'I'm doing it willingly': understanding moral agency, empathy, and stigma in the context of sexualised drug use.

Research on sexualised drug use often emphasises adverse health outcomes and risk management with limited exploration of the social and ethical dimensions of moral agency and harm reduction practices. This study examined the interplay between moral agency, empathy, and stigma. Participants (age >18 years and California residents) who engaged in drug use during sex within the past six months, excluding alcohol-only use, were recruited through mobile hook-up apps, websites, and snowball sampling. Eighteen semi-structured in-depth interviews were conducted with predominantly cisgender gay male participants between March 2022 and January 2023. Participants discussed personal responsibility for individual health, joint responsibility among partners, and informed substance use, including planning dosage and timing, communication around use, and reliance on support networks. Empathy fostered inclusive environments, mitigating internalised and externalised stigma. Critical social and ethical factors underpin the harm reduction practices documented in this study. They provide insights into developing prosocial interventions tailored to intracommunity needs by drawing attention to the importance of community support, empathy, and collective responsibility in promoting health and reducing stigma. A counterpublic health framework is advocated to guide future harm reduction efforts.