Chemsex among men who have sex with men in Germany: motives, consequences and the response of the support system

Additional keywords: drug use, sexual practices, risk reduction.

In Germany, drug use in sexual settings among men who have sex with men (MSM) has increasingly been the subject of discussion, sometimes in a discriminatory way, for considerable time.^1–3 However, at the same time, relatively little is known about this practice, also known as ‘chemsex’, due to a lack of data on the situation in Germany. Against this background, this article aims to present and discuss what is currently known about chemsex among MSM in Germany. To this end, we first describe the spread of chemsex in MSM communities in Germany. Second, we look at the motivations for, and consequences of, using drugs in sexual settings, in order to subsequently focus on the responses of the German support system to the increased requirement for support. We finish with a discussion of which further steps are necessary for a suitable support system that meets the needs of drug-using MSM, and outline further requirements for future research.

In addition to using the small amount of quantitative data available, our observations are mainly based on the results of two research projects of a qualitative–explorative nature that we have conducted during the past 2 years. In the first research project, 14 problem-centred interviews about the biographical backgrounds and contexts of drug use were conducted with drug-using MSM in three German cities (Berlin, Cologne and Frankfurt/Main).⁴ In contrast, the second research project, conducted under the guidance of the German AIDS service organisation, Deutsche AIDS-Hilfe (DAH), in cooperation with community organisations in seven German cities (i.e. Berlin, Cologne, Frankfurt/Main, Hamburg, Leipzig, Munich and Nuremberg), concentrated on the needs of MSM who take drugs in sexual settings with regard to an adequate support system. Both problem-centred interviews with drug-using MSM (n = 75) and expert interviews with professionals (n = 27) were conducted for this project.^5,6 In total, we hence interviewed 89 MSM experienced in using drugs in sexual settings. These men were aged between 22 and 64 years and nearly none of them had a migratory background.^4,5 Problem-centred interviews are loosely based on guiding questions which, in this case, explored a range of topics related to chemsex, but nevertheless provide leeway for the ideas of the interviewees. Besides the experiences of drug-using MSM, we also examined the perspectives of professionals confronted with drug-using MSM. In contrast to problem-centred interviews, expert interviews do not focus on an individual and its behaviour, but rather on the institutional logics of organisations relevant to a particular social field. On average, all of the interviews took between 45 min and 1.5 h. All of them were recorded, transcribed and then systematically encoded and analysed, and evaluated according to Mayring, in terms of content analysis.⁷ All interviewees provided written informed consent before interviews were conducted. The audio files were deleted after transcription and all identifiers were removed from the transcripts for data protection reasons.

The survey ‘Schwule Männer und HIV/Aids’ (‘gay men and HIV/Aids’) is carried out at regular intervals among MSM in Germany. While this survey does not focus explicitly on chemsex, it does constitute the most reliable source for the extent of drug consumption among MSM in Germany. According to the most recent survey,⁸ those substances that are typically associated with chemsex (amphetamine, ketamine, GHB/GBL, methamphetamine) were only consumed by a few MSM during the year before the survey (up to 6%, depending on the substance). Furthermore, as shown in Figure 1, regular consumption of these substances is the absolute exception. This especially applies to the much-debated use of methamphetamine (‘crystal meth’). Intravenous consumption of methamphetamine, in particular, also known as ‘slamming’ on the scene, had only been tried by 0.7% of those surveyed.⁸ Prevalence rates have hardly changed in comparison with the survey from 2010.⁹

Fig. 1.  Prevalence of drug use among men who have sex with men (MSM) in Germany in 2013. Source: Own elaboration based on Drewes/Kruspe 2016.⁸

On the basis of this data, it is, hence, possible to establish that the use of chemsex substances (and therefore also chemsex in a stricter sense) is only practised by a minority of MSM in Germany. An increased consumption is also not observable, at least on the basis of the available data. Moreover, it can be assumed that the use of these substances in sexual settings is even less marked, as the study covers use of these substances in general, independent of the actual setting. However, secondary analysis of the data from the European MSM Internet Survey (EMIS) shows that relevant regional differences exist with regard to consumption of chemsex substances. According to this, consumption (measured as use within the last 4 weeks) is much higher in the largest German cities with well-developed gay scenes (Berlin: 5.3%; Cologne: 3.8%).¹⁰ Interviewees also perceive that consumption of chemsex substances on the gay scene is becoming increasingly relevant, particularly in these cities:

‘Let’s just say, if you want to have sex, sex without drugs is as likely as winning the lottery.’ (Interview 13, line 315)

‘Berlin, really massive community, (...) It was a bit too intense for me, because, even in a normal cafe, where I’d started chatting to someone, I’d somehow got onto speed, ecstasy and other drugs after three, four or five sentences.’ (Interview 14, Line 235)

This perception tallies with the experiences of support and advisory projects that report an increased need for help among MSM who use drugs in sexual settings, especially in larger cities.^5,6 Yet, problematic consumption patterns appear to be quite rare. The results of our research indicate that, with regard to those MSM who take drugs in sexual settings, it is possible to differentiate between two ideal-typical groups of users. While one group describes relatively ‘controlled’ consumption that intentionally only takes place at irregular intervals and involves safer sex and safer use strategies, the second group perceives its drug use to be rather ‘uncontrolled’. MSM from the latter group feel the urge to regularly take drugs in sexual settings and describe that they find it difficult, while under the influence of drugs, to keep managing risks, even though they actually want to.^5,6 As shown in the following section, particularly men of the second group describe sometimes serious consequences of the practise of chemsex. Chemsex is therefore of great health-related relevance for MSM in Germany, even though it constitutes a minority behaviour.

Motivations for taking drugs in sexual settings are manifold in both groups, and are related to both a physical and a psychological level. On both levels, the effects of the drugs are used to intensify sexual feelings.

With regard to the physical level in particular, drugs can be regarded as a kind of ‘strategic resource’¹¹ that is used in order to be able to give full expression to sexuality more intensively and with greater stamina. In this sense, the men interviewed use drugs to boost their sexual performance (better erectility, delayed ejaculation, etc.) to experience more intense feelings during sex or to make certain sexual practices easier:^4–6

‘Yes, it’s just a means to an end for giving complete expression to all aspects of your sexuality. Many aspects of your sexuality just wouldn’t even be possible without these drugs, because neither your body nor the person could take it. It’s just not possible. [...] Here in Berlin, you go to a sex party, fill yourself with drugs and have sex from Thursday evening until Monday morning. With 20 different men, for three days. That’s not normal. That’s not normality. It’s just artificially brought about by the drugs.’ (Interview 1, line 225)

Looking at the psychological level, the persons interviewed appear to use drugs – more or less consciously – to achieve a kind of ‘cognitive freedom’ that enables them to ‘let go’ and experience sexuality free from care. In this sense, the breakdown of inhibitions and the repression of difficult situations in life (because of HIV infection, for example) play a significant role on a psychological level, in addition to striving for relaxation. Improving feelings of self-worth, to feel more physically attractive, for example, is also important. Reference is occasionally still made to drug use in sexual contexts because of peer pressure.^4–6 In particular, the latter two aspects – improving feelings of self-worth and peer pressure – refer to the fact that the community, with its specific standards, is perceived as a kind of safe refuge, but also as stressful. On the one hand, it is possible to give full expression to one’s own sexual identity in a safe environment, without experiencing prejudice. On the other hand, the scene can exert strong pressure (to adjust), for example, because of a perceived sexualisation or communication of certain body images, which men partly encounter by the use of drugs. It is striking that those men who perceive their drug use to be controlled tend to report increased wellbeing. By contrast, interviewees who assess their consumption (in sexual settings) to be more problematic, report a multitude of problems and negative consequences that they, themselves, directly associate with their substance use. In addition to negative effects and side-effects of the individual substances, such as overdoses, specific problems arise for men with regard to their sexual wellbeing. This includes, for example, an (unintended) loss of control that makes it difficult for them to keep to safer use and safer sex strategies:

‘Once, I had really taken a lot of crystal meth. And then I was in a place, a ‘playroom’ it’s called – it’s just for sex, with every possible toy and God only knows what. I was in there for three days and screwed every guy possible. And I tried out everything I had been wanting to try for a long time and never done, to protect myself. I’m still HIV negative. I took all sorts of crazy risks and ran out and thought, oh shit, what was that all about?’ (Interview 2, line 179)

In this sense, the entry of these men into risky sexual contact and their infection with sexually transmissible infections (STIs) is also attributed to situations in which they had sex under the influence of drugs. Among some interviewees, the increased intensity of sex under the influence of substances leads them to find sex without drugs difficult or even impossible to imagine. This is observed, in particular, among men who regularly take crystal meth for sex.

In summary, it can be stated that the causes, motives and consequences of drug use in sexual settings among gay and other MSM require further research. Drug use and the sexual risk behaviour partly associated with it thereby appear to be ‘influenced by individual biographical factors and different social contexts’.⁸ Whether drug use can be described as successful, integrated and low risk, depends on the backgrounds and contexts that determine consumption. In any case, it should be noted that drugs, apart from being a strategic resource, also constitute a kind of ‘social lubricant’. They break down (socially conditioned) boundaries of modesty, enable a more relaxed sexuality and bring about a feeling of belonging together; for example, by generating feelings of intimacy even when having sex with relatively unknown strangers. However, they also help to meet the standards and expectations that are (apparently) prescribed by (part of) the gay community.

Besides a discussion of the motivations for, and consequences of, chemsex, the interviewed MSM and experts were asked for their perspectives on and opinions about support system’s response to chemsex. Data obtained from these questions and a comparison of regional support structures in Germany show that established advice and help offers that are specifically orientated towards drug-using MSM currently only exist in Berlin and Cologne. As it is true for other European countries as well,¹² the existing support system in Germany is, hence, marked by a serious gap. The interviews clearly reveal that community-based advice offers and HIV prevention projects for MSM, on the one hand, lack knowledge about the effects and risks of the substances consumed, as well as about the treatment options for any substance dependency, while existing drug advice centres are so far not geared towards advising on drug use in sexual settings, let alone in the context of male homosexuality.⁶ In general, the interviews show that acceptance-orientated behaviour – both in relation to drug use and with regard to sexuality – is an essential prerequisite for drug-using MSM to even consider support services as a point of contact.

Nonetheless, some promising approaches can be observed in Germany, which could close the gaps in supply in the long term. The steps taken in Cologne and the surrounding area by Aidshilfe Köln since 2013 have made the most progress in this respect. Here, according to the interviewees, it has already been possible to set up a type of care network for gay men and other MSM, who take drugs in sexual settings. In this network, various institutions (emergency outpatient departments, specialised HIV practices, etc.) work together, in close cooperation with Aidshilfe Köln, and refer MSM who are looking for advice or support to the required place in each instance. In addition to medical care, this care network covers psychosocial advice, drug advice and elements of sexual therapy, with the option of in-patient withdrawal treatment.¹³ In this respect, Salus klinik Hürth, near Cologne, offers two withdrawal groups exclusively for MSM who consume substances in sexual settings, to which, as some of the interviewed experts stressed, MSM from all over Germany are now referred. As of recently, this medical rehabilitation can also be followed by outpatient aftercare at Aidshilfe Köln. This currently unique concept in Germany ensures target-group specific further support for substance-using MSM following rehabilitation. At the same time, Aidshilfe NRW and Aidshilfe Köln have begun establishing harm-reduction interventions in scene locations (clubs, saunas, etc.). They include, for example, handing out ‘Pip Pacs’ (safer slamming packs), which were developed in London.

There is also a range of target-group specific offers in Berlin, the German city where chemsex is probably most widespread. Particularly worthy of mention is the work of manCheck Berlin on location at gay scene venues. ManCheck Berlin also aims at reducing risks in the context of chemsex by, for example, handing out safer slamming packs. Inspired by the series of talks ‘Let’s Talk About Gay Sex and Drugs’, which was brought into being in London, a similar format was also created by the specialist HIV practice, Cordes. It receives financial support from Aidshilfe Berlin and offers interested persons, at more or less regular intervals, the opportunity to talk about topics relating to chemsex (e.g. shame or experiences of abuse) in a relaxed setting. Furthermore, Schwulenberatung Berlin offers abstinence- and non-abstinence-orientated drug counselling and addiction treatment programs. In comparison with the care structure in Cologne, and based on the assessments of the interviewed experts, it is yet striking that the various offers in Berlin are less interconnected and that there are still hardly any chains of referral between the institutions that are dedicated to the theme. Within one specialised project, the DAH has begun to tackle this fact, by interlinking prevention and advice offers from the whole of Germany and bringing together experiences. The aim is to further develop existing offers, on the one hand, and to set up new offers, on the other. For this purpose, regular further training is now available to doctors and staff from advice and prevention projects, for example. During this further training, basic knowledge is taught and options for target group-specific interventions are discussed. Furthermore, the DAH is currently working out requirements for brief interventions that can be used in different contexts by interested institutions, and offer a first opportunity to engage in conversation about drug use (in sexual settings).

As in other countries, chemsex is only practised by a minority of MSM in Germany. While chemsex tends to be depicted as being on the rise in social commentary,^2,3 existing data moreover do not indicate an increased use of drugs in sexual settings among MSM in Germany throughout the last years. Again, contrary to some media portrayals,^2,3 chemsex also does not constitute a ‘dangerous’ practice in every case.^11,14 In this respect, generalisations that could reproduce stigmatisation of MSM should be avoided, especially given the many different individual determinants and social contexts of drug use in sexual settings. Yet, chemsex can have serious consequences. Therefore, target group-specific support offers are required, especially for MSM who need or would like help. As MSM do not perceive the classic drug advice system to be sensitive to gay life worlds, and since this system also is de facto not geared to drug use in the context of male homosexuality, these support offers should ideally be established within the setting of community-based organisations and HIV prevention projects for gay men and other MSM. An abstinence-oriented approach, however, could have a deterrent effect because complete abstinence is not always the primary goal of drug-using MSM. While abstinence-orientated support offers should be made available to those men who want this themselves, development and implementation of specific support offers should focus more on harm reduction. However, it should also be noted that the establishment of such ‘chemsex support offers’ should not detract from the fact that there are a lot of other health-related issues, such as psychological problems, which are probably more relevant than chemsex for the majority of gay and other MSM.¹⁵

Our results indicate that chemsex is sometimes solely motivated by purely functional reasons, in that drugs are used as a ‘strategic resource’ to deliberately achieve certain sexual effects. Hence, it deserves more attention in future research that chemsex is not necessarily related to any kind of deficits implicitly contained in models of internalised homophobia or minority stress, which are widely discussed in the academic literature.^16,17 Yet, our study also displays a wide variety of backgrounds and social contexts of drug use in sexual settings that include, for example, feelings of inferiority, experiences of discrimination or dealing with HIV infection, along with other aspects. This indicates that appropriate offers of support should, at least in the long term, be aimed at holistic care that takes into consideration both the physical and psychological wellbeing of MSM. If, for MSM, drug use is an attempt to cope with stressors, such as experiences of discrimination, which particularly affect sexual minority groups,^8,18, the structural conditions that could potentially have a negative influence on the health of MSM would ideally have to be tackled, along with offers that are aimed at an individual level.¹⁹

While first steps towards a holistic care network can be observed in Cologne and Berlin, specific support offers still have to be developed in other large German cities. Building up of interdisciplinary and interinstitutional cooperations appears to be of particular urgency, on the one hand, in order to be able to build up care networks that will function in the long term and, on the other hand, to avoid referral chains that lead to nowhere, as has so far been the case.⁶ To this end, all potential links in a care chain (doctors, drug and gay advisory services, etc.) should be made more aware of the issue and given appropriate further training, as initiated by the DAH during the year. With all due focus on major cities, MSM in rural areas as well should not be forgotten. They are often affected by lack of provision of suitable support offers as it is.⁸ As described, chemsex primarily occurs in larger cities. However, there appears to be a kind of ‘chemsex tourism’ that makes offers of help for MSM who live in rural areas seem meaningful. One possibility for reaching these MSM could be in the implementation of online offers that could be used anyway, given that dating apps play a key role in the social organisation of chemsex.²⁰

In addition, further research is also necessary for developing and implementing suitable interventions. Along with further research into the individual backgrounds and social contexts of chemsex, three points, in particular, seem to be relevant from our perspective; consumption of drugs in sexual settings is evidently relatively ‘controlled’ in some cases. It would therefore be important to conduct further research to find out which conditions enable ‘controlled’ consumption and which risk-management strategies can be derived for practice from these conditions. Furthermore, the results of our research indicate that, along with the social norms of society in general, as emphasised in the minority stress model, for example,¹⁸ social norms within MSM communities also cause drug use in sexual settings. However, these norms have so far been underexposed in research into chemsex. Greater knowledge about how the social norms of MSM communities influence drug use in sexual settings, and how these norms can be involved in harm-reduction interventions, would therefore be necessary.²¹ After all, chemsex is associated with sexual risk behaviour both by some of the men we interviewed and by research studies.²² However, evidence with regard to the connections between transmission of STIs and drug use in sexual settings is limited and, for the most part, relates to the Anglo-American region.¹¹ Systematic studies about the links between chemsex and sexual risk behaviour, and which conclusions can be drawn from them for harm-reduction interventions, would therefore also be necessary in Germany.

The authors declare no conflicts of interest.