Комплексный подход к проблеме употребления наркотиков в сексуальных целях (Хемсекс) 3-methylmethcathinone:: отчет о деле.

Introduction

Chemsex overview

Chemsex refers to the use of drugs during sexual activity [ 1 , 2 ]. The term surfaced within the London lesbian, gay, trans, queer, and more (LGBTQ+) community and is mainly used in reference to men who have sex with men [ 3 ]. The prevalence of chemsex within the population of men who have sex with men is estimated to be 16% in Europe and 19% in Asia, and 12.66% in the general population and 3.5% in the female population [ 3 ]. It involves prolonged sexual encounters with multiple partners and various practices, aiming to enhance and extend sexual experiences through increased desire and mental excitement [ 1 , 2 , 4 ]. This leads to sexual disinhibition, boosted self-confidence, and a sense of intimacy and connection with partners [ 2 ]. Chemsex allows for broader sexual exploration by reducing fear of judgment and increasing pain tolerance [ 2 ]. Participants seek increased quantity and quality of sexual experiences, including more extreme practices and deeper emotional connections [ 2 ].

Chemsex can alleviate emotional distress from homophobia and human immunodeficiency virus (HIV) stigma, offering acceptance and belonging within the gay community [ 2 , 5 , 6 ]. However, it can also lead to hypersexualization and competition for sexual desirability, hindering deep relationships [ 5 , 7 , 8 ]. Some individuals feel pressured to participate due to peer influence [ 5 , 7 ].

Substances used in chemsex

Common drugs include methamphetamine, cathinones (mephedrone, 3-methylmethcathinone [MMC], and 4-MMC), gammahydroxybutyrate (GHB), gammabutyrolactone (GBL), cocaine, ketamine, and alkyl nitrites [ 1 , 2 , 9 ]. Multiple substances are often used simultaneously [ 1 , 2 , 10 ]. Erectile dysfunction drugs are also commonly used [ 1 , 2 ]. Synthetic cathinones—3-MMC and 4-MMC—increase dopamine, serotonin, and norepinephrine levels, leading to stimulant, empathogenic, and entactogenic effects [ 9 – 12 ]. They are typically sniffed or ingested, and less frequently injected (“slamming”) [ 1 , 9 ]. 3-MMC inhibits dopamine and norepinephrine reuptake and induces their release, binding to serotonin receptors [ 9 , 12 , 13 ]. A recent study on rats suggests 3-MMC activates the brain’s reward circuit [ 13 ]. It has a short half-life (3 hours for 3-MMC), requiring repeated doses [ 12 , 14 ]. Users seek euphoria, excitement, energy, and enhanced social skills [ 12 , 13 ].

Adverse effects

Adverse effects of 3-MMC include verbosity, fatigue, hyperthermia, hallucinations, confusion, tachycardia, hypertension, agitation, and insomnia [ 12 , 13 ]. Chemsex can lead to mood drops, anxiety, psychotic symptoms, and feelings of loneliness [ 2 ]. Risks include overdose, physical injuries, sexual abuse, addiction, and long-term physical, psychological, and social well-being consequences [ 1 , 2 , 7 , 10 , 12 , 13 ].

Chemsex addiction is a complex issue involving both substance addiction and compulsive sexual behavior disorder. Addiction to new synthetic cathinones is a recent phenomenon with limited research [ 11 ]. Symptoms include craving, tolerance, withdrawal, and loss of control [ 1 , 7 , 15 ].

Compulsive sexual behavior disorder is characterized by a persistent failure to control intense sexual impulses, leading to repetitive sexual behavior that causes distress or impairment [ 16 – 21 ]. It is often a coping mechanism for negative emotions and is associated with anxiety and mood disorders [ 21 , 22 ]. Attachment disorders, early life abuse, and marital dissatisfaction are risk factors [ 19 , 22 ].

Treatment

Pharmacological treatments of compulsive sexual behavior disorder include selective serotonin reuptake inhibitors (SSRIs), opiate antagonists such as naltrexone, and topiramate [ 23 , 24 ]. Psychotherapeutic approaches focus on emotional regulation, addressing attachment disorders, and improving couple and sexual difficulties, and group therapy can also be beneficial [ 25 , 26 ].

Through this case report, we aim to illustrate the complexity of clinical presentations, treatment strategies, and evolution of the case of a patient with chemsex addiction.

Case description

A 37-year-old white European man sought treatment at outpatient facility, ReConnecte, with his companion for chemsex addiction. ReConnecte is a public care facility specialized in the management of addictive behaviors, including those related to sex, at University Hospitals of Geneva in Switzerland.

The patient explained that he often attended parties (once a week) where he consumed 3-MMC to increase the sensations felt during sex with other participants. After the parties, the patient regularly paid for one or more male escorts to prolong the experience. The patient could then disappear for several days. He could just as well neglect friends or family gatherings to go partying instead.

This new behavior started 15 months ago. The patient explained that he discovered the world of partying and crack usage with an acquaintance. The patient and his companion identified that these behaviors took place in a context of particular distress. They explained that the year previous to the first chemsex behaviors was indeed marked by a series of events that negatively impacted the patient:

The death of the patient’s paternal grandmother, to whom he was very close;

A loss of interest in his work, following a change in hierarchy;

The change in his companion’s job, which led to the couple being apart during the week and only being able to get together on weekends;

A new depressive episode of the patient’s mother, who regularly calls him for psychological support.

The patient and his companion described that this negative period led, 11 months ago, to an episode of running away to a nearby city. The patient presented a massive consumption of crack in the context of chemsex activities when he ran away, with the desired end goal of suicide by overdose. Since this episode, the patient had decided to no longer consume crack but instead 3-MMC.

The patient was treated for 14 months by a psychiatrist in the private health sector. However, the couple sought specialized care at our facility for sex addiction. The couple described a negative impact of the patient’s risky behaviors on their relationship. They both noted a deterioration in their sense of trust, decreased communication, complicity, and sexuality. The patient expressed significant shame about his chemsex practice, and he had major difficulty addressing the couple’s issues. The patient also mentioned financial repercussions, as he was spending large sums of money hiring escorts. He described himself as usually thrifty but was no longer aware of his expenses when chemsex was involved.

On a professional level, the patient explained that he sometimes missed workdays or suffered great fatigue as a result of the chemsex parties.

The patient expressed his wish to be able to put an end to his practice of chemsex to preserve his relationship and not suffer any more from the various negative consequences.

During our psychiatric assessment and follow-up with this patient, we diagnosed a compulsive sexual behavior disorder, presenting with a failure to control recurrent sexual impulses resulting in repetitive sexual behaviors. The patient is unable to stop his behaviors despite the repercussions on his relationship, his finances, his work, his relationships with his family, and his self-esteem. These behaviors had been going on for more than 6 months and were causing significant distress to the patient and those around him.

The patient described a craving for 3MMC in combination with sexual practices. He was looking for a specific sensation attained during the association of sexual behaviors and 3MMC. The patient presented cravings and difficulties to stop his consumption despite the negative consequences, the prioritization over other activities, and the increased tolerance (that is, quantities consumed) over a period of 11 months; therefore, we appended a diagnosis of addiction to 3MMC.

Patient situation or background

The patient described having a childhood marked by the violence of his mother’s second husband, the depressive state of his mother, and the absence of his biological father. The patient explained that he had experienced great economic and social insecurity. He reported a childhood plagued by anxious, intrusive thoughts about the lack of parental support and affective neglect. The patient identified his paternal grandmother as the sole person of reference during his childhood, describing her as the reliable and supportive adult who instilled positive values in his life.

The patient’s family lives abroad. The patient observed an isolation from his family and friends, as the couple mainly hangs out with the companion’s friends.

On the professional level, the patient described a job in which he no longer found fulfillment following the change of his direct hierarchy. The patient noted difficulty in setting limits with amount of work he assumed, justifying it by the need to help others and succeed in his duties.

Outside of the work sphere, the patient described an absence of regular leisure or hedonic activities.

The patient and his companion had been a couple for 10 years, were living together, and were building their relationship around the values of fidelity and exclusivity. However, the patient described a feeling of loneliness and abandonment by his companion since he had started his new job and was absent during the weekdays. In addition, with regards to their sexuality, the patient described a certain gap with his companion. He explained that he wanted more foreplay and wanted to further explore their sexuality, a need to which his companion was not receptive.

The patient explained that he sought chemsex as a way to connect with his sexual partners. He describes pursuing sexual experiences, reflecting on the emotions experienced during sex while also engaging in various types of foreplay, gentle caresses, and the exploration of new practices. In this context, the first experience of chemsex allowed the patient to escape his emotions through intense sensations of pleasure and helped fulfill his need for social interaction and satisfaction, therefore making chemsex his preferred emotional regulation strategy.

Interventions and evolution

First 2 months of therapy

We proposed weekly psychotherapy sessions, in addition to the weekly follow-up with the general psychiatrist. It was agreed that our treatment would focus on the addiction problem and that the general psychiatrist would address the childhood traumas and carry out couple interviews (the couple did not wish to add couple therapy with a third therapist).

The initial interviews were used to explore different facets of the patient’s life and to identify the function of the chemsex behaviors. For example, the interactions, the communication within the couple, and their sexuality was the subject of many interviews. The practice of chemsex allowed, in part, for the patient to satisfy a dissatisfaction encountered within the couple. The patient complained of a lack of emotional exchanges, connection to his partner, and also tenderness within their sexual experiences.

On one hand, the patient reported a lack of self-confidence. He described a need for recognition from others and to feel appreciated, valued, and validated by others. This regularly led him to do what would please others, to his own detriment. On the other hand, we also noted a significant experience of loneliness, particularly since the patient’s companion was away during the weekdays. The patient had no close friends nor activities beyond work, which would have allowed him to overcome his sense of loneliness. He identified a sense of dependence on his companion, expressing feelings of abandonment by his companion and making the connection with the absence of his biological father.

In this context, the patient could not find sufficient feelings of security with his parental attachment figures. Indeed, a childhood and adolescence with a multitude of repeated traumas forced the patient to try to psychically manage by putting coping strategies in place as best as he could. We noted difficulties in emotional adaptation, with coping strategies of the internalization type, and then escape when the feelings became unbearable. We were able to understand with the patient that his fear of abandonment pushed him to internalize his emotions and to favor the needs of others over his own to ensure that he would not lose the love of others. The moments of loneliness were described as inner voids that were extremely unpleasant and that prompted the patient to opt for sweet foods or to seek out the possibility of partying. The patient presented an anxious attachment disorder, which we can understand in view of his childhood. He described a state of generalized anxiety, with anxious ruminations of a devaluing nature and a recurrent state of dysthymia. He explained that he felt as though he was constantly fighting against this negative emotional state that pushed him toward seeking sources of satisfaction or appeasement.

The patient identified several roles played by chemsex parties:

To let go and get relief from his generalized anxiety; the patient expressed that he did not feel judged at parties, and that he could be himself without questioning his performance.

As an avoidant coping strategy for the negative emotions and lowered mood.

As a means to decrease his feeling of loneliness by living experiences of connection to sexual partners.

As a way of externalizing his anger toward his companion in moments when he felt abandoned, describing it as “taking revenge” through chemsex behaviors.

As a means of filling the emotional and sexual dissatisfaction within the couple.

However, he also identified the negative repercussions of his chemsex behaviors:

An increased feeling of shame and personal devaluation, along with a lack of control of his behaviors.

A heavy feeling of guilt, anger, and sensed incomprehension of relatives.

We observed that the patient felt guilty and lacked a sense of legitimacy to open up to his companion about his anger, his feelings of abandonment, and the ways in which they could manage this difficulty together. In addition, the companion felt hurt and was less inclined to acknowledge the patient’s difficulties. The impairment in communication created distance between the patient and his companion and resentment from both sides. This intensified the patient’s experience of loneliness, as well as his fear of abandonment.

Our first pharmacological option was to propose the antidepressant sertraline at 50 mg per day. The objective of this medication was to alleviate the anxiety symptoms and the dysthymia and to decrease the patient’s libido.

In parallel, the psychotherapeutic approach consisted of several agreed treatment objectives:

Better coping strategies for anxiety and dysthymia. The first objectives were to set up leisure activities that would allow the patient to relax, to blossom, and to externalize his emotions.

Setting up activities outside the home; this was intended to allow the patient to build a social network and to fight loneliness. Rebuilding social networks and experimenting activities were also ways considered to improve low self-esteem.

At the couple’s level, we identified the need to work on a dependent attachment disorder [ 26 ], which was leading to the sentiment of abandonment. We discussed the need for the couple to express their emotions, and the couple was encouraged to consider working on their communication, including the topic of their sexuality.

The introduction of sertraline 50 mg was rapidly followed by a decrease in anxiety and depressive affects. The patient reported feeling more confident and effective at work.

In terms of medication, the introduction of an SSRI-type antidepressant treatment was beneficial at first. Indeed, it reduced the anxio-depressive effects as well as the libido of the patient, and we noticed a decrease in chemsex behaviors during its introduction. This corresponds to the elements described in the literature concerning the use of SSRI in the treatment of sexual addictions.

In terms of activities, the patient resumed reading and manual activities at home, with a feeling of fulfillment. However, he did not undertake any group activity outside the home. The patient stated that communication within the couple had improved and the chemsex behaviors had ceased since the beginning of the interviews, which had facilitated the recovery of trust and complicity.

Cognitive behavioral therapy was performed, targeting the erroneous cognitions induced by the attachment disorder as well as the negative impact of dysfunctional coping strategies such as internalization and escapism [ 27 ]. We identified the vicious cycles that led to an increase in depressive affects and self-depreciation. A reflection was made concerning the most adapted behaviors to put in place.

From the third to the fourth month of therapy

During the follow-ups, the patient spoke of a significant feeling of anger toward family members, who he felt had not protected him, especially his mother, who he felt had always relied on him through her multiple depressive episodes. The patient reported the difficulty of grieving the loss of his grandmother, who was the only stable and resourceful presence during his childhood.

We identified in all the patient’s interpersonal interactions (with his companion, colleagues, and family members) a difficulty in expressing his needs and asserting his limits. We observed that the patient endured and accumulated distress until it was unbearable and the implementation of escape strategies in compulsive sexual behaviors felt unavoidable. We were able to discuss the possibility of distancing himself from his family and allowing himself to express his boundaries to protect himself. During this reflection, the patient noted a feeling of dependence on his family members, whom he feared would abandon him if he no longer played his role of unwavering support.

During this period, we increased the medication of sertraline to 100 mg per day, with the objective of increasing the anxiolytic and antidepressant effect.

From the fifth to the sixth month of therapy

Progressively, during the follow-up, the patient identified a growing and unresolvable dissatisfaction at work. The questioning of the key aspects of the patient’s life—his family, his companion, and his work—disrupted the patient’s ability to function.

The patient experienced a crisis, with increased anxiety and depression. This crisis was accompanied by an increased participation in chemsex parties, followed by episodes of cathinone consumption alone at home with autoerotic behaviors. Amid this major examination of his life, the patient was able to express a new insight: his difficulty in totally accepting his homosexuality and the persistent fear of rejection.

Given the unfavorable evolution of the patient’s case, his general psychiatrist decided to put him on sick leave, and we decided to organize a hospitalization to contain this period of crisis in a secure environment.

While waiting for the hospitalization in an adapted institution, the patient’s general psychiatrist prescribed him pregabalin 75 mg and olanzapine 2.5 mg in the morning and evening, for anxiolytic purposes and to contain impulsivity, especially to prevent suicidal risk. In terms of the antidepressant, we could have considered increasing sertraline to 200 mg daily to rule out its positive impact on our patient; however, as the patient did not feel any additional relief by going from 50 to 100 mg, this was not considered.

During the hospitalization, the patient benefited from psychiatric, psychotherapeutic, and therapy support and sports, as well as group activities, including a group work for addictive disorders.

The patient described a newfound ability to adopt a broader perspective on his situation, in addition to having been able to work intensively on important psychological areas, such as:

Identification and management of his emotions.

Reflection on his addictions and what strategies to put in place for abstinence.

His dependent attachment disorder with his family members and his companion. The patient’s companion came to visit him regularly and more emphasis was placed on the couple’s communication and the patient’s dependent behavior.

His self-esteem and assertiveness. The patient successfully integrated into the group of patients and felt completely accepted for who he is, including his homosexuality. He explained that he was able to transform himself into a drag queen on two occasions, with the help of the other patients, and received validation from the healthcare staff, as well. This experience of being fully accepted and supported in his sexual orientation by both the patient and caregiver groups was a source of self-confidence and a foundation for the reduction of his fear of rejection.

His path toward greater acceptance of his new professional environment, which was marked by a mindset of letting go and the liberating decision to resign.

From the seventh to the eighth month of therapy

The patient was discharged from the hospital after 1 month.

His treatment at discharge was as follows:

Pregabalin 75 mg in the evening was maintained.

Sertraline was reduced to 50 mg, as the patient complained of a lack of libido.

Bupropion XR 150 mg in the morning was introduced with the goal of thymic improvement.

Given the decrease in anxiety symptoms, we agreed with the patient on a gradual decrease of pregabalin, before stopping it.

We decided to prescribe bupropion, as it is known as a treatment for major depressive disorder as well as a treatment against seasonal affective disorders [ 28 ]. It is a noradrenaline and dopamine reuptake inhibitor and part of the synthetic cathinone family [ 28 ]. The exact mechanisms of action are not yet fully understood, with studies differing in their results [ 28 ]. However, it is also known to be effective in smoking cessation, whether the patient is depressed or not, as well as for use in methamphetamine addictions [ 28 ]. Methamphetamine is a psychostimulant drug, like cathinone derivatives, and shares similar effects in terms of increased fluidity in social exchanges and increased empathy [ 12 ].

We conducted weekly interviews to provide sufficient support during this fragile initiation period of chemsex abstinence.

The patient set up multiple sport and creative activities outside the home. He also attended a Narcotics Anonymous discussion group support twice a week. The patient described a very beneficial impact of the group, where he felt integrated, accepted, and supported. We highlighted the importance of the patient feeling a sense of belonging to a group.

The couple regained satisfying communication and made the decision to move in together so as to not be separated during the weekdays. In terms of their sexuality, the couple was exploring a more fulfilling sexual experience. We addressed the issue of managing libido in the absence of his companion, including the role of autoerotic behaviors.

Furthermore, regarding his job, the patient made the decision to quit and to start thinking about future projects.

During the interviews, the patient raised questions about the role of bupropion and expressed a more specific effect of bupropion on his craving for 3-MMC, compared with his sertraline treatment. He also expressed that he felt a beneficial effect on his fear of being judged and that the introduction of bupropion enabled him to confidently dress as a drag queen in public during his hospitalization. With bupropion, he described being able to feel the thymic improvement he searched for (which he failed to achieve with cathinones) and the gain in self-confidence that came with taking 3-MMC at chemsex sessions, but over time and in a more stable fashion. He stated that this allowed him to stop craving for cathinones.

Ninth month of therapy

The patient continued showing signs of positive evolution, maintaining abstinence and thymic balance. Given the positive outcome of the whole treatment, we reduced the frequency of the interviews to twice a month and then monthly.

The couple found their sexual relationship to be completely satisfying. The patient described the disappearance of the feeling of loneliness, through developing a sense of intimacy with his companion and a feeling of belonging within the Narcotics Anonymous support group. He also testified to the important support he got from the support groups, which seems to propose a framework quite adapted to his addictive pattern of synthetic cathinones use. However, the patient noted that his attachment disorder remained a pervasive difficulty, feeling the need for vigilance and requiring continued psychotherapy to be able to respond appropriately to his emotional experience.

We decided to stop the bupropion, as the patient described that he no longer felt the need for it and felt overstimulated.

Tenth month of therapy

The couple moved, which caused the patient some anxiety and a slip up of a few hours, with a quick recovery using functional relapse prevention strategies. We discussed the re-establishment of activities and the rebuilding of a network (particularly participation in Narcotics Anonymous meetings) in this new city.

We returned to the elements of difficulty constituted by the attachment disorder and the patient’s childhood. A systemic reflection was made within the framework of the patient’s place within his family, his work, and his couple. The patient was able to engage these different systems during a crisis to achieve a new equilibrium by identifying his needs and setting his boundaries.

Having regained his equilibrium at the end of the month, we agreed to try a reduction of the sertraline to 25 mg.

Eleventh month of therapy

The patient found a rhythm within his daily life and resumed participation in a new Narcotics Anonymous support group. We discussed the aspects of the attachment style and the associated difficulties that the patient must remain conscious of.

He had the opportunity to see family members and described finding a new balance where he respects his own boundaries and feels comfortable. The couple also acknowledged sharing a strong bond and intimacy.

We decided to stop the sertraline completely and stop the treatment phase while making it clear that the patient could contact our facility if necessary.

Discussion

Addiction to chemsex is a complex addiction with several components to be considered: the substance addiction component, the compulsive sexual behavior disorder component, and the component of the socio-cultural context and its impact on individuals. We could see that all these complexities had to be considered in the treatment of this patient.

Addiction to a substance, 3-MMC

In the introduction, we have seen that 3-MMC has addictive effects; however, to our knowledge, there is no information in the literature regarding specific treatment strategies for this type of addiction [ 1 , 7 , 15 ].

Bupropion was prescribed because we believed its thymic stimulation and its efficacy in mitigating reward system dysregulation could help the patient decrease his dependence on cathinones in a more stable manner. However, it is important to note that, although bupropion is thought to have low abuse potential, cases of misuse have been reported in patients with addictive issues by nasal insufflation or intravenous administration and at dosages above the maximum recommendation of 450 mg [ 28 ].

The case of this patient raises the question of the efficacy of bupropion as a craving-reducing treatment in patients suffering from dependence on synthetic cathinones and more specifically on 3-MMC. In addition to its antidepressant role, it could play a substitution role in cases of dependence on shorter-acting synthetic cathinones. It would be interesting to undertake research trials to confirm this therapeutic potential.

On the psychotherapeutic level, the patient benefited from a cognitive behavioral treatment similar to that which can be proposed for other addictive disorders and was satisfied with it. Further investigation is needed to evaluate the broader efficacy of this multimodal approach in managing similar cases.

Compulsive sexual behavior disorder

In the introduction, we showed that depression, anxiety disorders, attachment disorders, childhood trauma, the use of sexual behaviors as an emotional coping strategy, and the presence of sexual dissatisfaction and/or communication difficulties within the couple are risk factors for the development of compulsive sexual behavior disorders [ 19 , 22 – 25 ].

Sexual behavior disorders are regularly described as a means of emotional regulation of negative emotions and thymic release, via sexual arousal and satisfaction, as well as the feeling of desirability by another person [ 19 , 22 ]. These sexual behaviors are a dysfunctional coping strategy to combat psychological distress and are frequently associated with mood and attachment disorders [ 19 , 22 , 24 ]. These comorbidities then contribute to a cycle in which anxiety is exacerbated by stressful life events, reinforcing the anxiety through the negative consequences of the compulsive sexual behavior disorder. As the sexual disorder becomes a maladaptive coping mechanism, this emotional distress is intensified, and a feedback loop that compounds both the psychological and functional impairments experienced by the individual is further perpetuated. The different layers of sexual behavior disorders, especially those that also include chemsex, appeal to a treatment approach that is equally as multilayered.

We noted that this patient’s situation (the mourning of a secure figure, fear of abandonment, and the lack of fulfillment at work) corresponds to the aforementioned risk factors for the development of compulsive sexual behavior. The dysfunctional emotional coping strategies put in place by the patient favored the installation of sexual addiction and tendencies of self-devaluation.

In our patient’s case, the SSRI treatment proved insufficient in managing the emotional insecurity induced by the simultaneous occurrence of multiple stressful life events. This is why the psychotherapeutic management of the patient required a multimodal and individualized approach based on the factors that predisposed him to compulsive sexual behavior disorder. Thus, the patient’s childhood and adolescence were revisited from a psychodynamic viewpoint, emphasizing the repercussions on the construction of the patient’s identity, basic security, and attachment style.

The clinical situation of this patient corroborates our hypothesis of a dimension of compulsive sexual behavior disorder in chemsex addictions. Indeed, we find the diagnostic criteria, as well as the predisposing factors, described in the literature [ 16 – 22 ]. Although the observations of treatment of sexual addiction described in the literature are not validated by studies with rigorous methodologies, we noted the effectiveness of a multimodal approach, focused on the predisposing factors to sexual addiction. In fact, we have seen in the introduction that psychotherapeutic approaches involve working on possible childhood traumas, attachment disorders, emotional regulation disorders, relationship difficulties, sexual difficulties, and psychiatric comorbidities [ 19 , 24 ]. It is imperative then to understand how different types of cognitive behavioral trauma-informed therapy, as well as attachment-focused interventions, can inform clinical practices in patients within the context of chemsex and compulsive sexual behavior disorders. Further studies on the scientific validation of models of understanding of the psychological phenomena at work in sexual addiction, as well as the treatments to be considered, are crucial to allow for the implementation of quality, efficient, and evidence-based care.

Impact of the socio-cultural environment

The patient expressed the struggle of accepting his differences and the impact that this had on his sense of identity and self-confidence. He spoke about the difficulties of living his homosexuality within his family, as well as more generally in society and of a constant fear of judgment and rejection due to his sexual preferences. It is important to note that, although chemsex diagnoses are seen within other populations, they are highly recurrent within the homosexual community [ 3 ]. The chemsex parties served to mitigate these feelings of rejection, internalized homophobia, and loneliness. However, during his hospitalization, the patient was positively affected by his successful integration within the patient group, as well as by the encouragement he received when he dressed as a drag queen and later by support groups. These positive experiences allowed the patient to break out of his feelings of loneliness and to assert himself more easily in his homosexual identity.

Homophobia and the marginalization of sexual minorities remain very prevalent in our society. For many individuals, affirming their sexual orientation is accompanied by rejection, judgment, and violence. These challenges can lead to a range of negative outcomes, including the occurrence of trauma, disruptions in identity and sexual development, decreased self-confidence, and difficulties trusting others. These experiences are frequently associated with possible attachment-related disorders, depressive moods, anxiety disorders, and heightened feelings of loneliness [ 5 , 6 ]. Let us recall that all these elements constitute major risk factors for the development of sexual addictions [ 19 , 22 – 25 ].

The current context of performance and aestheticism norms amplified by social networks impacts our relationships with others and our relationship to our sexuality [ 7 , 8 ]. It seems increasingly difficult to feel connected to the other and to oneself in a society where the other, oneself, and sexuality have become consumables, whose market value fluctuates according to the number of likes, followers, or sexual partners.

The gay community represents an essential support system for the individuals experiencing homophobia, acting as refuge and a place where the individuals can encounter a sense of belonging [ 5 ]. The practice of chemsex takes place in a society that remains marked by homophobia and where individuals experience a liberation of sexuality while experiencing a disappearance of the collective in favor of individuality. Chemsex, therefore, can represent a space of experimentation regarding one’s sexuality and of assertion of the homosexual identity, displaying a transgressive, liberated sexuality and a way of finding a feeling of intimacy with the other and of collective ties in a society more and more disused. This practice can be lived positively and without negative impacts in the long run for certain individuals, as the studies of Evers et al. and of Glynn et al. demonstrated [ 4 , 29 ]. However, it is not without risk, and a quarter of chemsex users express a need to see a professional (more preferably a sexual health expert or an addictologist) to discuss their use of chemsex [ 4 ].

Thus, it is essential to think of other spaces where individuals can feel accepted and integrated within a group of peers, not judged, welcomed in their individuality, and able to be offered support. These spaces should be thought of not only as tertiary prevention but also as primary and secondary prevention in a society that is still marked by homophobia and that advocates for an isolating individualism. For this patient, we can see how the impact of social connection was as critical to recovery as pharmacological interventions.

As caregivers, we must pay particular attention to the impacts of rejection on the identity and sexual construction of individuals who are part of a social minority, as well as the impacts of the deconstruction of social ties on the mental health of our patients.

Conclusion

This case report invites the conceptualization of chemsex addiction as the result of the interaction between an individual with his predisposing addictive factors, a socio-cultural environment that influences these risk factors, and a behavior associated with the intake of one or several substances.

The treatment of our patient, who used 3-MMC, led us to note the paucity of the literature on addiction to this new synthetic cathinone and to consider the possible usefulness of bupropion as a substitution treatment during withdrawal. Indeed, bupropion can have an antidepressant action, coupled with an effect similar to that of synthetic cathinones, but with a longer effect duration.

Regarding psychotherapeutic treatment, we have observed that the existing data in the literature on compulsive sexual behavior disorders correspond to the profile and the needs of the patient described in the current case report. Thus, we recommend a multimodal approach to address possible childhood traumas, attachment disorders, emotional regulation disorders, relationship difficulties, sexual difficulties, and psychiatric comorbidities.

The psychotherapeutic treatment was personalized according to the patient’s needs and considered the impact of the socio-cultural environment on the patient. Particular attention was paid to the difficulties he faced in living his homosexuality authentically as a gay man, as well as to the sense of rejection he experienced. Group therapy can provide a welcoming and caring place and a sense of belonging and support and can allow individuals experiencing social rejection to step outside their feelings of loneliness.

It is crucial to carry out research trials, which can scientifically validate the predisposing factors, the diagnostic criteria, and the treatments to be put in place for chemsex addiction cases. These elements are essential to design adapted public health programs for addictive disorders involving chemsex practices.

Acknowledgements

Not applicable.

Abbreviations

3-Methylmethcathinone

4-Methylmethcathinone

Bondage and discipline, dominance and submission, and sadism and masochism

Diagnostic and Statistical Manual of Mental Disorders

Gammabutyrolactone

Gammahydroxybutyrate

Human immunodeficiency virus

International Classification of Diseases 11th Revision

Selective serotonin reuptake inhibitor

Author contributions

EK provided care to the patient; EK drafted the first manuscript with support from SA, who supervised her for the clinical work with the patient and revised the first draft and all revised versions of the manuscript; SAA revised the second draft manuscript and checked for language accuracy, and DZ revised the manuscript. All authors have read and agreed to the published version of the manuscript.

Funding

Open access funding provided by University of Geneva. This research received no external funding, except for the

Data availability

Not applicable.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Competing interests

The authors declare that they have no competing interests.

Footnotes

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References

Associated Data

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