsex describes a range of sexual practices involving the deliberate use of psychoactive substances to enhance and facilitate sexual experiences among gay, bisexual and other men who have sex with men (MSM) 1 .These practices are usually organised around house parties, known as chills, which can last several days and involve multiple sexual partners 2 .They are often associated with the use of substances such as mephedrone, methamphetamine (Tina) or liquid ecstasy (GHB) but should not be limited to these as the practices vary according to the physical and temporal context in which they occur.Although the combination of sex and drugs is not new, what is specific to chemsex is the sexualised use of these substances to prolong the duration and increase the intensity of the sessions.At the same time, there has been a transition from the clandestine concealment of these practices to an increasingly public exposure within the MSM community.
This paper understands chemsex and its practices as part of a subculture of gay culture 3 , with which it shares symbols, norms, meanings, and language, but which also presents differentiated spaces of sexual sociability, as well as specific codes 4 .Thus, it seeks to differentiate itself from the prevailing normativity of hegemonic gay culture, without rejecting its core values.A culture in which sexuality is a central aspect of sociability and which rewards the search for pleasure, showing itself to be tolerant and permissive with drugs 5 .
The study of this phenomenon began in the last decade with the publication of papers such as The Chemsex Study 6 .It has been on the increase in the last five years, with a higher incidence after the Covid-19 pandemic.These early studies warned of a risk behaviour with public health implications.Subsequent studies have mostly focused on the prevalence of drug use among MSM 7 , especially among gay and HIV-positive MSM, and its association with an increased likelihood of engaging in sexual practices considered risky, with HIV transmission as an indicator 8 .Other publications have focused on the problematic use, with an emphasis on practices such as injecting or slamming 9 .The literature review by Maxwell et al 10 showed the negative impact of chemsex on the health of its practitioners but highlighted the need to investigate its impact on psychosocial wellbeing.In line with this, other publications also call for the need to understand the social and cultural dimensions of sexualised drug use among MSM 11 .Key debates revolve around defining and delineating chemsex, identifying its characteristic practices 12 , and understanding its classification as a health issue due to its links with HIV, other sexually transmitted infections (STIs), and addiction.
This large volume of data has been produced from a predominantly biomedical perspective, reducing chemsex to a single phenomenon that can be quantified.Another purpose of these publications, in addition to measuring the consequences and implications for public health, was to profile the practitioner through massive data collection methods 13 .All this production of discourse around chemsex created a moral panic 14 that served as a pretext for the UK to declare it a public health priority in 2015 15 .Subsequently, other countries have developed policies and programmes from a prevention and harm reduction perspective.They use the concept of risk as a tool to problematise and address the phenomenon from an epidemiological perspective 16 .Problematising the pathologization involves rethinking the historical impact of risk models on sexuality, especially for those designated to the margins 12 .The assumption that certain practices are problematic implies the assertion of a set of prejudices, as well as the denial of the subjectivity of risk, which is an obstacle to interventions that target a specific profile and forget those who do not perceive it.An example of this is a study carried out during the Madrid Pride in 2016, in which only 5% of a total of 365 men considered their drug use to be problematic and 80% rejected the need for professional help 8 .
In addition, there are other implications and dimensions less studied that concern those who practice chemsex.For example, consent, acts of violence, self-perceived stigma for HIV-positive men during practices 17 , acts of care 18 , increased confidence to engage in certain practices 19 or pleasure 20 .
A qualitative approach can contribute to the understanding of the meanings attached to these practices, as well as to the study of the phenomenon as a social construction, as a set of social practices linked to a particular socio-historical context and constantly produced by its practitioners 21 .Therefore, the aim of this article is to explore the experience of risk among men who practice or have practiced chemsex in the Barcelona Metropolitan Area (hereafter AMB), to identify strategies for its management.

Method
We used a qualitative methodology from a socio-constructivist approach 22 that allowed us to explore the different meanings that circulate in chemsex.Given the specific characteristics of these practices in terms of difficulty of access and intimacy, the interview was chosen as the technique for collecting information and, in response to the research objective, experiences and perceptions of risk were gathered through the oral narration of events experienced.
Given the complexity and ambiguity of the concept of risk, we propose to use the definition used in epidemiology and public health, where chemsex policies and interventions are planned and implemented: risk as the probability of an adverse event occurring 16 .

Sampling strategy
Participants were recruited using snowball sampling, a type of non-probability sampling that is particularly useful in populations that are difficult to access or in which the researcher is not fully immersed 23 , as well as in cases where the object of study tends to cluster individuals, such as chemsex.The objective was to find practitioners who did not seek specialized attention to quit chemsex, thus identifying those outside the scope of risk reduction programs, usually excluded in previous research.Five men were interviewed who met the inclusion criteria of identifying as male, being of legal age and having practiced chemsex more than once, and the exclusion criteria of not seeking or receiving professional help.The final number of informants was not pre-established, but was adjusted according to theoretical saturation, meaning that the sequence of experiences covers the relationships of the study subject in a way that the arrival of new data did not enhance the understanding of the proposed objective 24 .

Data collection
Semi-structured interviews were conducted with each participant.They last approximately one hour and were audio recorded priori consent.A script of topics was used: (1) entry routes to chemsex practices; (2) physical and social environment; (3) sexual practices; and (4) sexualised drug use.The interviews took place at the participants' homes, except for one that was conducted via video conference.The conversations in their familiar environment were themselves observational scenes that provided useful information 25 .

Data analysis
For the analysis of the information, the thematic analysis method proposed by Braun and Clarke 26 was followed.The interviews were transcribed verbatim using the Otranscribe tool.The analysis was conducted concurrently with data collection and started with a phase of data familiarisation.This was followed by coding on the basis of recording units, i.e. identifiable fragments with meaning relevant to the purpose of the study.These units were grouped according to similarity, resulting in themes and sub-themes in a process that considered the criteria of inclusion and exclusion, with each thematic unit belonging to only one category 27 .Finally, the coherence between the extracts selected for each category was checked.The themes were then named and defined and the interpretation phase continued.
This work is based on reflexivity, as a process of awareness and criticism of the researcher's subjectivity, in which the creation of a state of question prior to analysis provides tools for understanding the object of study and contribute to its subsequent interpretation.The exhaustiveness of the verbatim transcription of the interviews, which also includes pointing out and indicating various forms of non-verbal communication, corresponds to a principle of reliability of the data presented.Finally, the intersubjectivity of the narratives is demonstrated by the repetition of themes, the accumulation of experiences and the contradictions between the different narratives, which provide a common validity to the themes derived 28 .

Ethical considerations
This research complies with the general ethical principles of the Declaration of Helsinki 29 for research involving humans and follows the Autonomous University of Barcelona (UAB) code of good research practices 30 .Following these guidelines, participants were informed of the participation conditions and their informed consent was obtained.The interviewer took the necessary time to clarify the terms of participation, both verbally and in writing, in an act of empowerment of the interviewee's rights.Interview data, including audios and transcripts, were anonymised and stored on secure servers at UAB.

Results
The present study includes the experiences of five men who have participated or are still involved in chemsex practices within the Barcelona Metropolitan Area (AMB).Chart 1 shows the characteristics of the participants, with pseudonyms to facilitate reading, preserve anonymity, and avoid depersonalising the narratives.
All the participants defined themselves as homosexuals and none of them have been born or raised in the AMB, although the practices they described take place there, mainly in Barcelona.During the analysis phase of the experiences, the following themes emerged (1) social relations in chemsex environments, (2) perceptions of safety and vulnerability, and (3) risk management strategies.

Social relations in chemsex practice settings
Four of the participants reported that the first time they use drugs during sex was with someone they knew and through whom they had access to subsequent encounters.All had previously used psychoactive substances in a party context and agreed that their first sexual experience was positive.As their participation in sex parties increased, so did their networks, providing them with more and more opportunities to engage in chemsex.These encounters, with their great potential for socialisation, became particularly important for the three participants who had moved to Barcelona.For them, moving to this big city was a determining factor in their ability to engage in chemsex and attend sex parties more frequently.They also linked this to the reduced social circle and lack of close family responsibilities at the time of their arrival.One mentioned how periods of confinement during the pandemic, with limited options for partying, contributed to the spread of chills: 'You couldn't do anything.So what did you do?Fuck and get high at home with more guys (Mario).
When talking about practice environments, these men spoke about the diversity of environments and physical spaces, distinguishing mainly between commercial spaces, such as saunas, and non-commercial spaces, such as chills, where men of different ages and backgrounds, with different economic and relational situations, gather.
Alex highlighted the heterogeneity of bodies present in this scenario and how this improved his body image at the time and allowed him to enjoy his sexuality more.Guille, for his part, mentioned that these spaces had allowed him to explore practices that he defined as less normative, highlighting the trust with the group and the type of relationships created as necessary ingredients for such experimentation: "you don't feel judged, you can have whatever sexual practices you want" (Samu).Two of the participants -one of them HIV-positive -also reported that they felt less stigma towards HIV-positive people in these settings.
Interviewees agree that chills encourage sociability, but the bonds formed there do not extend to other everyday scenarios.For example, those who attended weekly found that their social circle consisted only of other practitioners, distancing them from their previous relationships outside of chemsex: "I've lost my friendships that I had before.I've lost them because of this issue.So the circle that I used to relate to were only those who were into it" (Mario).
Finally, there is a frequent mention about caring practices in their social relationships, whether it is sought, wanted, or desired.They relate its quality to the level of trust with other practitioners, which in turn is linked to the variation of environments they frequent.For Mario, a great variability of people and practice environments affects the type of bonds that are generated, which he perceives as more futile and less close, leading to a perceived absence of care.

Perception of security and vulnerability
One of the incentives to practise chemsex is the possibility to engage in prolonged sexual sessions, thanks to the effects of certain psychoactive substances.This leads to altered states of consciousness, which reduces the capacity to act and make decisions about oneself, something that is expected and even desired by these men.Samu explains how, paradoxically, he had chosen to lose the ability to make decisions: 'When I was on drugs, I was not choosing what I was doing.I had chosen not to choose, I had chosen to take drugs to not choose.
This controlled loss of control leads in some cases to a state of complete but temporary unconsciousness, which they refer to as estar doblado.This state, produced mainly by the depressant effect of GHB on the nervous system, is frequently mentioned in interviews as being common in practice and can be either intentional by the individual or unintentional as a result of overdose.Three of the five interviewees had experienced this state and the other two had observed it in third parties.Faced with such situations, which can last several hours and be repeated during a session, there are different reactions, ranging from inaction, motivated by the normalisation of these events in the practice setting and the frequency with which they occur, to the activation of caring practices, such as offering the person a comfortable space until he or she recovers.Some men consider the possibility of being penetrated by one or more participants in the encounter while unconscious, although in most cases this intentionality is not communicated previously, leaving room for ambiguity.This elicited conflicting opinions from the interviewees.While they report situations in which they have experienced or witnessed sex without explicit consent, they are reluctant to classify it as sexual assault and offer multiple interpretations of these complex situations: If there were ten people in the house, many of them fucked me and came in while I was unconscious on the sofa.[…] At that moment it wasn't traumatic, it even turned me on.[

...] I wouldn't know how, I wouldn't know exactly how to analyse the situation [...] If I felt vulnerable before I lost my state of consciousness one hundred percent, when I lost it one hundred percent... (Samu).
However, when this state is by others action, against their will or in an unplanned way, it can lead to a sense of vulnerability or insecurity: Once I blacked out and I don't remember anything... it was a trauma for me.It made me very insecure, and I felt very bad because I was with a friend.I felt that the guy made me faint on purpose.[...] I don't really know what happened, but feeling so vulnerable and losing consciousness, I felt violated and I distanced myself a lot from that (chemsex) (Guille).
Another aspect that concerns the participants in this study is the recent emergence and escalation of the use of methamphetamine, known as tina, in sex parties.Mario noticed a difference in the atmosphere of the chills over time, which he linked to the presence of this substance, and which he associated with increased violence: "The chills functioned better without tina.Above all, the violence has increased".Luis also points out the difference between those environments where this substance is used regularly and those where it is not, concerning the behaviour between participants.Another risk attributed to this substance by these men is its higher likelihood of causing addiction compared to other substances.

Risk management strategies
While the use of condoms as a method of protection against STIs is uncommon in these sexual contexts, respondents consider the use of pre-exposure prophylaxis (PrEP) as prevalent, especially in larger cities where it is more available.This method has gained popularity in recent years and has become integrated in chemsex contexts: "In my first experiences in Barcelona, there was no PrEP.It was something that was known to exist, but it was not clear how to access it.[…] Now most of them take it regularly and in a controlled way" (Samu).Information about this method, provided by the organisations, has been disseminated through the exchange of experiences among users in the context of practice: "If you go to the places where it is distributed, they explain how it works, and if not, people explain how they have done it, where they have gone or where you can go to ask.In general, people talk openly about these things" (Luis).
All of them claimed to understand how PrEP worked and those who adopted this pharmacological strategy at some point expressed confidence and recognised it as an effective measure against the risk of contracting HIV: 'I've had sex with HIV-positive people who are on PrEP and I've never been afraid [...]

why should I be afraid when it's very clear that I can't get it if they're on PrEP?" (Guille).
Another common topic in the interviews was the possibility of developing addiction to drugs or their sexualised use.Two of the interviewees identify periods when their ability to have sex without drugs was affected, even after they had temporarily stopped using drugs.The others recognise the risk associated with repeated and frequent use of psychoactive substances, but while they do not perceive it in themselves at the time of the interviews, they identify others who are susceptible or who have become dependent:

"I have colleagues who are addicted to chemicals and everything. And the truth is that it's very hard and it helps me to think about what I don't want" (Guille).
There is a recurring discourse that advocates self-control as a strategy for controlling the frequency of participation in sexual parties.This strategy is based on the idea that the greater the frequency, the greater the likelihood of addiction: "It's important never to go for two weeks in a row.[

...] Because in the beginning you go alone because you love it and in the end you can't leave because of the drugs" (Guille).
Also reflected in their narratives are self-imposed red lines or limits on the use of certain substances or routes of administration, which allow them to determine the potential risk involved.For some men, for example, injecting drugs represents a limit in the same way as having the tools to use methamphetamine does for Luis: "I think that buying tina and having a pipe at home is a different level.It's like smoking joints but not knowing how to roll them.If you have a pipe... it is the necessary tool to access this drug in a more continuous way" (Luis).
Another risk associated with the prolonged use of different psychoactive substances is overdose.This can also be increased by loss of sense of time between doses, interactions between chemicals and, in the case of GHB/GBL, the reduced safety margin.Respondents reported self-dosing as a preventive strategy, which also allows them to better control the frequency of use: "I have learnt that I have to control the amount of GHB myself and also be very aware of the time frame in which I take it.And this is also a piece of advice that I give to many people, especially young people: keep a close eye on how much GHB you put in your body, always put it in yourself.Not even if he invites you, you put it on yourself!Because they can put three doses in your body and that's enough to make you faint" (Guille).
They point to experimentation with different doses and combinations as the key to achieving a more effective modulation of the desired intensity, which increases the sense of control and safety when using drugs.This is facilitated by the sharing of experiences among chill participants: "You try and people give you a taste.And you talk about this and that, and people explain to you how they feel and what happens to them with each drug, and from there you start to try them.Someone tells you that it's better to take a hit of this or that in order to do this or that during sex" (Luis).
These chills can bring together large numbers of men with a wide variety of participants.This, in addition to its socialising potential, offers the possibility of experiencing a wide variety of sexual practices and interacting with more bodies.Interviewees describe how they sought out this type of session when they were first introduced to these practices and how, over time, they adopted a strategy of attending smaller parties with more familiar participants: "I closed a circle.[...] before I was more into that, innovating and searching, but you find that's what's cool, you know?That the market is diverse.But in the end you realise that when it comes down to it, it doesn't work well" (Mario).
This increased their sense of security and trust in others, making it easier for them to deal with uncomfortable situations or situations where they might have felt vulnerable: "I want there to be a space for everything.Also a space for you to be 'quiet', a space for someone to look after you or if you have a bad trip at some point, well, we all know how to manage it super well and no one is judged and there is no mismanagement of the trip... which can be dangerous" (Guille).
Care between practitioners is a recurring theme in the interviews.Mario, for example, explains how, at the time of initiation, he felt looked after by other more experienced participants in times of need: "They kept me in a room and took care of me.They continued to have orgies and from time to time they would come to the room.Luis and Guille also see care as necessary, especially in overdose situations: Care? well, it's mainly when someone doubles up, isn't it?It is very different, for example, if someone takes advantage of this moment to rape or if there is a care that this person is looked after, accompanied" (Luis).

Discussion
The diverse experiences reported underscore the existence of varied risk management approaches within chemsex practices.Risks are acknowledged, known, and consciously assumed by these men.The embodiment of risky experiences and their transmission among practitioners enables the development and implementation of diverse risk management strategies.Consistent with Bourne et al. 6 , many chemsex users effectively incorporate sexualised drug use into their daily lives, maintaining control over their actions in pursuit of pleasure.This study reveals that regular STI testing is one of the most common and standardised risk management measures among gay and bisexual men.Furthermore, the information provided by the participants in this study allows us to assert that there is ample knowledge of other available preventive measures, whose information is disseminated by sexual health organisations and is integrated into the knowledge generated collectively in the same sexual encounters.
When it comes to implementing such measures, this paper agrees with Meunier et al 4 that the negotiation of individual protection preferences tends to be tacit and sometimes presumed.Often a preference such as barebacking, penetration without a condom, is implicit in the nature of the encounter for all participants, so there is no need to negotiate condom use.At other times, each participant applies his preferences without the need to discuss them.
Another risk experience identified in this work relates to temporary unconsciousness, described as 'estar doblado'.In line with sociological studies of risk, Hickson 31 explores the boundaries that men define and experience in chemsex practices.The participants in this study show how the risk experience generates a particular perception that shapes individual norms of behaviour, differing from those advocated by public health.For example, 'estar doblado' or blacking out takes on a different meaning in chemsex environments, and while it may be something to be avoided for some, it may be sought or experienced as normal for others.This state, when achieved involuntarily or unexpectedly, can create a sense of vulnerability.This paper identifies self-administration as a preventive strategy against this and locates the care practices that are generated in these situations, which, as Florêncio 32 points out, are culturally reproduced.
However, there remains a debate in the chemsex literature about acts of sexual violence.Fernández-Dávila 33 explores consent in some contexts where these practices occur, and warns that affirming the occurrence of sexual violence in these contexts contributes to the stigmatisation of MSM sexuality.Although experiences such as being penetrated while unconscious or having sex without explicit consent are mentioned in this work, respondents are initially reluctant to label them as sexual violence.We agree that consent needs to be understood within the specific context of chemsex, which, as this study shows, is a concept that generates ambiguity and is questioned by the respondents themselves, and which is far from the classically heterosexual conceptualisation in this enclave.This research is in line with other research 34 that highlights the importance of communication in terms of preferences and limits that one is willing to accept in sexual contexts, as well as the fact that attending smaller sessions with a greater degree of trust towards the participants are some of the preventive strategies that men generate.It is therefore important to consider the use of terms such as consent or rape in sexual health services, especially in the MSM population.
The possibility of becoming dependent on or having sex with psychoactive substances emerged as a concern in the interviews.It also appears in the research by Drysdake et al 35 , in which participants in their study prioritised preventing this risk over other risks, such as contracting sexually transmitted diseases.As this work shows, controlling participation in sexual encounters involving drug use is a preventive strategy that is highly valued as a process of individual and sometimes collective regulation.Collective in that it takes the form of caring for others and, as they point out, the social circle available to them is relevant.
Finally, it is important to point out the existence of a collective pharmacological knowledge, the fruit of experience, which is transmitted between participants in sexual encounters and which goes beyond the knowledge disseminated by services and organisations.This knowledge is specific to this subculture and includes implications such as pleasure, which are not always taken into consideration.According to Hickson 31 , the culture of risk reduction can emerge from below, from the sites of practice themselves.

Conclusions
The complexity of chemsex and the variability of its practices require a broad approach that does not reduce it to a single, uniform phenomenon.Although risk is intrinsic to chemsex, the analysis of the stories collected here shows how it is perceived, assumed, and managed by its practitioners according to their interactions and experiences, which determine the ways in which they expose themselves to it.Something that in another context would be interpreted as dangerous, such as being bent, can be desired in this context.
In the process of risk regulation, management strategies emerge that both prevent and protect against the dangers posed by these practices.Individual choices about the measures to be taken and the limits that can be accepted are intertwined with the community norms set by the contexts of practice in a process of mediation that modifies them after each experience, whether one's own or that of others.Recognising chemsex practitioners' capacity for self-management of risk means considering not only external support networks but also internal ones.
Sexual health organisations have a fundamental role to play in providing information about safe sexual practices and consumption.However, this research highlights the need to consider the knowledge generated in practice settings, as well as its transmission between practitioners and its capacity to generate more desirable and effective ways of managing risk.This route of transmission may be particularly important for novice practitioners who are not supervised in these organisations.In contrast to other studies that focus on individual factors, we believe that collective preventive and protective strategies are also generated in the same settings where chemsex is practised, and are not simply the result of public health policy.
Future research aimed at identifying and analysing the psychosocial needs of practitioners may provide new strategies and forms of risk management.Interventions should also recognise that risk taking is voluntary and conscious.Therefore, the approach to chemsex should extend beyond mere informational campaigns, fostering supportive networks among practitioners to facilitate the transmission of collective knowledge.

Limitations and strengths of the study
This qualitative study presents the experiences of five men with varying levels of involvement in chemsex practices.While the findings do not attempt to generalise these experiences, they do seek to improve understanding of the phenomenon through their experiences of risk and to provide insights into the strategies they construct in practice.The rigorous application of an analytical method widely used in the social sciences, which promotes an understanding of subjectivities, is presented as a strength, particularly interesting for discussion in social psychology, epidemiology and public health studies.

Collaborations
O Cano-Ruiz worked on the conception, design and writing of the paper.He also conducted the interviews and carried out the transcription and subsequent analysis.L Íñiguez-Rueda contributed to drafting and critical revision.Both authors approved the final version and share responsibility for all aspects of the work.