The Silent Advance: Chemsex Practices and Their Implications in Türkiye

The Silent Advance: Chemsex Practices and Their Implications in Türkiye | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Silent Advance: Chemsex Practices and Their Implications in Türkiye Gökhan Vatansever, Benjamin Collins, Harun Tulunay, Georges Āzzi, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8671993/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 13 You are reading this latest preprint version Abstract Background Chemsex, a form of sexualised substance use, is using psychoactive substances to enhance sexual activity. It is most commonly practiced by gay, bisexual and other men who have sex with men, trans and non-binary people and is increasing in prevalence across multiple regions worldwide. Yet, it remains insufficiently studied due to the stigma and criminalisation of some forms of drug use and sexual behaviour in many societies. We aimed to explore the prevalence, substance use patterns, motivations, and associated risks of chemsex in Türkiye. Methods An online survey including 18 multiple-choice questions assessing substance use, behavioural patterns, and psychosocial aspects of chemsex was distributed through Hornet and civil society contacts. Turkish people who have lived chemsex experience participated in developing the survey language to ensure its accessibility. Descriptive statistics and the Pearson Chi-Square Test were used to analyse the data. Results Overall, 290 people across 44 cities in Türkiye responded. Chemsex was reported as a growing practice by 72%. The majority of respondents (71.3%) were from metropolitan areas, where 62.3% reported ongoing chemsex practices for ˃3 years. Methamphetamine (70.5%), 3,4-Methylenedioxymethamphetamine (MDMA) (43.8%), snorted cocaine (35.1%), and γ-Hydroxybutyric acid/γ-Butyrolactone (GHB/GBL) (29.5%) were the most common substances. The main motivations for engaging in chemsex included enhanced sexual pleasure (70.7%) and relaxation (61.7%). Reported harms were psychological distress (80.7%), social and relational issues (60.0%), and legal or financial consequences (59.0%). Overall, 54.1% stated that chemsex could not be discussed openly. Conclusions Chemsex is a growing phenomenon in Türkiye, accompanied by significant health, social, and psychological risks. The lack of harm reduction services and open discourse underscores the gaps in healthcare and community support that require urgent action, such as targeted, culturally sensitive, sex- and pleasure-positive harm reduction strategies that address stigma, improve mental health support, and expand access to HIV/STI prevention and treatment. Chemsex Sexual behavior Substance-related disorders Men who have sex with men Transgender persons Türkiye Figures Figure 1 Figure 2 Figure 3 Background Sexualised substance use is the intentional use of drugs for sex and chemsex is one form of sexualised substance use referring to the practice of using highly active psychoactive chemicals to initiate, enhance, and prolong sexual activities and pleasure ( 1 – 3 ). Chemsex is characterised by a marked increase in the prevalence of sexually transmitted infections (STIs), the facilitation of high-risk sexual networks, heightened incidence of non-consensual encounters under the influence of substances, and even fatal outcomes such as drug overdose deaths. These compounded risks not only escalate individual health burdens but also pose significant public health challenges by aggravating the transmission dynamics of HIV and other STIs within key populations ( 4 ). People engaging in chemsex use one or more psychoactive substances to change how they feel and act during sexual encounters. This can lead to longer encounters, sometimes lasting days, and sometimes with multiple partners having sex at the same time ( 4 – 8 ). Lesbian, gay, bisexual, transgender, queer, intersex and other (LGBTQI+) individuals generally use substances at higher rates than heterosexual individuals do, and chemsex is practiced predominantly among gay, bisexual and other men who have sex with men (gbMSM) ( 6 , 9 ). Chemsex, or a comparable form of sexualised substance use amongst LGBTQI+ individuals and others, is reported from most geographical regions around the globe, often with their own slang terms and social media emojis to signal in settings where sexualised substance use and non-heterosexual relations are at least stigmatised if not criminalised. In this article, we will use the term “chemsex” as a blanket term for these forms of sexualised substance use common in the LGBTQI+ population, but it needs to be understood that other terms are also used locally. A study from the United Kingdom revealed that 25% of gbMSM had consumed three or more recreational drugs within the preceding 3 months ( 10 ). Another one from the Netherlands reported that 41% of HIV-negative gbMSM and transgender people who have sex with men had experienced chemsex with casual partners in the preceding three months ( 11 ). Similarly, a study from the Republic of Ireland showed that 27% of gbMSM had chemsex within the previous 12 months ( 12 ). An organization based in Hong Kong found that 9% of gbMSM respondents had participated in chemsex at some point. Individuals aged 31–35 were reported to be the most likely to engage in chemsex ( 13 ). Approximately 60% of gbMSM in Australia have engaged in the use of recreational drugs within the previous six months ( 14 ). While it’s usually associated with pleasure seeking amongst users, chemsex is also linked to higher health-risk behaviours such as needle sharing behaviours and neglect in adopting safe sex practices during substance use sessions that can result in an increase in the prevalence of STIs and even drug overdose deaths ( 5 , 15 – 18 ). People frequently consume more psychoactive substances during chemsex than intended due to the disinhibition caused by substance use, which may result in severe intoxications and fatal overdoses ( 19 ). Sex dates are frequently scheduled using dating apps or other social media platforms. The parties exchange details about each other in advance, such as the number of participants, type of substance use, and HIV status ( 17 ). Substances used in chemsex may also have adverse effects on health. In many regions, methamphetamine, mephedrone, ketamine and γ-butyrolactone (GBL)/γ-hydroxy butyric acid (GHB) are the most commonly used psychoactive substances. The adverse effects of methamphetamine include aggression, panic attacks, motor restlessness, concentration problems, and long-term brain damage. An overdose of GHB/GBL may cause respiratory depression and loss of consciousness ( 20 , 21 ). Ketamine use has been linked to drug-induced psychosis and near-death experiences ( 22 ). Mephedrone overdoses can result in palpitations, nausea, vomiting, anxiety states, panic attacks, auditory hallucinations, and thought disorders ( 23 , 24 ). Certain psychoactive substances can interact with specific antiretroviral medications—especially ritonavir- or cobicistat-boosted regimens—leading to elevated drug levels and potentially serious toxicity. Fatal events are possible but rare and generally associated with strong metabolic inhibition and high-dose stimulant or sedative use. ( 25 ). Additionally, drug interactions can reduce the therapeutic effect of antiretrovirals ( 26 , 27 ), which may have significant consequences. Chemsex is linked to a higher risk of participating in other unsafe sexual behaviours like condom-free anal sex, injecting drug use and higher alcohol consumption, fisting, sharing sex toys, and group sex because of the sexual disinhibition and hypersexuality induced by the drugs. Sexual activities may last longer due to the anaesthetic properties of some substances and this might lead to mucosal trauma which can further contribute to STI and HIV transmission ( 28 , 29 ). Türkiye accommodates one of the fastest growing HIV epidemics in the world. The annual number of newly diagnosed persons with HIV in Türkiye has shown a continuous and marked increase over the last two decades. The number of confirmed new diagnoses nearly doubled from 3,137 in 2020 to 6,185 in 2023, according to official data reported by the Ministry of Health ( 30 ). Consistently, a recent age–period–cohort analysis reported an age-standardized average annual percentage change (AAPC) of 6.19% (95% CI: 5.56–6.83) in HIV incidence between 1990–2021, with a faster rise among women (AAPC = 6.98%) compared to men (AAPC = 5.81%). The most striking increases were observed in younger age groups, particularly those aged 15–19 years (AAPC = 11.77%) and 20–24 years (AAPC = 7.49%), with incidence in women showing a marked increase after 2008 ( 31 ). While the lack of prevention measures, non-prioritization of HIV and STIs by the health authority, lack of sex education, and non-engagement of vulnerable populations in program development are suggested as the major causes of this striking increase, accurate data on this is unavailable. Moreover, the high percentage of the young population and the challenging availability of sexual and reproductive health services in Türkiye result in a critical vulnerability where early diagnosis, timely treatment initiation, and effective prevention strategies are severely compromised. Chemsex has become a growing global public health concern recently, and despite its risks, stigma and discrimination often prevent open discussions about it, particularly in conservative or religious communities. Chemsex is a novel concept in Türkiye and is usually experienced behind closed doors without being vocalized. The aim of this study was to lift the veil on chemsex in Türkiye, to explore its dimensions, and to bring it forward for discussion. Methods Study design and setting We conducted a cross-sectional, anonymous online survey to describe chemsex practices in Türkiye, including perceived substance use patterns, motivations, harms, and barriers to discussion and support. Data collection took place between 01 January 2024 and 31 March 2024. Participants and eligibility criteria Participants were eligible if they were aged ≥ 18 years, resided in Türkiye, and provided informed consent to participate. The survey was designed to capture community perspectives on chemsex and included respondents with lived experience and those reporting on chemsex practices in their location. Participation was voluntary and anonymous. Survey instrument We used an 18-item questionnaire developed by ReShape/International HIV Partnerships ( 32 ). To ensure cultural appropriateness and accessibility, the questionnaire was reviewed by Turkish people with chemsex experience, coordinated by a Turkish person with chemsex experience. The questions in English were translated into Turkish and Arabic and then back-translated to English to check accuracy. Community members piloted and edited the survey questions as required. The survey was distributed through various online platforms including dating apps and community networks to reach a broad audience. Variables The primary outcomes were descriptive measures of chemsex-related perceptions and practices, including (i) perceived duration and growth of chemsex practices in participants’ locations, (ii) substances reportedly used in chemsex contexts, (iii) perceived motivations and harms associated with chemsex, (iv) ease of discussing chemsex within the community and with healthcare providers, and (v) perceived access to harm reduction and HIV/STI prevention and treatment services. Location was categorised as metropolitan versus smaller cities, based on self-report. Statistical analysis Survey responses were summarised using frequencies and percentages. For questions allowing multiple selections, participants could select more than one option and percentages may therefore exceed 100%. Percentages were calculated using the number of respondents who answered each item as the denominator. Associations between categorical variables were assessed using Pearson’s chi-square test. A two-sided p value of < 0.05 was considered statistically significant. All analyses were performed using SPSS version 24 (SPSS Inc., Chicago, IL, USA). Ethical approval The study received ethical approval from the Ege University Clinical Research Ethics Committee (Approval No: 24-5T/30 Date: 09.05.2024). All procedures involving human participants were conducted in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki Declaration and its later amendments. Written informed consent was obtained from all participants. The survey was designed to protect participant anonymity and confidentiality. Results The survey included responses from 290 participants across 44 cities in Türkiye, with the majority (207, 71.3%) reporting from metropolitan areas such as Ankara, Istanbul, and Izmir. A smaller proportion (83, 28.7%) of respondents were from smaller cities. Chemsex was reported to be increasingly popular, with 201 (72%) of respondents indicating that it is practised by a small but growing number of users. However, 14 (5%) noted that chemsex was declining in popularity. Only 24 (8.6%) respondents reported injecting substance use as a chemsex practice. Among respondents from metropolitan areas, 129 (62.3%) reported that chemsex has been practised for three years or more in their regions, 23 (11.1%) indicated less than three years, and 55 (26.6%) stated that they did not know. In smaller cities, 43 (51.8%) participants reported chemsex for three years or more, 13 (15.7%) for less than three years, and 27 (32.5%) were unsure. There was no statistically significant association between the duration of chemsex and the location of respondents (p = 0.24) (Figure 1). The most frequently used term for chemsex was “Chem’s fun” which was reported by 216 (74.7%) respondents, followed by “High Fun” (“124, 42.9%) and “Ice” (58, 20.1%). Participants also reported some local Turkish terms and symbols that would depict chemsex such as “Tina”, “Metin Amca (Uncle Metin)”, “şeker (sweets, candy)” and “crystal symbol”. The survey identified varying rates of chemsex engagement across different groups. The largest group mentioned included gbMSM and transgender women with a history of drug use (187, 65.2%), followed by local gbMSM (155, 53.5%) and those regularly attending nightlife venues (150, 51.7%). Younger gbMSM and transgender women (123, 42.4%) and people exchanging sex for drugs (102, 35.2%) were also frequently cited. Other groups such as sex workers, higher-income individuals, migrants, people with unstable housing, and tourists were mentioned less often (Table 1). Table 1. Groups reported to engage in chemsex in Türkiye (n = 290) Group (n = 290) n (%) gbMSM and trans women with a long history of drug use 187 (65.2) Local gbMSM 155 (53.5) gbMSM and trans women frequenting bars, nightclubs, parties 150 (51.7) Younger gbMSM and trans women 123 (42.4) People exchanging sex for drugs 102 (35.2) Higher-income individuals 95 (32.8) Sex workers 86 (29.7) Local trans women 79 (27.2) Older gbMSM and trans women 61 (21.0) Street-involved /homeless and other precariously housed 53 (18.3) Tourists 52 (17.9) Migrants 45 (15.5) Other 23 (7.9) Do not know 37 (12.8) gbMSM, gay and bisexual men who have sex with men The most common ways of finding chemsex partners were through apps (213, 73.5%) and the internet (189, 65.2%), followed by nightclubs (123, 42.4%). Smaller proportions reported dealers (99, 34.1%), other chemsex participants (104, 35.9%), or sex venues (90, 31.0%) (Table 2). Table 2. Locations/ways of finding chemsex partners in Türkiye (n = 290) Location/Way of finding partners (n = 290) n (%) Apps 213 (73.5) Internet (other than apps) 189 (65.2) Nightclubs 123 (42.4) Other chemsex partners 104 (35.9) Dealers 99 (34.1) Sex parties 92 (31.7) Sex venues (discos, saunas, cruising bars, etc.) 90 (31.0) Organized chillouts/group chemsex parties 65 (22.4) Cruising on the street, in parks, or toilets 45 (15.5) Pimps or agencies 32 (11.0) Hustling 19 (6.6) Other 13 (4.5) Do not know 35 (12.1) Methamphetamine was the most common substance reported to be used during chemsex (203, 70.5%), followed by ecstasy/MDMA (126, 43.8%), snorted cocaine (101, 35.1%), and GHB/GBL (85, 29.5%). Other substances, including freebase cocaine (61, 21.2%), ketamine (52, 18.1%), mephedrone, MDPV, or yaba (<5%), were reported less frequently (Figure 2). A question on the perceived benefits of chemsex revealed several key motivations for engaging in this practice. The most frequently reported benefits of chemsex were enhanced sexual experience and pleasure (205, 70.7%), relaxation during sex (179, 61.7%), and increased duration of sexual activity (158, 54.5%). Other reported motivations are presented in Table 3. Table 3. Perceived benefits of chemsex among survey participants in Türkiye. Perceived Benefits of Chemsex (n=290) n (%) Enhanced sexual experience and pleasure 205 (70.7) Easier to relax and enjoy sex 179 (61.7) Increased duration of sexual activity 158 (54.5) Sense of liberation and less judgement about sex partners 135 (46.6) Facilitates meeting new people and fulfilling sexual fantasies 119 (41.0) Cheaper than alcohol 69 (23.8) Reduced sexual inhibitions and shame, including around HIV+ status 68 (23.5) Other 34 (11.7) Participants also reported an array of harms and adverse outcomes that they associated with chemsex. The most frequently reported harms associated with chemsex were psychological and emotional impacts (234, 80.7%) and physical health risks (201, 69.3%), followed by social/relational issues (152, 60.0%) and legal/financial consequences (150, 59.0%). Other reported harms, including overdose, are presented in Table 4. Table 4. Reported harms of chemsex among survey participants in Türkiye. Reported Harms of Chemsex (n=290) n (%) Psychological and emotional impacts 234 (80.7) Physical health risks 201 (69.3) Social and relational issues 152 (60.0) Legal and financial consequences 150 (59.0) Death/ overdose 104 (40.7) Other 35 (12.1) The survey also examined how easily chemsex could be discussed within the community. More than half of the participants reported that chemsex was not openly discussed (152, 54.1%). A smaller proportion stated it could be discussed openly (73, 26.0%), or mainly in terms of its harms (42, 14.9%) in their community, while very few felt it could be comfortably discussed with healthcare providers or local officials (14, 5.0%) (Figure 3). A question about support services was included in the survey to assess whether people engaging in chemsex had access to harm reduction or STI prevention interventions in their location. Among 284 valid responses, the majority (255, 89.8%) reported that no such services were available, while only 29 (10.2%) indicated access. Reported services among this minority included HIV, HCV, and STI testing and treatment (44.8%), abstinence programmes (41.4%), and peer support (31.0%). It is important to note that there are no publicly available harm reduction services in Türkiye, and the few responses indicating availability most likely reflect limited, community-based or informal initiatives rather than structured national programmes. Discussion This is the first study providing an overview of chemsex practices in Türkiye, shedding light on its presence, motivations, and associated risks among diverse populations. Our findings illustrate the complex intersections of substance use, sexual behaviour, and psychosocial vulnerabilities. Chemsex was reported to be an established and growing practice in Türkiye, with many respondents indicating that it has been present in their communities for several years. This shows that chemsex is not a newly emerging phenomenon but rather a consolidated but clandestine practice within certain networks, particularly in urban centres. No significant differences were found between metropolitan and smaller cities, although reports of increasing popularity were concentrated in Ankara, Istanbul, and Izmir, as expected. These metropolitan areas may provide environments where anonymity, digital networks, and nightlife economies intersect, creating spaces where chemsex practices can grow. The largest groups identified as engaging in chemsex were gbMSM and transgender women with a history of drug use, along with local gbMSM and those regularly attending nightlife venues. Younger gbMSM and transgender women and those exchanging sex for drugs also represented important subgroups. This aligns with global evidence that chemsex disproportionately affects marginalized sexual and gender minorities, who are already at elevated risk of HIV and other STIs, substance use disorders, and social exclusion (6,9). The engagement in chemsex of vulnerable populations such as sex workers, migrants, and precariously housed individuals underscores the diversity of those affected and highlights overlapping structural risks. These groups may face compounded vulnerabilities, as they often have limited access to healthcare, fewer financial resources, and heightened exposure to stigma and discrimination. The sexual minority stress theory is the leading theoretical model to explain these health disparities. It states that sexual minority individuals are, in addition to general stressors, exposed to unique forms of stress that stem from a society’s prejudice and stigma directed at sexual minorities (33). Consequently, sexual minority individuals experience more negative life events that increase the risk for stress-sensitive mental health problems. Methamphetamine emerged as the most frequently reported substance, followed by ecstasy/MDMA, cocaine, and GHB/GBL. These substances are known for their disinhibiting and psychoactive effects, which might enhance sexual experiences but also increase the risk of adverse health outcomes. The use of methamphetamine is concerning due to its association with long-term neurological damage, aggressive behaviour, and increased risk of HIV transmission through unsafe sexual practices (34,35). Reported prevalences of these substances in our study aligns with global trends, where methamphetamine, GHB/GBL, and mephedrone are frequently reported in chemsex contexts (3,6,8,36). The most frequently reported motivations for chemsex were the enhancement of sexual pleasure, relaxation during sex, and prolonged duration of sexual activity. These findings are consistent with previous studies that indicate the role of psychoactive substances in prolonging sexual sessions, reducing inhibitions, and enabling individuals to explore sexual fantasies (10,34,37,38). However, the substantial adverse effects of chemsex, such as the risk of overdosing, psychological harm, and physical health hazards, must be weighed against the perceived benefits of chemsex. Participants also reported a range of harms attributed to chemsex such as psychological and emotional distress, physical health risks, social and relational issues, legal and financial consequences, and overdose. Current literature stresses the mental health challenges faced by individuals engaged in chemsex, including anxiety, depression, and drug-induced psychosis(3,7,39). Physical health risks, including the risk of overdose and other adverse effects of substances such as respiratory depression, loss of consciousness, neurotoxicity and cardiovascular outcomes further exacerbate these risks (24,40,41). This spectrum of harms indicates that chemsex is not only a medical and psychological concern but also a broader social issue with implications for relationships, employment, and financial stability. Given the strong association between mental health conditions and substance use, integrating psychological support into harm reduction and sexual health services is essential. Social and relational issues and legal and financial consequences reported in our survey suggest that chemsex practices can have a broader impact on people’s lives. The stigma surrounding chemsex and substance use within the LGBTQI+ community may contribute to these challenges, rendering it even more difficult for individuals to seek help safely and discuss their experiences openly in the community. The survey revealed a predominant existence of significant barriers to the access of harm reduction. More than half of respondents stated that chemsex could not be openly discussed, while only a small fraction reported feeling able to talk about it with healthcare providers or local authorities. This silence is highly consequential. The inability to discuss chemsex within communities and healthcare settings perpetuates isolation, delays and undermines opportunities for prevention. Critically, only a small minority of respondents reported any access to harm reduction services. Importantly, no publicly available harm reduction programmes exist in Türkiye, meaning the few reports of access likely reflect informal or community-based initiatives rather than structured services. This structural absence is striking when compared with several European countries, where chemsex-specific services, peer networks, and community-led harm reduction programs have been developed. The lack of such infrastructure in Türkiye places already vulnerable populations at even greater risk. In addition to the unavailability of open discussion with healthcare workers and harm reduction programs, the lack of knowledge and awareness of healthcare professionals on how to question and handle chemsex, the paucity and low accessibility of centres specialising in substance use, and the limited data on chemsex in the country further challenge the situation. Our findings have important implications for public health policy and practice. Stigma and discrimination of people living with HIV, especially in Türkiye, remains a major factor resulting in a hidden population that can be extremely difficult to reach. Both community and healthcare workers have entrenched moral views on HIV which result in deeply rooted stigma and discrimination against persons with HIV and those perceived to be at high risk of infection (42). Therefore, there is a clear and an urgent need for targeted harm reduction strategies that address the specific needs of gbMSM and transgender women engaged in chemsex. These strategies can be listed as follows: (1) Expanding the availability of HIV, HCV, and STI testing, as well as providing access to pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP), is essential to reducing the health risks associated with chemsex; (2) Efforts to reduce stigma and increase awareness about the risks of chemsex should be prioritised. This includes training healthcare providers to understand chemsex and its consequences and address chemsex-related issues sensitively and effectively; (3) Peer-led interventions can provide a safe space for individuals to discuss their experiences and access support. These programmes should be tailored to the specific needs of gbMSM and transgender women; (4) Given the high prevalence of psychological harm, mental health services should be integrated into harm reduction programmes. This includes providing access to counselling and support for individuals experiencing anxiety, depression, or drug-induced psychosis. This study has several limitations. As a cross-sectional survey based on self-reporting, results may be subject to recall or social desirability bias. The respondents may not be chemsex users themselves and may be reporting on what they hear from others. Furthermore, the absence of representative sampling limits the generalizability of the findings. Nonetheless, this study is the first assessment of chemsex in Türkiye, providing critical baseline data for future research and intervention development. Future studies could build on this work by employing longitudinal designs, integrating biomarker data, and evaluating the effectiveness of culturally adapted interventions. Conclusion In conclusion, this study shows a growing presence of chemsex in Türkiye, particularly among gbMSM and transgender individuals. While chemsex is often motivated by the pursuit of enhanced sexual experiences and relaxation, the associated risks such as substance dependence, psychological distress, and increased transmission risk of HIV and STIs pose serious challenges for both individuals and healthcare providers. Our findings reveal a concerning gap in harm reduction services, with only a small fraction of participants having access to appropriate healthcare support. It is clear that there is a need for an urgent multifaceted approach to this phenomenon. Both policymakers and healthcare providers must put significant effort into the implementation of targeted programmes. Reducing stigma within both LGBTQI+ communities and healthcare settings carries vital significance to advancing open discussions and encouraging individuals to seek support. Future research and public health interventions should focus on developing culturally competent and evidence-based strategies to mitigate the harms associated with chemsex in Türkiye. Looking forward, addressing chemsex in Türkiye will require aligning national health policies with international best practices, such as expanding access to PrEP and PEP, scaling up HIV/STI testing, and integrating harm reduction principles into mainstream healthcare. Without such evidence-based interventions, chemsex will continue to pose serious challenges to individual well-being, public health, and HIV prevention efforts. Abbreviations gbMSM: gay, bisexual and other men who have sex with men GHB/GBL: gamma-hydroxybutyric acid/gamma-butyrolactone HCV: hepatitis C virus HIV: human immunodeficiency virus MDMA: 3,4-methylenedioxymethamphetamine PEP: post-exposure prophylaxis PrEP: pre-exposure prophylaxis SPSS: Statistical Package for the Social Sciences STI: sexually transmitted infection Declarations Ethics approval and consent to participate The study received ethical approval from the Ege University Clinical Research Ethics Committee (Approval No: 24-5T/30; Date: 09.05.2024). Informed consent was obtained from all participants. The survey was anonymous and designed to protect participant confidentiality. Consent for publication Not applicable. Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Authors’ contributions DG and GV conceptualised the study. GA, BC, ND and CDA contributed to questionnaire adaptation and dissemination strategy. GV coordinated the analysis and drafted the manuscript. DG supervised the work. HT contributed to community engagement and interpretation of findings. All authors reviewed, edited, and approved the final manuscript. Acknowledgments We acknowledge Hornet and community webpages (including “Kırmızı Kurdele”) for their support in disseminating the survey link to potential participants. References Bourne A, Weatherburn P. Substance use among men who have sex with men: patterns, motivations, impacts and intervention development need. Sex Transm Infect. 2017;93(5):342–6. Lafortune D, Blais M, Miller G, Dion L, Lalonde F, Dargis L. Psychological and Interpersonal Factors Associated with Sexualized Drug Use Among Men Who Have Sex with Men: A Mixed-Methods Systematic Review. Arch Sex Behav. 2021;50(2):427–60. Maxwell S, Shahmanesh M, Gafos M. Chemsex behaviours among men who have sex with men: A systematic review of the literature. Int J Drug Policy. 2019;63:74–89. Stuart D. Chemsex: origins of the word, a history of the phenomenon and a respect to the culture. Drugs Alcohol Today. 2019;19(1):3–10. Hockenhull J, Murphy KG, Paterson S. An observed rise in γ-hydroxybutyrate-associated deaths in London: Evidence to suggest a possible link with concomitant rise in chemsex. Forensic Sci Int. 2017;270:93–7. McCall H, Adams N, Mason D, Willis J. What is chemsex and why does it matter? BMJ. 2015;h5790. Giorgetti R, Tagliabracci A, Schifano F, Zaami S, Marinelli E, Busardò FP. When Chems Meet Sex: A Rising Phenomenon Called ChemSex. Curr Neuropharmacol [Internet]. 2017 June 15 [cited 2024 Mar 24];15(5). http://www.eurekaselect.com/147471/article Bourne A, Reid D, Hickson F, Torres-Rueda S, Weatherburn P. Illicit drug use in sexual settings (‘chemsex’) and HIV/STI transmission risk behaviour among gay men in South London: findings from a qualitative study: Table 1. Sex Transm Infect. 2015;91(8):564–8. Green KE, Feinstein BA. Substance use in lesbian, gay, and bisexual populations: An update on empirical research and implications for treatment. Psychol Addict Behav. 2012 June;26(2):265–78. Sewell J, Miltz A, Lampe FC, Cambiano V, Speakman A, Phillips AN, et al. Poly drug use, chemsex drug use, and associations with sexual risk behaviour in HIV-negative men who have sex with men attending sexual health clinics. Int J Drug Policy. 2017;43:33–43. Hoornenborg E, Coyer L, Van Laarhoven A, Achterbergh R, De Vries H, Prins M et al. Change in sexual risk behaviour after 6 months of pre-exposure prophylaxis use: results from the Amsterdam pre-exposure prophylaxis demonstration project. AIDS 2018 July 17;32(11):1527–32. Glynn RW, Byrne N, O’Dea S, Shanley A, Codd M, Keenan E, et al. Chemsex, risk behaviours and sexually transmitted infections among men who have sex with men in Dublin, Ireland. Int J Drug Policy. 2018;52:9–15. Choi EPH, Chau PH, Wong WCW, Kowk JYY, Choi KWY, Chow EPF. Developing and testing of an interactive internet-based intervention to reduce sexual harm of sexualised drug use (‘chemsex’) among men who have sex with men in Hong Kong: a study protocol for a randomised controlled trial. BMC Public Health. 2021;21(1):713. Chow EPF, Grulich AE, Fairley CK. Epidemiology and prevention of sexually transmitted infections in men who have sex with men at risk of HIV. Lancet HIV. 2019 June;6(6):e396–405. Schwarcz S, Scheer S, McFarland W, Katz M, Valleroy L, Chen S, et al. Prevalence of HIV Infection and Predictors of High-Transmission Sexual Risk Behaviors Among Men Who Have Sex With Men. Am J Public Health. 2007 June;97(6):1067–75. Darrow WW. Risky Sexual Behaviors Associated with Recreational Drug Use Among Men who have Sex with Men in an International Resort Area: Challenges and Opportunities. J Urban Health Bull N Y Acad Med. 2005;82(4):601–9. Ahmed AK, Weatherburn P, Reid D, Hickson F, Torres-Rueda S, Steinberg P, et al. Social norms related to combining drugs and sex (chemsex) among gay men in South London. Int J Drug Policy. 2016;38:29–35. Rosenberger C, Gertzen M, Strasburger M, Schwarz J, Gernun S, Rabenstein A, et al. We Have a Lot to Do: Lack of Sexual Protection and Information—Results of the German-Language Online Survey Let’s Talk About Chemsex. Front Psychiatry. 2021;12:690242. Bourne A, Reid D, Hickson F, Torres-Rueda S, Steinberg P, Weatherburn P. Chemsex and harm reduction need among gay men in South London. Int J Drug Policy. 2015;26(12):1171–6. Yu S, Zhu L, Shen Q, Bai X, Di X. Recent Advances in Methamphetamine Neurotoxicity Mechanisms and Its Molecular Pathophysiology. Behav Neurol. 2015;2015:1–11. Corkery JM, Loi B, Claridge H, Goodair C, Schifano F. Deaths in the Lesbian, Gay, Bisexual and Transgender United Kingdom Communities Associated with GHB and Precursors. Curr Drug Metab. 2018;19(13):1086–99. Morgan CJA, Curran HV, the Independent Scientific Committee on Drugs (ISCD). Ketamine use: a review. Addiction. 2012;107(1):27–38. Baumeister D, Tojo LM, Tracy DK. Legal highs: staying on top of the flood of novel psychoactive substances. Ther Adv Psychopharmacol. 2015;5(2):97–132. Winstock A, Mitcheson L, Ramsey J, Davies S, Puchnarewicz M, Marsden J. Mephedrone: use, subjective effects and health risks: Mephedrone and health risks. Addiction. 2011;106(11):1991–6. Ma R, Perera S. Safer ‘chemsex’: GPs’ role in harm reduction for emerging forms of recreational drug use. Br J Gen Pract. 2016;66(642):4–5. Hinkin CH, Barclay TR, Castellon SA, Levine AJ, Durvasula RS, Marion SD, et al. Drug Use and Medication Adherence among HIV-1 Infected Individuals. AIDS Behav. 2007;11(2):185–94. Antoniou T, Tseng ALI. Interactions between Recreational Drugs and Antiretroviral Agents. Ann Pharmacother. 2002;36(10):1598–613. Hibbert MP, Brett CE, Porcellato LA, Hope VD. Psychosocial and sexual characteristics associated with sexualised drug use and chemsex among men who have sex with men (MSM) in the UK. Sex Transm Infect. 2019;95(5):342–50. Kenyon C, Wouters K, Platteau T, Buyze J, Florence E. Increases in condomless chemsex associated with HIV acquisition in MSM but not heterosexuals attending a HIV testing center in Antwerp, Belgium. AIDS Res Ther. 2018;15(1):14. HIV–AIDS Statistics [Internet]. Ankara: Republic of Türkiye Ministry of Health, General Directorate of Public Health, Department of Communicable Diseases and Early Warning.; 2024 [cited 2025 Aug 5] p. 2. https://hsgm.saglik.gov.tr/depo/birimler/bulasici-hastaliklar–ve–erken–uyari–db/Dokumanlar/Istatistikler/Ek_HIV–AIDS_Istatistikleri.pdf Derin O. Gender and Age Trends in HIV Incidence in Turkey between 1990 and 2021: Joinpoint and Age–Period–Cohort Analyses. Med (Mex). 2024;60(8):1357. Georges Azzi. Chemsex Today Around the World [Internet]. ReShape/International HIV Partnerships; 2023 [cited 2025 Aug 5]. Available from: https://reshapeorg.com/chemsexforum/ Meyer IH. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychol Bull. 2003 Sept;129(5):674–97. Halkitis PN, Mukherjee PP, Palamar JJ. Longitudinal Modeling of Methamphetamine Use and Sexual Risk Behaviors in Gay and Bisexual Men. AIDS Behav. 2009;13(4):783–91. Plankey MW, Ostrow DG, Stall R, Cox C, Li X, Peck JA, et al. The Relationship Between Methamphetamine and Popper Use and Risk of HIV Seroconversion in the Multicenter AIDS Cohort Study. JAIDS J Acquir Immune Defic Syndr. 2007;45(1):85–92. Daskalopoulou M, Rodger A, Phillips AN, Sherr L, Speakman A, Collins S, et al. Recreational drug use, polydrug use, and sexual behaviour in HIV-diagnosed men who have sex with men in the UK: results from the cross-sectional ASTRA study. Lancet HIV. 2014;1(1):e22–31. Bracchi M, Stuart D, Castles R, Khoo S, Back D, Boffito M. Increasing use of ‘party drugs’ in people living with HIV on antiretrovirals: a concern for patient safety. AIDS. 2015;29(13):1585–92. Krasnova IN, Cadet JL. Methamphetamine toxicity and messengers of death. Brain Res Rev. 2009;60(2):379–407. Rodríguez-Expósito B, Rieker JA, Uceda S, Beltrán-Velasco AI, Echeverry-Alzate V, Gómez-Ortega M, et al. Psychological characteristics associated with chemsex among men who have sex with men: Internalized homophobia, conscientiousness and serostatus as predictive factors. Int J Clin Health Psychol. 2024;24(2):100465. Schifano F, Albanese A, Fergus S, Stair JL, Deluca P, Corazza O, et al. Mephedrone (4-methylmethcathinone; ‘meow meow’): chemical, pharmacological and clinical issues. Psychopharmacology. 2011;214(3):593–602. Kaye S, Darke S. The diversion and misuse of pharmaceutical stimulants: what do we know and why should we care? Addiction. 2012;107(3):467–77. Gökengin D, Doroudi F, Tohme J, Collins B, Madani N. HIV/AIDS: trends in the Middle East and North Africa region. Int J Infect Dis. 2016;44:66–73. Additional Declarations No competing interests reported. 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Partnerships","correspondingAuthor":false,"prefix":"","firstName":"Benjamin","middleName":"","lastName":"Collins","suffix":""},{"id":588947112,"identity":"f767d224-7ccd-46d1-8b32-7642f6436614","order_by":2,"name":"Harun Tulunay","email":"","orcid":"","institution":"Positively UK","correspondingAuthor":false,"prefix":"","firstName":"Harun","middleName":"","lastName":"Tulunay","suffix":""},{"id":588947113,"identity":"7c925021-06ea-4200-9fad-6115a372b114","order_by":3,"name":"Georges Āzzi","email":"","orcid":"","institution":"ReShape/International HIV Partnerships","correspondingAuthor":false,"prefix":"","firstName":"Georges","middleName":"","lastName":"Āzzi","suffix":""},{"id":588947114,"identity":"9f8a8afd-d790-49ce-a2fb-37b07277a398","order_by":4,"name":"Nia Dunbar","email":"","orcid":"","institution":"ReShape/International HIV Partnerships","correspondingAuthor":false,"prefix":"","firstName":"Nia","middleName":"","lastName":"Dunbar","suffix":""},{"id":588947115,"identity":"455f8124-afb1-49b3-a9f6-408f6b4810c3","order_by":5,"name":"Charlie Dunbar-Aldred","email":"","orcid":"","institution":"ReShape/International HIV Partnerships","correspondingAuthor":false,"prefix":"","firstName":"Charlie","middleName":"","lastName":"Dunbar-Aldred","suffix":""},{"id":588947116,"identity":"12f53265-8b6a-49a4-a2bc-f57ab3fa0e09","order_by":6,"name":"Deniz Gökengin","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA40lEQVRIiWNgGAWjYDACHhBhwCDHxt4AYlgQr8WYj+cAiCFBrBYGhkQ5iQQQTYQWeZ/Dxx5+KbiTwCb5/OqGHwUSDPzt3Ql4tRiebUs3ljF4lscmnVN2swfoMIkzZzfg19LPYyYtYXC4GKgl7QYPUIuBRC4hLfzfQFoS2yTPpN38Q4wWed4eNskPIC0S7MduE2WLAc8xM2kGg8PGbDw5bLdlDCR4CPpFvif5meSPP4fl5NuPP7v55o+NHH97LwFbDjAwMEPihscATOJVDralgYGB8QeYyf6AoOpRMApGwSgYmQAAjthENmJ05sEAAAAASUVORK5CYII=","orcid":"","institution":"Ege University","correspondingAuthor":true,"prefix":"","firstName":"Deniz","middleName":"","lastName":"Gökengin","suffix":""}],"badges":[],"createdAt":"2026-01-22 16:41:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8671993/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8671993/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102424151,"identity":"2abfbb28-a4ef-4670-b42f-00fd032bbb46","added_by":"auto","created_at":"2026-02-11 14:22:22","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":225684,"visible":true,"origin":"","legend":"\u003cp\u003eDuration of chemsex practices by location.\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8671993/v1/0463a64c2fcd2d1a02a66e0d.jpg"},{"id":102424152,"identity":"773caeeb-3da5-4a6f-b94f-aada0dc207af","added_by":"auto","created_at":"2026-02-11 14:22:22","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":512382,"visible":true,"origin":"","legend":"\u003cp\u003eSubstances reported to be used in chemsex practices in Türkiye.\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8671993/v1/31cdac05a9b6530054782b08.jpg"},{"id":102424153,"identity":"756859c7-8a5d-43c9-8d19-bacfe7ee0b3f","added_by":"auto","created_at":"2026-02-11 14:22:22","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":157026,"visible":true,"origin":"","legend":"\u003cp\u003eEase of discussing chemsex in the community.\u003c/p\u003e","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8671993/v1/24cd9e016b76533862b0bddf.jpg"},{"id":103049185,"identity":"621042ed-f4ed-47f0-b524-222ad715760e","added_by":"auto","created_at":"2026-02-20 07:36:55","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1646960,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8671993/v1/35a26bb9-34a8-4ecf-8465-b3af28b2b8e5.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Silent Advance: Chemsex Practices and Their Implications in Türkiye","fulltext":[{"header":"Background","content":"\u003cp\u003eSexualised substance use is the intentional use of drugs for sex and chemsex is one form of sexualised substance use referring to the practice of using highly active psychoactive chemicals to initiate, enhance, and prolong sexual activities and pleasure (\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Chemsex is characterised by a marked increase in the prevalence of sexually transmitted infections (STIs), the facilitation of high-risk sexual networks, heightened incidence of non-consensual encounters under the influence of substances, and even fatal outcomes such as drug overdose deaths. These compounded risks not only escalate individual health burdens but also pose significant public health challenges by aggravating the transmission dynamics of HIV and other STIs within key populations (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePeople engaging in chemsex use one or more psychoactive substances to change how they feel and act during sexual encounters. This can lead to longer encounters, sometimes lasting days, and sometimes with multiple partners having sex at the same time (\u003cspan additionalcitationids=\"CR5 CR6 CR7\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Lesbian, gay, bisexual, transgender, queer, intersex and other (LGBTQI+) individuals generally use substances at higher rates than heterosexual individuals do, and chemsex is practiced predominantly among gay, bisexual and other men who have sex with men (gbMSM) (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eChemsex, or a comparable form of sexualised substance use amongst LGBTQI+ individuals and others, is reported from most geographical regions around the globe, often with their own slang terms and social media emojis to signal in settings where sexualised substance use and non-heterosexual relations are at least stigmatised if not criminalised. In this article, we will use the term \u0026ldquo;chemsex\u0026rdquo; as a blanket term for these forms of sexualised substance use common in the LGBTQI+ population, but it needs to be understood that other terms are also used locally.\u003c/p\u003e \u003cp\u003eA study from the United Kingdom revealed that 25% of gbMSM had consumed three or more recreational drugs within the preceding 3 months (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Another one from the Netherlands reported that 41% of HIV-negative gbMSM and transgender people who have sex with men had experienced chemsex with casual partners in the preceding three months (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Similarly, a study from the Republic of Ireland showed that 27% of gbMSM had chemsex within the previous 12 months (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). An organization based in Hong Kong found that 9% of gbMSM respondents had participated in chemsex at some point. Individuals aged 31\u0026ndash;35 were reported to be the most likely to engage in chemsex (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Approximately 60% of gbMSM in Australia have engaged in the use of recreational drugs within the previous six months (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWhile it\u0026rsquo;s usually associated with pleasure seeking amongst users, chemsex is also linked to higher health-risk behaviours such as needle sharing behaviours and neglect in adopting safe sex practices during substance use sessions that can result in an increase in the prevalence of STIs and even drug overdose deaths (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan additionalcitationids=\"CR16 CR17\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). People frequently consume more psychoactive substances during chemsex than intended due to the disinhibition caused by substance use, which may result in severe intoxications and fatal overdoses (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Sex dates are frequently scheduled using dating apps or other social media platforms. The parties exchange details about each other in advance, such as the number of participants, type of substance use, and HIV status (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSubstances used in chemsex may also have adverse effects on health. In many regions, methamphetamine, mephedrone, ketamine and γ-butyrolactone (GBL)/γ-hydroxy butyric acid (GHB) are the most commonly used psychoactive substances. The adverse effects of methamphetamine include aggression, panic attacks, motor restlessness, concentration problems, and long-term brain damage. An overdose of GHB/GBL may cause respiratory depression and loss of consciousness (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Ketamine use has been linked to drug-induced psychosis and near-death experiences (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Mephedrone overdoses can result in palpitations, nausea, vomiting, anxiety states, panic attacks, auditory hallucinations, and thought disorders (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Certain psychoactive substances can interact with specific antiretroviral medications\u0026mdash;especially ritonavir- or cobicistat-boosted regimens\u0026mdash;leading to elevated drug levels and potentially serious toxicity. Fatal events are possible but rare and generally associated with strong metabolic inhibition and high-dose stimulant or sedative use. (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Additionally, drug interactions can reduce the therapeutic effect of antiretrovirals (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e), which may have significant consequences.\u003c/p\u003e \u003cp\u003eChemsex is linked to a higher risk of participating in other unsafe sexual behaviours like condom-free anal sex, injecting drug use and higher alcohol consumption, fisting, sharing sex toys, and group sex because of the sexual disinhibition and hypersexuality induced by the drugs. Sexual activities may last longer due to the anaesthetic properties of some substances and this might lead to mucosal trauma which can further contribute to STI and HIV transmission (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eT\u0026uuml;rkiye accommodates one of the fastest growing HIV epidemics in the world. The annual number of newly diagnosed persons with HIV in T\u0026uuml;rkiye has shown a continuous and marked increase over the last two decades. The number of confirmed new diagnoses nearly doubled from 3,137 in 2020 to 6,185 in 2023, according to official data reported by the Ministry of Health (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Consistently, a recent age\u0026ndash;period\u0026ndash;cohort analysis reported an age-standardized average annual percentage change (AAPC) of 6.19% (95% CI: 5.56\u0026ndash;6.83) in HIV incidence between 1990\u0026ndash;2021, with a faster rise among women (AAPC\u0026thinsp;=\u0026thinsp;6.98%) compared to men (AAPC\u0026thinsp;=\u0026thinsp;5.81%). The most striking increases were observed in younger age groups, particularly those aged 15\u0026ndash;19 years (AAPC\u0026thinsp;=\u0026thinsp;11.77%) and 20\u0026ndash;24 years (AAPC\u0026thinsp;=\u0026thinsp;7.49%), with incidence in women showing a marked increase after 2008 (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). While the lack of prevention measures, non-prioritization of HIV and STIs by the health authority, lack of sex education, and non-engagement of vulnerable populations in program development are suggested as the major causes of this striking increase, accurate data on this is unavailable. Moreover, the high percentage of the young population and the challenging availability of sexual and reproductive health services in T\u0026uuml;rkiye result in a critical vulnerability where early diagnosis, timely treatment initiation, and effective prevention strategies are severely compromised.\u003c/p\u003e \u003cp\u003eChemsex has become a growing global public health concern recently, and despite its risks, stigma and discrimination often prevent open discussions about it, particularly in conservative or religious communities. Chemsex is a novel concept in T\u0026uuml;rkiye and is usually experienced behind closed doors without being vocalized. The aim of this study was to lift the veil on chemsex in T\u0026uuml;rkiye, to explore its dimensions, and to bring it forward for discussion.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and setting\u003c/h2\u003e \u003cp\u003eWe conducted a cross-sectional, anonymous online survey to describe chemsex practices in T\u0026uuml;rkiye, including perceived substance use patterns, motivations, harms, and barriers to discussion and support. Data collection took place between 01 January 2024 and 31 March 2024.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eParticipants and eligibility criteria\u003c/h3\u003e\n\u003cp\u003eParticipants were eligible if they were aged\u0026thinsp;\u0026ge;\u0026thinsp;18 years, resided in T\u0026uuml;rkiye, and provided informed consent to participate. The survey was designed to capture community perspectives on chemsex and included respondents with lived experience and those reporting on chemsex practices in their location. Participation was voluntary and anonymous.\u003c/p\u003e\n\u003ch3\u003eSurvey instrument\u003c/h3\u003e\n\u003cp\u003eWe used an 18-item questionnaire developed by ReShape/International HIV Partnerships (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). To ensure cultural appropriateness and accessibility, the questionnaire was reviewed by Turkish people with chemsex experience, coordinated by a Turkish person with chemsex experience. The questions in English were translated into Turkish and Arabic and then back-translated to English to check accuracy. Community members piloted and edited the survey questions as required. The survey was distributed through various online platforms including dating apps and community networks to reach a broad audience.\u003c/p\u003e\n\u003ch3\u003eVariables\u003c/h3\u003e\n\u003cp\u003eThe primary outcomes were descriptive measures of chemsex-related perceptions and practices, including (i) perceived duration and growth of chemsex practices in participants\u0026rsquo; locations, (ii) substances reportedly used in chemsex contexts, (iii) perceived motivations and harms associated with chemsex, (iv) ease of discussing chemsex within the community and with healthcare providers, and (v) perceived access to harm reduction and HIV/STI prevention and treatment services. Location was categorised as metropolitan versus smaller cities, based on self-report.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eSurvey responses were summarised using frequencies and percentages. For questions allowing multiple selections, participants could select more than one option and percentages may therefore exceed 100%. Percentages were calculated using the number of respondents who answered each item as the denominator.\u003c/p\u003e \u003cp\u003eAssociations between categorical variables were assessed using Pearson\u0026rsquo;s chi-square test. A two-sided p value of \u0026lt;\u0026thinsp;0.05 was considered statistically significant. All analyses were performed using SPSS version 24 (SPSS Inc., Chicago, IL, USA).\u003c/p\u003e \u003c/div\u003e\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study received ethical approval from the Ege University Clinical Research Ethics Committee (Approval No: 24-5T/30 Date: 09.05.2024). All procedures involving human participants were conducted in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki Declaration and its later amendments. Written informed consent was obtained from all participants. The survey was designed to protect participant anonymity and confidentiality.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe survey included responses from 290 participants across 44 cities in T\u0026uuml;rkiye, with the majority (207, 71.3%) reporting from metropolitan areas such as Ankara, Istanbul, and Izmir. A smaller proportion (83, 28.7%) of respondents were from smaller cities.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eChemsex was reported to be increasingly popular, with 201 (72%) of respondents indicating that it is practised by a small but growing number of users. However, 14 (5%) noted that chemsex was declining in popularity. Only 24 (8.6%) respondents reported injecting substance use as a chemsex practice.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAmong respondents from metropolitan areas, 129 (62.3%) reported that chemsex has been practised for three years or more in their regions, 23 (11.1%) indicated less than three years, and 55 (26.6%) stated that they did not know. In smaller cities, 43 (51.8%) participants reported chemsex for three years or more, 13 (15.7%) for less than three years, and 27 (32.5%) were unsure. There was no statistically significant association between the duration of chemsex and the location of respondents (p = 0.24) \u003cstrong\u003e(Figure 1).\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe most frequently used term for chemsex was \u0026ldquo;Chem\u0026rsquo;s fun\u0026rdquo; which was reported by 216 (74.7%) respondents, followed by \u0026ldquo;High Fun\u0026rdquo; (\u0026ldquo;124, 42.9%) and \u0026ldquo;Ice\u0026rdquo; (58, 20.1%). Participants also reported some local Turkish terms and symbols that would depict chemsex such as \u0026ldquo;Tina\u0026rdquo;, \u0026ldquo;Metin Amca (Uncle Metin)\u0026rdquo;, \u0026ldquo;şeker (sweets, candy)\u0026rdquo; and \u0026ldquo;crystal symbol\u0026rdquo;.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe survey identified varying rates of chemsex engagement across different groups. The largest group mentioned included gbMSM and transgender women with a history of drug use (187, 65.2%), followed by local gbMSM (155, 53.5%) and those regularly attending nightlife venues (150, 51.7%). Younger gbMSM and transgender women (123, 42.4%) and people exchanging sex for drugs (102, 35.2%) were also frequently cited. Other groups such as sex workers, higher-income individuals, migrants, people with unstable housing, and tourists were mentioned less often \u003cstrong\u003e(Table 1).\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cstrong\u003eTable 1. Groups reported to engage in chemsex in T\u0026uuml;rkiye (n = 290)\u003c/strong\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"606\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 484px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup (n = 290)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 484px;\"\u003e\n \u003cp\u003egbMSM and trans women with a long history of drug use\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e187 (65.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 484px;\"\u003e\n \u003cp\u003eLocal gbMSM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e155 (53.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 484px;\"\u003e\n \u003cp\u003egbMSM and trans women frequenting bars, nightclubs, parties\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e150 (51.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 484px;\"\u003e\n \u003cp\u003eYounger gbMSM and trans women\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e123 (42.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 484px;\"\u003e\n \u003cp\u003ePeople exchanging sex for drugs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e102 (35.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 484px;\"\u003e\n \u003cp\u003eHigher-income individuals\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e95 (32.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 484px;\"\u003e\n \u003cp\u003eSex workers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e86 (29.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 484px;\"\u003e\n \u003cp\u003eLocal trans women\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e79 (27.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 484px;\"\u003e\n \u003cp\u003eOlder gbMSM and trans women\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e61 (21.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 484px;\"\u003e\n \u003cp\u003eStreet-involved /homeless and other precariously housed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e53 (18.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 484px;\"\u003e\n \u003cp\u003eTourists\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e52 (17.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 484px;\"\u003e\n \u003cp\u003eMigrants\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e45 (15.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 484px;\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e23 (7.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 484px;\"\u003e\n \u003cp\u003eDo not know\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e37 (12.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003egbMSM, gay and bisexual men who have sex with men\u003c/p\u003e\n\u003cp\u003eThe most common ways of finding chemsex partners were through apps (213, 73.5%) and the internet (189, 65.2%), followed by nightclubs (123, 42.4%). Smaller proportions reported dealers (99, 34.1%), other chemsex participants (104, 35.9%), or sex venues (90, 31.0%) \u003cstrong\u003e(Table 2).\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Locations/ways of finding chemsex partners in T\u0026uuml;rkiye (n = 290)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"601\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eLocation/Way of finding partners (n = 290)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eApps\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e213 (73.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eInternet (other than apps)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e189 (65.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNightclubs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e123 (42.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOther chemsex partners\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e104 (35.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDealers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e99 (34.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSex parties\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e92 (31.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSex venues (discos, saunas, cruising bars, etc.)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e90 (31.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOrganized chillouts/group chemsex parties\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e65 (22.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCruising on the street, in parks, or toilets\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e45 (15.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePimps or agencies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e32 (11.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHustling\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e19 (6.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e13 (4.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDo not know\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e35 (12.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eMethamphetamine was the most common substance reported to be used during chemsex (203, 70.5%), followed by ecstasy/MDMA (126, 43.8%), snorted cocaine (101, 35.1%), and GHB/GBL (85, 29.5%). Other substances, including freebase cocaine (61, 21.2%), ketamine (52, 18.1%), mephedrone, MDPV, or yaba (\u0026lt;5%), were reported less frequently \u003cstrong\u003e(Figure 2).\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA question on the perceived benefits of chemsex revealed several key motivations for engaging in this practice. The most frequently reported benefits of chemsex were enhanced sexual experience and pleasure (205, 70.7%), relaxation during sex (179, 61.7%), and increased duration of sexual activity (158, 54.5%). Other reported motivations are presented in \u003cstrong\u003eTable 3.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3.\u003c/strong\u003e Perceived benefits of chemsex among survey participants in T\u0026uuml;rkiye.\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePerceived Benefits of Chemsex (n=290)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003eEnhanced sexual experience and pleasure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003e205 (70.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003eEasier to relax and enjoy sex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003e179 (61.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003eIncreased duration of sexual activity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e158 (54.5)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003eSense of liberation and less judgement about sex partners\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e135 (46.6)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003eFacilitates meeting new people and fulfilling sexual fantasies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e119 (41.0)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003eCheaper than alcohol\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e69 (23.8)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003eReduced sexual inhibitions and shame, including around HIV+ status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e68 (23.5)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e34 \u0026nbsp;(11.7)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eParticipants also reported an array of harms and adverse outcomes that they associated with chemsex. The most frequently reported harms associated with chemsex were psychological and emotional impacts (234, 80.7%) and physical health risks (201, 69.3%), followed by social/relational issues (152, 60.0%) and legal/financial consequences (150, 59.0%). Other reported harms, including overdose, are presented in \u003cstrong\u003eTable 4.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4.\u003c/strong\u003e Reported harms of chemsex among survey participants in T\u0026uuml;rkiye.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eReported Harms of Chemsex (n=290)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 463px;\"\u003e\n \u003cp\u003ePsychological and emotional impacts\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 130px;\"\u003e\n \u003cp\u003e234 (80.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 463px;\"\u003e\n \u003cp\u003ePhysical health risks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 130px;\"\u003e\n \u003cp\u003e201 (69.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 463px;\"\u003e\n \u003cp\u003eSocial and relational issues\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 130px;\"\u003e\n \u003cp\u003e152 (60.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 463px;\"\u003e\n \u003cp\u003eLegal and financial consequences\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 130px;\"\u003e\n \u003cp\u003e150 (59.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 463px;\"\u003e\n \u003cp\u003eDeath/ overdose\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 130px;\"\u003e\n \u003cp\u003e104 (40.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 463px;\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 130px;\"\u003e\n \u003cp\u003e35 (12.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe survey also examined how easily chemsex could be discussed within the community. More than half of the participants reported that chemsex was not openly discussed (152, 54.1%). A smaller proportion stated it could be discussed openly (73, 26.0%), or mainly in terms of its harms (42, 14.9%) in their community, while very few felt it could be comfortably discussed with healthcare providers or local officials (14, 5.0%) \u003cstrong\u003e(Figure 3).\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;A question about support services was included in the survey to assess whether people engaging in chemsex had access to harm reduction or STI prevention interventions in their location. Among 284 valid responses, the majority (255, 89.8%) reported that no such services were available, while only 29 (10.2%) indicated access. Reported services among this minority included HIV, HCV, and STI testing and treatment (44.8%), abstinence programmes (41.4%), and peer support (31.0%). It is important to note that there are no publicly available harm reduction services in T\u0026uuml;rkiye, and the few responses indicating availability most likely reflect limited, community-based or informal initiatives rather than structured national programmes.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis is the first study providing an overview of chemsex practices in T\u0026uuml;rkiye, shedding light on its presence, motivations, and associated risks among diverse populations. Our findings illustrate the complex intersections of substance use, sexual behaviour, and psychosocial vulnerabilities.\u003c/p\u003e\n\u003cp\u003eChemsex was reported to be an established and growing practice in T\u0026uuml;rkiye, with many respondents indicating that it has been present in their communities for several years. This shows that chemsex is not a newly emerging phenomenon but rather a consolidated but clandestine practice within certain networks, particularly in urban centres. No significant differences were found between metropolitan and smaller cities, although reports of increasing popularity were concentrated in Ankara, Istanbul, and Izmir, as expected. These metropolitan areas may provide environments where anonymity, digital networks, and nightlife economies intersect, creating spaces where chemsex practices can grow.\u003c/p\u003e\n\u003cp\u003eThe largest groups identified as engaging in chemsex were gbMSM and transgender women with a history of drug use, along with local gbMSM and those regularly attending nightlife venues. Younger gbMSM and transgender women and those exchanging sex for drugs also represented important subgroups. This aligns with global evidence that chemsex disproportionately affects marginalized sexual and gender minorities, who are already at elevated risk of HIV and other STIs, substance use disorders, and social exclusion (6,9). The engagement in chemsex of vulnerable populations such as sex workers, migrants, and precariously housed individuals underscores the diversity of those affected and highlights overlapping structural risks. These groups may face compounded vulnerabilities, as they often have limited access to healthcare, fewer financial resources, and heightened exposure to stigma and discrimination. The sexual minority stress theory is the leading theoretical model to explain these health disparities. It states that sexual minority individuals are, in addition to general stressors, exposed to unique forms of stress that stem from a society\u0026rsquo;s prejudice and stigma directed at sexual minorities (33). Consequently, sexual minority individuals experience more negative life events that increase the risk for stress-sensitive mental health problems.\u003c/p\u003e\n\u003cp\u003eMethamphetamine emerged as the most frequently reported substance, followed by ecstasy/MDMA, cocaine, and GHB/GBL. These substances are known for their disinhibiting and psychoactive effects, which might enhance sexual experiences but also increase the risk of adverse health outcomes. The use of methamphetamine is concerning due to its association with long-term neurological damage, aggressive behaviour, and increased risk of HIV transmission through unsafe sexual practices (34,35). Reported prevalences of these substances in our study aligns with global trends, where methamphetamine, GHB/GBL, and mephedrone are frequently reported in chemsex contexts (3,6,8,36).\u003c/p\u003e\n\u003cp\u003eThe most frequently reported motivations for chemsex were the enhancement of sexual pleasure, relaxation during sex, and prolonged duration of sexual activity. These findings are consistent with previous studies that indicate the role of psychoactive substances in prolonging sexual sessions, reducing inhibitions, and enabling individuals to explore sexual fantasies (10,34,37,38). However, the substantial adverse effects of chemsex, such as the risk of overdosing, psychological harm, and physical health hazards, must be weighed against the perceived benefits of chemsex.\u003c/p\u003e\n\u003cp\u003eParticipants also reported a range of harms attributed to chemsex such as psychological and emotional distress, physical health risks, social and relational issues, legal and financial consequences, and overdose. Current literature stresses the mental health challenges faced by individuals engaged in chemsex, including anxiety, depression, and drug-induced psychosis(3,7,39). Physical health risks, including the risk of overdose and other adverse effects of substances such as respiratory depression, loss of consciousness, neurotoxicity and cardiovascular outcomes further exacerbate these risks (24,40,41). This spectrum of harms indicates that chemsex is not only a medical and psychological concern but also a broader social issue with implications for relationships, employment, and financial stability. Given the strong association between mental health conditions and substance use, integrating psychological support into harm reduction and sexual health services is essential.\u003c/p\u003e\n\u003cp\u003eSocial and relational issues and legal and financial consequences reported in our survey suggest that chemsex practices can have a broader impact on people\u0026rsquo;s lives. The stigma surrounding chemsex and substance use within the LGBTQI+ community may contribute to these challenges, rendering it even more difficult for individuals to seek help safely and discuss their experiences openly in the community.\u003c/p\u003e\n\u003cp\u003eThe survey revealed a predominant existence of significant barriers to the access of harm reduction. More than half of respondents stated that chemsex could not be openly discussed, while only a small fraction reported feeling able to talk about it with healthcare providers or local authorities. This silence is highly consequential. The inability to discuss chemsex within communities and healthcare settings perpetuates isolation, delays and undermines opportunities for prevention. Critically, only a small minority of respondents reported any access to harm reduction services. Importantly, no publicly available harm reduction programmes exist in T\u0026uuml;rkiye, meaning the few reports of access likely reflect informal or community-based initiatives rather than structured services. This structural absence is striking when compared with several European countries, where chemsex-specific services, peer networks, and community-led harm reduction programs have been developed. The lack of such infrastructure in T\u0026uuml;rkiye places already vulnerable populations at even greater risk.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn addition to the unavailability of open discussion with healthcare workers and harm reduction programs, the lack of knowledge and awareness of healthcare professionals on how to question and handle chemsex, the paucity and low accessibility of centres specialising in substance use, and the limited data on chemsex in the country further challenge the situation.\u003c/p\u003e\n\u003cp\u003eOur findings have important implications for public health policy and practice. Stigma and discrimination of people living with HIV, especially in T\u0026uuml;rkiye, remains a major factor resulting in a hidden population that can be extremely difficult to reach. Both community and healthcare workers have entrenched moral views on HIV which result in deeply rooted stigma and discrimination against persons with HIV and those perceived to be at high risk of infection (42). Therefore, there is a clear and an urgent need for targeted harm reduction strategies that address the specific needs of gbMSM and transgender women engaged in chemsex. These strategies can be listed as follows: \u003cstrong\u003e(1)\u0026nbsp;\u003c/strong\u003eExpanding the availability of HIV, HCV, and STI testing, as well as providing access to pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP), is essential to reducing the health risks associated with chemsex; \u003cstrong\u003e(2)\u003c/strong\u003e Efforts to reduce stigma and increase awareness about the risks of chemsex should be prioritised. This includes training healthcare providers to understand chemsex and its consequences and address chemsex-related issues sensitively and effectively; \u003cstrong\u003e(3)\u003c/strong\u003e Peer-led interventions can provide a safe space for individuals to discuss their experiences and access support. These programmes should be tailored to the specific needs of gbMSM and transgender women; \u003cstrong\u003e(4)\u0026nbsp;\u003c/strong\u003eGiven the high prevalence of psychological harm, mental health services should be integrated into harm reduction programmes. This includes providing access to counselling and support for individuals experiencing anxiety, depression, or drug-induced psychosis.\u003c/p\u003e\n\u003cp\u003eThis study has several limitations. As a cross-sectional survey based on self-reporting, results may be subject to recall or social desirability bias. The respondents may not be chemsex users themselves and may be reporting on what they hear from others. Furthermore, the absence of representative sampling limits the generalizability of the findings. Nonetheless, this study is the first assessment of chemsex in T\u0026uuml;rkiye, providing critical baseline data for future research and intervention development. Future studies could build on this work by employing longitudinal designs, integrating biomarker data, and evaluating the effectiveness of culturally adapted interventions.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, this study shows a growing presence of chemsex in T\u0026uuml;rkiye, particularly among gbMSM and transgender individuals. While chemsex is often motivated by the pursuit of enhanced sexual experiences and relaxation, the associated risks such as substance dependence, psychological distress, and increased transmission risk of HIV and STIs pose serious challenges for both individuals and healthcare providers. Our findings reveal a concerning gap in harm reduction services, with only a small fraction of participants having access to appropriate healthcare support.\u003c/p\u003e\n\u003cp\u003eIt is clear that there is a need for an urgent multifaceted approach to this phenomenon. Both policymakers and healthcare providers must put significant effort into the implementation of targeted programmes. Reducing stigma within both LGBTQI+ communities and healthcare settings carries vital significance to advancing open discussions and encouraging individuals to seek support. Future research and public health interventions should focus on developing culturally competent and evidence-based strategies to mitigate the harms associated with chemsex in T\u0026uuml;rkiye.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLooking forward, addressing chemsex in T\u0026uuml;rkiye will require aligning national health policies with international best practices, such as expanding access to PrEP and PEP, scaling up HIV/STI testing, and integrating harm reduction principles into mainstream healthcare. Without such evidence-based interventions, chemsex will continue to pose serious challenges to individual well-being, public health, and HIV prevention efforts.\u003c/p\u003e\n"},{"header":"Abbreviations","content":"\u003cp\u003egbMSM: gay, bisexual and other men who have sex with men\u003c/p\u003e\n\u003cp\u003eGHB/GBL: gamma-hydroxybutyric acid/gamma-butyrolactone\u003c/p\u003e\n\u003cp\u003eHCV: hepatitis C virus\u003c/p\u003e\n\u003cp\u003eHIV: human immunodeficiency virus\u003c/p\u003e\n\u003cp\u003eMDMA: 3,4-methylenedioxymethamphetamine\u003c/p\u003e\n\u003cp\u003ePEP: post-exposure prophylaxis\u003c/p\u003e\n\u003cp\u003ePrEP: pre-exposure prophylaxis\u003c/p\u003e\n\u003cp\u003eSPSS: Statistical Package for the Social Sciences\u003c/p\u003e\n\u003cp\u003eSTI: sexually transmitted infection\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study received ethical approval from the Ege University Clinical Research Ethics Committee (Approval No: 24-5T/30; Date: 09.05.2024). Informed consent was obtained from all participants. The survey was anonymous and designed to protect participant confidentiality.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDG and GV conceptualised the study. GA, BC, ND and CDA contributed to questionnaire adaptation and dissemination strategy. GV coordinated the analysis and drafted the manuscript. DG supervised the work. HT contributed to community engagement and interpretation of findings. All authors reviewed, edited, and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe acknowledge Hornet and community webpages (including \u0026ldquo;Kırmızı Kurdele\u0026rdquo;) for their support in disseminating the survey link to potential participants.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBourne A, Weatherburn P. Substance use among men who have sex with men: patterns, motivations, impacts and intervention development need. Sex Transm Infect. 2017;93(5):342\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLafortune D, Blais M, Miller G, Dion L, Lalonde F, Dargis L. Psychological and Interpersonal Factors Associated with Sexualized Drug Use Among Men Who Have Sex with Men: A Mixed-Methods Systematic Review. Arch Sex Behav. 2021;50(2):427\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMaxwell S, Shahmanesh M, Gafos M. Chemsex behaviours among men who have sex with men: A systematic review of the literature. Int J Drug Policy. 2019;63:74\u0026ndash;89.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStuart D. Chemsex: origins of the word, a history of the phenomenon and a respect to the culture. Drugs Alcohol Today. 2019;19(1):3\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHockenhull J, Murphy KG, Paterson S. An observed rise in γ-hydroxybutyrate-associated deaths in London: Evidence to suggest a possible link with concomitant rise in chemsex. Forensic Sci Int. 2017;270:93\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcCall H, Adams N, Mason D, Willis J. What is chemsex and why does it matter? BMJ. 2015;h5790.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGiorgetti R, Tagliabracci A, Schifano F, Zaami S, Marinelli E, Busard\u0026ograve; FP. When Chems Meet Sex: A Rising Phenomenon Called ChemSex. Curr Neuropharmacol [Internet]. 2017 June 15 [cited 2024 Mar 24];15(5). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.eurekaselect.com/147471/article\u003c/span\u003e\u003cspan address=\"http://www.eurekaselect.com/147471/article\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBourne A, Reid D, Hickson F, Torres-Rueda S, Weatherburn P. Illicit drug use in sexual settings (\u0026lsquo;chemsex\u0026rsquo;) and HIV/STI transmission risk behaviour among gay men in South London: findings from a qualitative study: Table 1. Sex Transm Infect. 2015;91(8):564\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGreen KE, Feinstein BA. Substance use in lesbian, gay, and bisexual populations: An update on empirical research and implications for treatment. Psychol Addict Behav. 2012 June;26(2):265\u0026ndash;78.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSewell J, Miltz A, Lampe FC, Cambiano V, Speakman A, Phillips AN, et al. Poly drug use, chemsex drug use, and associations with sexual risk behaviour in HIV-negative men who have sex with men attending sexual health clinics. Int J Drug Policy. 2017;43:33\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHoornenborg E, Coyer L, Van Laarhoven A, Achterbergh R, De Vries H, Prins M et al. Change in sexual risk behaviour after 6 months of pre-exposure prophylaxis use: results from the Amsterdam pre-exposure prophylaxis demonstration project. AIDS 2018 July 17;32(11):1527\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGlynn RW, Byrne N, O\u0026rsquo;Dea S, Shanley A, Codd M, Keenan E, et al. Chemsex, risk behaviours and sexually transmitted infections among men who have sex with men in Dublin, Ireland. Int J Drug Policy. 2018;52:9\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChoi EPH, Chau PH, Wong WCW, Kowk JYY, Choi KWY, Chow EPF. Developing and testing of an interactive internet-based intervention to reduce sexual harm of sexualised drug use (\u0026lsquo;chemsex\u0026rsquo;) among men who have sex with men in Hong Kong: a study protocol for a randomised controlled trial. BMC Public Health. 2021;21(1):713.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChow EPF, Grulich AE, Fairley CK. Epidemiology and prevention of sexually transmitted infections in men who have sex with men at risk of HIV. Lancet HIV. 2019 June;6(6):e396\u0026ndash;405.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchwarcz S, Scheer S, McFarland W, Katz M, Valleroy L, Chen S, et al. Prevalence of HIV Infection and Predictors of High-Transmission Sexual Risk Behaviors Among Men Who Have Sex With Men. Am J Public Health. 2007 June;97(6):1067\u0026ndash;75.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDarrow WW. Risky Sexual Behaviors Associated with Recreational Drug Use Among Men who have Sex with Men in an International Resort Area: Challenges and Opportunities. J Urban Health Bull N Y Acad Med. 2005;82(4):601\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAhmed AK, Weatherburn P, Reid D, Hickson F, Torres-Rueda S, Steinberg P, et al. Social norms related to combining drugs and sex (chemsex) among gay men in South London. Int J Drug Policy. 2016;38:29\u0026ndash;35.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRosenberger C, Gertzen M, Strasburger M, Schwarz J, Gernun S, Rabenstein A, et al. We Have a Lot to Do: Lack of Sexual Protection and Information\u0026mdash;Results of the German-Language Online Survey Let\u0026rsquo;s Talk About Chemsex. Front Psychiatry. 2021;12:690242.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBourne A, Reid D, Hickson F, Torres-Rueda S, Steinberg P, Weatherburn P. Chemsex and harm reduction need among gay men in South London. Int J Drug Policy. 2015;26(12):1171\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYu S, Zhu L, Shen Q, Bai X, Di X. Recent Advances in Methamphetamine Neurotoxicity Mechanisms and Its Molecular Pathophysiology. Behav Neurol. 2015;2015:1\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCorkery JM, Loi B, Claridge H, Goodair C, Schifano F. Deaths in the Lesbian, Gay, Bisexual and Transgender United Kingdom Communities Associated with GHB and Precursors. Curr Drug Metab. 2018;19(13):1086\u0026ndash;99.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMorgan CJA, Curran HV, the Independent Scientific Committee on Drugs (ISCD). Ketamine use: a review. Addiction. 2012;107(1):27\u0026ndash;38.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaumeister D, Tojo LM, Tracy DK. Legal highs: staying on top of the flood of novel psychoactive substances. Ther Adv Psychopharmacol. 2015;5(2):97\u0026ndash;132.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWinstock A, Mitcheson L, Ramsey J, Davies S, Puchnarewicz M, Marsden J. Mephedrone: use, subjective effects and health risks: Mephedrone and health risks. Addiction. 2011;106(11):1991\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMa R, Perera S. Safer \u0026lsquo;chemsex\u0026rsquo;: GPs\u0026rsquo; role in harm reduction for emerging forms of recreational drug use. Br J Gen Pract. 2016;66(642):4\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHinkin CH, Barclay TR, Castellon SA, Levine AJ, Durvasula RS, Marion SD, et al. Drug Use and Medication Adherence among HIV-1 Infected Individuals. AIDS Behav. 2007;11(2):185\u0026ndash;94.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAntoniou T, Tseng ALI. Interactions between Recreational Drugs and Antiretroviral Agents. Ann Pharmacother. 2002;36(10):1598\u0026ndash;613.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHibbert MP, Brett CE, Porcellato LA, Hope VD. Psychosocial and sexual characteristics associated with sexualised drug use and chemsex among men who have sex with men (MSM) in the UK. Sex Transm Infect. 2019;95(5):342\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKenyon C, Wouters K, Platteau T, Buyze J, Florence E. Increases in condomless chemsex associated with HIV acquisition in MSM but not heterosexuals attending a HIV testing center in Antwerp, Belgium. AIDS Res Ther. 2018;15(1):14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHIV\u0026ndash;AIDS Statistics [Internet]. Ankara: Republic of T\u0026uuml;rkiye Ministry of Health, General Directorate of Public Health, Department of Communicable Diseases and Early Warning.; 2024 [cited 2025 Aug 5] p. 2. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://hsgm.saglik.gov.tr/depo/birimler/bulasici-hastaliklar\u0026ndash;ve\u0026ndash;erken\u0026ndash;uyari\u0026ndash;db/Dokumanlar/Istatistikler/Ek_HIV\u0026ndash;AIDS_Istatistikleri.pdf\u003c/span\u003e\u003cspan address=\"https://hsgm.saglik.gov.tr/depo/birimler/bulasici-hastaliklar\u0026ndash;ve\u0026ndash;erken\u0026ndash;uyari\u0026ndash;db/Dokumanlar/Istatistikler/Ek_HIV\u0026ndash;AIDS_Istatistikleri.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDerin O. Gender and Age Trends in HIV Incidence in Turkey between 1990 and 2021: Joinpoint and Age\u0026ndash;Period\u0026ndash;Cohort Analyses. Med (Mex). 2024;60(8):1357.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGeorges Azzi. Chemsex Today Around the World [Internet]. ReShape/International HIV Partnerships; 2023 [cited 2025 Aug 5]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://reshapeorg.com/chemsexforum/\u003c/span\u003e\u003cspan address=\"https://reshapeorg.com/chemsexforum/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeyer IH. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychol Bull. 2003 Sept;129(5):674\u0026ndash;97.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHalkitis PN, Mukherjee PP, Palamar JJ. Longitudinal Modeling of Methamphetamine Use and Sexual Risk Behaviors in Gay and Bisexual Men. AIDS Behav. 2009;13(4):783\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePlankey MW, Ostrow DG, Stall R, Cox C, Li X, Peck JA, et al. The Relationship Between Methamphetamine and Popper Use and Risk of HIV Seroconversion in the Multicenter AIDS Cohort Study. JAIDS J Acquir Immune Defic Syndr. 2007;45(1):85\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDaskalopoulou M, Rodger A, Phillips AN, Sherr L, Speakman A, Collins S, et al. Recreational drug use, polydrug use, and sexual behaviour in HIV-diagnosed men who have sex with men in the UK: results from the cross-sectional ASTRA study. Lancet HIV. 2014;1(1):e22\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBracchi M, Stuart D, Castles R, Khoo S, Back D, Boffito M. Increasing use of \u0026lsquo;party drugs\u0026rsquo; in people living with HIV on antiretrovirals: a concern for patient safety. AIDS. 2015;29(13):1585\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKrasnova IN, Cadet JL. Methamphetamine toxicity and messengers of death. Brain Res Rev. 2009;60(2):379\u0026ndash;407.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRodr\u0026iacute;guez-Exp\u0026oacute;sito B, Rieker JA, Uceda S, Beltr\u0026aacute;n-Velasco AI, Echeverry-Alzate V, G\u0026oacute;mez-Ortega M, et al. Psychological characteristics associated with chemsex among men who have sex with men: Internalized homophobia, conscientiousness and serostatus as predictive factors. Int J Clin Health Psychol. 2024;24(2):100465.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchifano F, Albanese A, Fergus S, Stair JL, Deluca P, Corazza O, et al. Mephedrone (4-methylmethcathinone; \u0026lsquo;meow meow\u0026rsquo;): chemical, pharmacological and clinical issues. Psychopharmacology. 2011;214(3):593\u0026ndash;602.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKaye S, Darke S. The diversion and misuse of pharmaceutical stimulants: what do we know and why should we care? Addiction. 2012;107(3):467\u0026ndash;77.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eG\u0026ouml;kengin D, Doroudi F, Tohme J, Collins B, Madani N. HIV/AIDS: trends in the Middle East and North Africa region. Int J Infect Dis. 2016;44:66\u0026ndash;73.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Chemsex, Sexual behavior, Substance-related disorders, Men who have sex with men, Transgender persons, Türkiye","lastPublishedDoi":"10.21203/rs.3.rs-8671993/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8671993/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eChemsex, a form of sexualised substance use, is using psychoactive substances to enhance sexual activity. It is most commonly practiced by gay, bisexual and other men who have sex with men, trans and non-binary people and is increasing in prevalence across multiple regions worldwide. Yet, it remains insufficiently studied due to the stigma and criminalisation of some forms of drug use and sexual behaviour in many societies. We aimed to explore the prevalence, substance use patterns, motivations, and associated risks of chemsex in T\u0026uuml;rkiye.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eAn online survey including 18 multiple-choice questions assessing substance use, behavioural patterns, and psychosocial aspects of chemsex was distributed through Hornet and civil society contacts. Turkish people who have lived chemsex experience participated in developing the survey language to ensure its accessibility. Descriptive statistics and the Pearson Chi-Square Test were used to analyse the data.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOverall, 290 people across 44 cities in T\u0026uuml;rkiye responded. Chemsex was reported as a growing practice by 72%. The majority of respondents (71.3%) were from metropolitan areas, where 62.3% reported ongoing chemsex practices for ˃3 years. Methamphetamine (70.5%), 3,4-Methylenedioxymethamphetamine (MDMA) (43.8%), snorted cocaine (35.1%), and γ-Hydroxybutyric acid/γ-Butyrolactone (GHB/GBL) (29.5%) were the most common substances. The main motivations for engaging in chemsex included enhanced sexual pleasure (70.7%) and relaxation (61.7%). Reported harms were psychological distress (80.7%), social and relational issues (60.0%), and legal or financial consequences (59.0%). Overall, 54.1% stated that chemsex could not be discussed openly.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eChemsex is a growing phenomenon in T\u0026uuml;rkiye, accompanied by significant health, social, and psychological risks. The lack of harm reduction services and open discourse underscores the gaps in healthcare and community support that require urgent action, such as targeted, culturally sensitive, sex- and pleasure-positive harm reduction strategies that address stigma, improve mental health support, and expand access to HIV/STI prevention and treatment.\u003c/p\u003e","manuscriptTitle":"The Silent Advance: Chemsex Practices and Their Implications in Türkiye","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-11 14:22:17","doi":"10.21203/rs.3.rs-8671993/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-09T11:56:32+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-05T17:57:48+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-04T11:10:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"163249187213886598576854052167054022034","date":"2026-02-25T07:30:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"42072260395620981284155664596263694777","date":"2026-02-20T07:17:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"186787370702172319075037639671993079561","date":"2026-02-19T12:02:17+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-13T19:20:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"339722700023770342140928208565897637733","date":"2026-02-11T17:10:09+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-09T14:55:49+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-28T12:47:21+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-26T06:54:40+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-26T06:54:35+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2026-01-22T16:09:06+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"36f06a67-60e9-4622-b8c4-2fd23309e89c","owner":[],"postedDate":"February 11th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-07T13:08:52+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-11 14:22:17","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8671993","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8671993","identity":"rs-8671993","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}