Guideline

South African harm reduction guideline for chemsex

Andrew Scheibe, Yolaan Andrews, Ben Brown, Naeem Cassim, Thato Chidarikire, Johan Hugo, Regina Maithufi, Sive Mjindi, Dawie Nel, Shaun Shelly, Jabulile Sibeko, Mariette Slabbert, Londeka Xulu, Antons Mozalevskis

Received: 13 Aug. 2025; Accepted: 14 Aug. 2025; Published: 30 Sept. 2025

Copyright: © 2025. The Author(s). Licensee: AOSIS.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Executive summary

The intentional use of psychoactive substances to enhance sexual experiences is known as chemsex. Chemsex is one form of sexualised substance use. Chemsex is primarily, but not exclusively, practised by key population groups including gay, bisexual and other men who have sex with men (GBMSM), transgender people, people who use drugs, and sex workers.

The potential harms result from the intersecting stigma and risks relating to substance use, criminalisation of drug use and possession for personal use, sex work, HIV and other sexually transmitted infections (STIs), prolonged and higher-risk sexual practices, substance-use disorders, mental health conditions, and sexual- and gender-based violence. Chemsex is not always problematic, but some people may develop health and/or social issues with this practice.

While data on the prevalence of chemsex in South Africa (SA) are limited, HIV and STI programmes for key populations regularly reach people who engage in chemsex. Chemsex sessions are frequently posted on GBMSM social networking and dating applications. This phenomenon is taking place in the context of increasing psychoactive substance use and a high prevalence of HIV and other STIs among key populations in the country.

Locally, there is a lack of knowledge, services, and support for people who engage in chemsex. This exacerbates their risk of exposure to HIV and other STIs, heightens barriers to accessing comprehensive care, and intensifies potential harms.

This guideline provides recommendations to address the key health and psychosocial aspects relating to chemsex in SA. Box 1 summarises the key components of chemsex harm reduction services. Recommendations are aligned with international evidence and informed by the professional experience of the authors, and research on the values and preferences of South African GBMSM who engage in chemsex.¹ This guideline was thoroughly reviewed by external peer reviewers.

This guideline should be viewed within the context of the Southern African HIV Clinicians Guidelines for Harm Reduction.²

Scope and purpose

• Provide an overview of chemsex in SA.
• Offer evidence-based clinical guidance for chemsex harm-reduction services.
• Provide a directory of useful resources and sensitised providers.

Audience

This guideline is aimed at clinicians (doctors, nurses, and clinical associates); however, pharmacists, psychologists, social workers, programme officers, peer outreach workers, advocates, and policymakers may also benefit from the guidance provided. The term ‘healthcare provider’ has been used throughout and refers to all providers involved in providing health services for people who engage in chemsex.

Guideline development

The authors made up the guideline development team. A subgroup of authors conducted a values and preferences research study among GBMSM engaging in chemsex in SA.¹ This guideline is based on an international chemsex framework,³ that was adapted based on findings from the values and preference research,¹ a scoping review of chemsex and harm reduction interventions, WHO guidance, and input from authors who provide services to people who engage in chemsex. The draft guideline was circulated for local and international peer review, and feedback and recommendations were integrated to produce a final version. Table 1 provides definitions of key terms.

Introduction

Chemsex is defined as the intentional use of psychoactive substances (‘chems’) to initiate, facilitate, enhance and prolong sexual encounters.^{12,13,14,15,16} Chemsex is one form of sexualised substance use. In chemsex, stimulant, depressant and/or psychedelic-type substances are used, and often in combination.¹⁶ Other substances, such as amyl nitrate and medications for erectile dysfunction, may also be used.¹⁶ Substance use usually results in short-term euphoria, relaxation, increased sexual arousal, lowering of inhibitions, and a sense of emotional connection with sex partners.^1,17,18 Chemsex can include an exploration of various sexual practices such as group sex, ‘marathon’ sex (sex lasting days) or other forms of sexual play (e.g. fetish and kink).^19,20,21

The motivation to engage in chemsex is primarily to facilitate, sustain, and/or intensify sexual experiences and pleasure, and enhance connections among sexual partners.¹⁸ Among GBMSM and people from the lesbian, gay, bisexual, transgender, queer, intersex, asexual, and other identities (LGBTQIA+) community, it may also be linked to a short-term escape from internalised homo-/transphobia, internalised/self-stigma, low self-esteem, minority stress, intra-minority stress, or as part of transactional sex.^{1,14,15,17,22,23,24,25,26}

In high-income settings, chemsex practices have been reported in up to a third of GBMSM.¹⁶ Available data suggest that chemsex among GBMSM from low- and middle-income countries (LMICs) in the past year ranges from 5.0% to 28.4%.²⁷ Chemsex among transgender women and sexual minorities has been identified in several LMICs, but data are limited.²⁸ For example, in Brazil, 40.7% of transgender women (n = 280) participating in a cross-sectional survey in 2020 reported chemsex in the past 6 months.²⁹

The potential harms of chemsex relate to substance use (type of substance, dose, route of administration, and individual and contextual factors),³⁰ unsafe sexual practices, increased exposure to HIV and other STIs, stigma, and the intersections between these components.^21,26 The longer a chemsex session lasts, the higher the risk for blood-borne and sexually transmissible infections, psychosis and physical injury.¹⁷ Drug interactions between substances are often difficult to predict and pose significant risk, including overdose, loss of consciousness, and death.¹⁷ The psychoactive effects of substances may also affect the person’s ability to give informed consent.

Longer term consequences of ongoing chemsex include mood and anxiety disorders, and substance dependence.^3,31,32 Prolonged engagement in chemsex may also lead to challenges in engaging in sex without the use of psychoactive substances.¹⁷ Stigmatisation can trigger social exclusion and restrict the ability of those who engage in chemsex to live authentically.³³ These factors can negatively affect the mental health and wellbeing of people who engage in chemsex and are often barriers to accessing healthcare, psychosocial, and other services.²⁶ There is also increased risk for violence.¹ Additionally, the context in which chemsex takes place (e.g. in the context of sex work, at sex-on-premises venues or among people without stable housing), can exacerbate these potential harms.¹⁶ However, chemsex is not always harmful, nor problematic, and can contribute to social connection, sexual exploration, and deepened self-understanding.^18,21,32

Distinguishing harmful from non-harmful substance use and identifying substance use disorders can enable triage and the provision of appropriate care. Harm reduction interventions should be offered to all people who engage in chemsex, despite moral objections (Box 2).^34,35 People with harmful patterns of substance use or dependence should also have access to specialised services.³⁵

Chemsex in South Africa

Chemsex has emerged as a growing health concern in SA. Over the past 20 years, the availability and use of methamphetamine among adults in SA has increased dramatically; from < 0.5% reporting use in the past 3 months in 2002 to 1.5% in 2017.³⁷

In 2012, over half (53.0%) of GBMSM and transgender women attending a sexual health clinic in Cape Town (n = 200) reported having ever had sex under the influence of substances, and 37.0% having ever used methamphetamine. In the same cohort, 30.0% reported group sex and 38.5% had engaged in transactional sex in the past year.³⁸ More recent surveys^39,40 among GBMSM and transgender women have identified frequent drug use, but did not explore chemsex practices. In 2019, the prevalence of methamphetamine use in the past 6 months among GBMSM in Cape Town and Johannesburg was estimated to range between 10.7% and 20.7%.³⁹ In 2018/19, 40.2% – 66.6% of transgender women in three cities were estimated to have used drugs in the past 12 months.⁴⁰

Programmatic and qualitative data from Cape Town and Johannesburg show that chemsex takes place in private residences, guest houses and sex-on-premises venues, and is facilitated through online platforms (e.g. Grindr®) and word of mouth.^1,25,26,41

Psychoactive substances commonly used in chemsex are listed in Table 2. Crystal methamphetamine, known locally as ‘Tik’ or ‘Crystal’, is the most widely used substance, followed by crack cocaine. It is typically smoked but can also be injected (‘slamming’) or administered rectally (‘booty bumping’).^1,25,26,42 The use of gamma-hydroxybutyrate (GHB)/gamma-butyrolactone (GBL) is reported to be more prevalent in affluent areas.¹ Other substances commonly used in addition to chemsex drugs are outlined in Online Appendix 1, Table 2-A1.

Condomless anal intercourse (‘barebacking’), sharing of injecting equipment, polysubstance use, and transactional sex occur locally in the context of chemsex.^41,43 Research into the values and preferences of GBMSM who engage in chemsex identified preferences for services that provide accurate and non-judgemental information, enable informed decision-making and increase access to confidential and tailored physical and mental healthcare in safe spaces.¹ Access to sterile injecting equipment, HIV pre-exposure prophylaxis (PrEP), STI testing and treatment, peer support, and post-violence care were also reported as priority needs.¹

Harm-reduction framework

Harm-reduction interventions in the context of chemsex can address issues relating to substance use, sexual health and STIs (Figure 1). This guideline provides an approach to clinical consultation and then provides additional information for the various components of the chemsex harm-reduction framework.

FIGURE 1: Framework for chemsex harm-reduction interventions.

Clinical consultation

The clinical consultation for a person who engages in chemsex should involve history taking, examination, diagnostic tests, and counselling and management plans that align to their unique risk profile and specific needs.^1,35,51 A risk-reduction approach should be taken, and the consultation should take place in a safe space and be conducted in a non-judgmental manner. It is important to always explain why an examination is being done and what it will entail.

History, examination and diagnostics

Table 3 details what should be assessed during a clinical consultation. A more detailed history should be taken at the initial visit. Changes should be enquired about in subsequent (3–6-monthly) visits.

Management

It is important to provide the client with an individualised management plan. Consider the following:

• Vaccination:
  • Consider hepatitis A, hepatitis B, human papilloma virus (HPV) and mpox vaccination.
  • See the National Department of Health (NDoH) viral hepatitis guidelines⁵⁴ and NDoH mpox guidance⁵⁵ for more detail.
• Information, Education and Communication (IEC):
  • Provide accurate information on substances, safer substance use, drug-drug and drug-medication interactions, safer sex and sexual reproductive health, and mental health.
• Counselling:
  • Discuss risk-reduction (including on overdose) and safety management plan (including crisis support).
  • Provide additional information on other specific health condition(s) as needed.
  • If not living with HIV, explain post-exposure prophylaxis (PEP) and encourage PrEP. See the latest NDoH PEP guideline, Southern African HIV Clinicians Society (SAHCS) PEP guideline, NDoH PrEP guideline and SAHCS PrEP guideline for more detail.^56,57,58,59 If available, offer long-acting injectable PrEP.
  • If living with HIV, explain undetectable = untransmissible (U = U) and support adherence.
  • Ask about intimate and family relationships, and self-care.
  • Provide condoms and lubricants.
• Provision of doxyPEP⁶⁰:
  • Discuss the risks of syphilis, chlamydia and gonorrhoea infection, and the pros and cons of doxyPEP.
  • Following shared decision-making, provide a prescription for the self-administration of doxycycline 200 mg orally as soon as possible and within 72 h after having oral, vaginal or anal sex (maximum dose is 200 mg every 24 h). Prescribe sufficient doses based on the client’s planned sexual activity until their next visit. Reassess the need for doxyPEP every 3–6 months.
• Referral:
  • Provide information on where to access harm reduction initiatives, specialised drug treatment services, mental health services and psychosocial support. See Online Appendix 1, Table 1-A1 for available resources.

People who engage in long-term, intense chemsex may benefit from long-term support to resolve their substance use issues and gain control of their sex lives. Considerations of interventions should take the person’s life stage into account (see Box 3).

Retention and re-engagement in care

Adherence support should be provided to increase the clients’ retention in care. It should focus on supporting persistence on PrEP or ART, as appropriate. Counselling should support people around maximising the protective effect of PrEP or of HIV viral suppression (including clear messaging around U = U), respectively. People who have experienced disruptions in care should be supported to re-engage in care.

Substance use

Supporting safer substance use

Selected interventions to reduce substance-related harms are included in Table 4 and are detailed in the SAHCS harm reduction guidelines.²

Intoxication and overdose management

Intoxication refers to a transient condition following the intake of a psychoactive substance resulting in disturbances of behaviour, perception, cognition, affect, perception and/or consciousness.⁷⁰ Prevention involves educating clients on risks, risk reduction and detection of overdose and emergency management. Clients should be informed about potential bulking agents and contaminants in illicit substances, which could include a range of new psychoactive substances and other adulterants.¹⁷

Stimulants

A stimulant overdose is characterised by hyperthermia while being conscious. Management involves the use of long-acting benzodiazepines (e.g. a titrated dose of 5 mg – 10 mg diazepam orally, intravenously, or per rectum). Antipsychotic medication may be needed as an adjunct (e.g. haloperidol, 1 mg – 2.5 mg orally or intramuscularly). Additional supportive therapy is required to manage people with chest pain, tachyarrhythmias or additional neurological symptoms. Following an episode of stimulant intoxication, clients should be screened for suicidality and managed accordingly.⁷⁰

Gamma-hydroxybutyrate/gamma-butyrolactone

High doses (1.25 mL – 2 mL) of GHB⁷¹ can lead to central nervous system and respiratory depression, and potentially death. Management is supportive, with airway protection and mechanical ventilation if needed. Naloxone may be given to exclude co-ingestion of an opioid, though it is not effective for reversing the effects of GHB/GBL.

Opioids

Chemsex does not usually involve opioids (depressants), but opioids may be used concomitantly and, in some cases, unintentionally (e.g. consuming stimulants contaminated by fentanyl). Management involves respiratory support and administration of naloxone. Additional information on the management of overdose is detailed in the SAHCS Harm Reduction guidelines.²

Come-down and withdrawal support

A come-down is the physical and psychological after-effects of substance use, often characterised by fatigue, mood swings, anxiety, low mood and physical discomfort. Clients who have developed tolerance for or dependence on substances may experience a withdrawal syndrome after a period of abstinence. Managing a come-down safely is crucial to reduce harm and support recovery. Guidance on come-down support is included in Online Appendix 6, Table 1-A1.

Methamphetamine

Management should focus on supportive and symptomatic treatment (e.g. anti-emetics for nausea, simple analgesics for pain, light sedatives for insomnia). Depressive symptoms may occur, and healthcare providers should be alert for and screen for the risk of suicide.

Gamma-hydroxybutyrate/gamma-butyrolactone

The come-down from GHB/GBL can involve physical and psychological symptoms such as fatigue, anxiety, depression, and in some cases, withdrawal symptoms.^14,16 Withdrawal is characterised by anxiety, agitation, tremors, insomnia, sweating and an increased heart rate. In severe withdrawal hallucinations, confusion, seizures, and delirium may occur, which can be life-threatening.¹⁴ Urgent medical attention is required in these cases. Management involves the use of benzodiazepines tailored to the individual’s symptoms and hospitalisation may be required.⁷²

Brief interventions and treating dependence

A non-judgemental, harm reduction approach should be used when engaging clients around changes in drug use. Interventions could include motivational interviewing screening brief intervention and referral to treatment, cognitive behavioural therapy, and contingency management.^{13,16,73,74,75} Additional guidance on substance use interventions are included in the SAHCS harm reduction guidelines.²

Sexual health

Sexual health interventions include encouraging safer sex, managing erectile dysfunction, and encouraging good dental and oral health.

Safer sex

Information on safer sexual practices with a lower risk of transmission (e.g. oral sex, mutual masturbation) and methods to reduce the risks of HIV and STI transmission during anal sex should be provided. Examples include:

• If ejaculation in the mouth occurs, spit out the semen and rinse mouth with water.
• Avoid oral sex in the presence of open wounds or bleeding in the mouth.
• Use condoms with compatible lubricant for anal intercourse.
• Reduce the number of sexual partners, or those with whom sex is unprotected.
• Avoid ejaculation in the anus by removal of penis before ejaculation.
• Avoid engaging in sexual practices that may cause anal lesions (e.g. fisting).
• Minimise the use of laxatives as these weaken the anal mucosa.
• Avoid sharing of sex toys.
• Avoid sharing of lubricant (write initials on bottle) and have individual towels or use disposable towels.
• Use latex gloves with water- or silicone-based lubricant.

Erectile dysfunction

GBMSM engaging in chemsex may experience erectile dysfunction, either because of prolonged sex or as a drug side effect. It is important to exclude chronic conditions and medications as causes by taking a thorough medical history. Treatment options should be discussed, including the use of a phosphodiesterase-type 5 inhibitor such as sildenafil. If a client is started on sildenafil, or other erectile dysfunction treatment medications, it is important to educate them about possible medication reactions that may cause hypotension. This includes ritonavir (maximum sildenafil dose 25 mg in 48 h), amyl nitrite (poppers) and cobicistat.

Dental and oral health

Encourage clients to maintain regular brushing and to take toothpaste, a toothbrush and mouthwash to chemsex sessions. Chewing gum can also be helpful for a dry mouth.

Cross-cutting interventions

Services for people who engage in chemsex should aim to address the intersecting risks related to substance use and sexual behaviour (Figure 1). The context in which these occur is also important. Guidance on implementing interventions that are tailored to the context of chemsex are outlined below.

Healthcare provider sensitisation and key competencies

Sensitisation of healthcare providers should include the following topics:

• Sexual orientation, gender identity and gender expression
• Transactional sex and sex work
• Drug classes, effects, risks and potential interactions
• Harm reduction, treatment interventions and referral options.

Key competencies for healthcare providers providing chemsex-related services include:

• Effective communication and ability to develop a trusting therapeutic relationship
• Knowledgeable about priority health issues relating to chemsex
• Appropriate history taking around sexuality, sexual behaviour, and drug use
• Effective counselling and engagement techniques (e.g. motivational interviewing)
• Use of appropriate screening and diagnostic tools
• Assessment triage and assessment of risks
• Joint decision-making and health management planning aligned to the client’s personal health goals.¹⁷

Planning and consent

Healthcare providers should be aware and acknowledge that a client’s ability to develop or implement harm reduction plans may be affected by substance dependence and/or a desire for chemsex. Clients should be supported to think through feasible plans to enable safer chemsex sessions. Healthcare providers should emphasise that participation in chemsex sessions does not mean that a person loses their right to choose, and control their body and sexual experiences.⁷⁶

Clients should be reminded that the ability to provide consent can be affected by substance use. Clients should be encouraged to agree with their sexual partner on acceptable sexual behaviour prior to a chemsex session. Discussions around consent should also include the taking of photos or videos.⁷⁷ It is important to remind clients that it is against the law to have sex with someone who is unconscious or asleep, which could result in sexual assault charges.⁷⁶

Self-care

Self-care is the ability of individuals, families and communities to promote and maintain their own health, prevent disease, and to cope with illness.⁷⁸ Self-care can be encouraged by healthcare providers and peers, and services can be provided in-person or online. These may include:^35,78,79

• Self-assessment questionnaires around wellbeing (e.g. Self-care-inventor⁸⁰), drug use (e.g. WHO eASSIST⁸¹) and mental health conditions (e.g. for anxiety⁸²)
• IEC materials to help clients to increase personal responsibility to reduce harms
• Self-collection of samples for STI testing, including self-testing for HIV and syphilis⁸³ (and hepatitis C, once locally available)^35,84
• ‘Sign posting’ and guiding people on how to join peer and other support groups (see Online Appendix 1, Table 1-A1), and where to access nutrition, safe housing, mental health services and other psychosocial support.

Psychosocial services

Stigma surrounding chemsex is complex, intersecting with internalised stigma and societal views on substance use, sexuality and health, and occurs at multiple levels.^{14,16,17,73,85} Stigma can result in mental health challenges, social exclusion, barriers to health and social services, and unsafe sex behaviours.^{14,16,17,73,85} Psychosocial services should be provided by trained and sensitised healthcare providers. Psychological assessment, counselling and therapy, trauma-informed care, post-violence care, crisis intervention, facilitated disclosure, and family therapy may provide benefit to clients.

Conclusion

Chemsex is a contemporary phenomenon and is becoming more common in SA. Healthcare providers should be sensitised to chemsex and be capacitated to provide supportive and evidence-based care to people who engage in chemsex. The use of a harm reduction approach that addresses risks related to substance use and sexual practices can reduce potential harms and support people to engage in safer chemsex. Online Appendix 1 includes a range of useful tools.

Acknowledgements

The authors would like to acknowledge OUT LGBT Well-being as well as the participants and facilitators involved in the values and preferences research that helped to inform this guideline. They would also like to acknowledge Dr Camilla Wattrus from the Southern African HIV Clinicians Society (SAHCS) for her support of the editing process of the guideline. The authors would like to thank Sheridan Walters for his involvement in the early phases of the project. They would also like to thank the external peer reviewers who reviewed the guideline, including Richard Kaplan, Stephane Wen-Wei Ku, and Global Chemsex Network members, Ben Collins, Jorge Flores-Aranda, Maurice Nagington, Ashwin Thind, and Charlie Dunbar-Aldred.

The authors reported that they received partial funding from the WHO South Africa and LoveAlliance, through AIDS and Rights Alliance for Southern Africa (ARASA), which may be affected by the research reported in the enclosed publication. The authors have disclosed those interests fully and have implemented an approved plan for managing any potential conflicts arising from their involvement. The terms of these funding arrangements have been reviewed and approved by the affiliated university in accordance with its policy on objectivity in research

This article followed all ethical standards for research without direct contact with human or animal subjects.

All authors, A.S., Y.A., B.B., N.C., T.C., J.H., R.M., S.M., D.N., S.S., J.S., M.S., L.X., and A.M., contributed equally to the guideline.

Development of this guideline was partially funded by the WHO South Africa and LoveAlliance, through AIDS and Rights Alliance for Southern Africa (ARASA).

The authors confirm that the data supporting the findings of this study are available within the article and its references.

The views and opinions expressed in this article are those of the authors and are the product of professional research. The article does not necessarily reflect the official policy or position of any affiliated institution, funder, agency, or that of the publisher. The authors are responsible for this article’s results, findings, and content.

References