從事危險的「藥愛」之患者受益於適當的治療
資料來源：Marine Cygler / 2022 年 8 月 9 日 / Medscape / 財團法人台灣紅絲帶基金會編譯
法國 — 談到 chemsex，各種國際研究的結果都同意：20% 到 30% 的男男性行為者 (MSM) 從事這種做法，這種做法越來越普遍。 Chemsex 結合了性、藥物和智能手機，而醫生對此知之甚少。 2019 年秋季，在巴黎聖路易斯醫院的傳染病科進行了專門的諮詢。據估計，那裡有 1,000 名患者從事 chemsex。
醫學博士 Alexandre Aslan 是該部門的醫生之一；他還是一名性學家和心理治療師兼精神分析師。在 6 月在法國首都舉行的 ALBATROS 國際成癮大會上，他介紹了一項對從事 chemsex 並定期參加這些諮詢的患者的研究結果。透過這項研究，人們正在闡明這一現象。
Medscape 法語版邀請 Aslan 討論與這種做法相關的問題。
Medscape：chemsex 到底是什麼，也稱為 ” party ‘n’ play” (PnP)？
阿斯蘭 ( Aslan )：聽到“chemsex”這個詞，人們會自然而然地認為這就如同它所聽起來的樣子：在使用毒品時發生性行為。事實並非如此。根據科學文獻中發表的定義，藥愛性行為是男男性行為者 (MSM) 中常見的一種做法，他們在性活動期間服用一些非常特殊的物質來維持、增強或加強性體驗，但仍然「管理」與親密關係、表現和對性傳播感染 (STI) 等相關擔憂的問題。這些物質最常見的是三種藥物的混合物：GHB [γ-羥基丁酸]、卡西酮和冰毒（甲基安非他命）。在 chemsex 中，智能手機也發揮著核心作用，透過使用社交網絡和約會應用程式——這些基於位置的應用程式允許用戶立即找到伴侶。
Medscape：通過應用程式見面會以何種方式影響性關係和物質的使用？
阿斯蘭：因為約會計畫是透過這類應用程式制定的，所以經常暗示發生性行為的承諾——這甚至是在個人於現實生活見面之前。讓我解釋。這不是一種相遇或一個人打算去引發性慾。相反的，它是內在的東西——個身體內部的性「衝動」——這將驅使他們進行性活動。現在，發現自己承諾與某人發生性關係——一個你不認識、沒有交談過、也沒有真正見過的人——在一個你可能會遇到幾個人的環境中，並且在主要與色情相關的表演劇本為特徵的某些時刻發生性行為：這會促使您服用藥物，藉此您可以「放手」以達到能夠適應情況所要求的程度。為了表現得好，不被過度抑制，這些人發現這種雞尾酒式藥物混合物被證明是相當具爆炸性的，賦予了非常強的體驗興奮的能力，甚至帶來了新的性行為。
Medscape：你能談談藥物增強的性行為嗎？
阿斯蘭：我們性學家認為這是一種非常特殊的性行為。參與其中的人會覺得這種性非常地激烈，有著令人難以置信的經驗，並且與他們性伴侶的聯結更深。事實上服用這些物質，是一種會破壞性生理學原則的性行為——換句話說，慾望之後是興奮、高原、性高潮和決心。漸漸地，性愛過程中一個人的性伴侶將不再存在，其好處是一連串的性伴侶，而其唯一目的是維持興奮之火的燃燒，這種興奮也因服用的物質而增強。這是在影響下的「性」，而不是與慾望相關的性接觸。
Medscape：它對健康有什麼影響？
阿斯蘭：這種做法會帶來許多併發症，例如性傳播感染，並且會造成身體傷害，因為這些過程可能會持續 24 到 48 小時以上。還有心理併發症，因為這些藥物會導致抑鬱、偏執、自殘，甚至代償失調之發作。然後，需注意的是，後來，聚光的焦點從性——一開始的藉口——轉移到藥物使用上：個人將不再能夠將性的接觸與藥物的使用區分開來。然後，幾年後，則不再有性接觸，卻只有藥物的使用。在美國，在2021 年至 2022 年間，海洛因和處方的阿片類藥物所導致的死亡人數有所減少。但另一方面，自 2020 年以來，與芬太尼、非處方類阿片類藥物和興奮劑（可卡因和甲基安非他命）有關的藥物過量之數量激增，可回歸到特別是透過看似「好玩」的性領域的行為中。
Medscape：事情到底是如何從一種可控的行為轉變成為全面的藥物成癮呢？
阿斯蘭：你仍然會看到有人設法去讓事情受控。但這些被服用藥物的種類很容易上癮，並迫使個人服用更多。這是一個大循環：令人興奮的性關係本身，你所添加的物質導致更多的多巴胺被釋放，以及智能手機屏幕上不斷顯示令人興奮的色情圖片。在我們看到的所有患者中，我們注意到一種軌跡看起來就像經歷每種藥物的軌跡。當他們最剛開始時——換句話說，第一年——在他們經歷了被認為是爆炸性的第一次之後，他們可能不會馬上又立即回到場景，然後他們會再次回到場景。他們意識到這次可能不像第一次那麼奇妙，但他們會再試一次。在這個新奇階段，他們會採取一種策略，使他們適應並做出調整，試圖再次感受他們第一次的感受。在一兩年結束時，他們變得幻想破滅，他們重新關注與藥物使用有關的所有活動。我們的醫院部門進行了一項調查，我們向 100 多人提出了詳細的問題。結果顯示，人們注意到藥愛性行為對他們的工作（60%）、他們的私人生活和性生活（55%）以及他們與朋友和家人的關係（63%）的負面影響。這意味著人們很清楚這種做法在他們生活中非常重要的領域所產生的負面影響。但即使他們注意到了這一切，即使他們決心在不涉及藥物的情況下進行一定數量的性關係，這些物質在釋放多巴胺方面非常強大，以至於這一事實可以掃除個人可能擁有的做出決定並堅持下去之任何能力，他們實際上會感到「被迫」使用。這就是所謂的渴望。
Medscape：您如何在傳染病科的患者中識別出從事藥愛性行為的患者？
阿斯蘭：作為一項規則，我們科室收治的所有患者都會被問到一系列問題。您是否在從事性行為時使用藥物？你較喜歡哪種藥？你如何去使用它？使用時你會有好的感覺嗎？你覺得它對你有好處嗎？你使用了多少仍然覺得還好呢？我們還要求患者告訴我們他們上次進行無藥性行為的時間。這是一個非常重要的問題，因為如果我們能找出一個每月有 10 個左右的性伴侶但卻一個多月沒有進行過無藥性行為的人，我們將嘗試將對話引導到他們會來的地方認為談論它可能不是一個壞主意。
Medscape：醫生是否應該詢問年輕患者是否從事藥愛性行為？
阿斯蘭：是的，但醫生必須非常小心。我們經常傾向於相信我們有能力與我們的病人談論與性有關的相關問題。我們認為自己是那種人，更不用說我們是思想開放的。現在，就像在所有醫學領域一樣，我們必須教育自己如何最好地去接近病人——在這種情況下，關於他們的性健康。因為有時，儘管我們的意圖是最好的，我們還是會造成傷害。我們對自己的性行為的看法並不一定有助於為他人的性行為提供建議，尤其是當兩者之間存在差異時。如果你對這個問題感興趣，你需要接受所有可能出現的答案相關的培訓。網上有培訓課程。在一個網站上有一個關於性健康和藥愛的模組，旨在為私人執業醫師提供有關 PrEP 的指導。這至少是一個開始的地方。這樣，醫生就會知道他們可以問些什麼問題，以及何時應該聯繫專家，例如在這些特定問題上受過培訓的性學家。
Medscape：治療的依據是什麼？
Aslan：成癮醫學醫師採用的傳統方法可能還不夠全面。同樣，性學家的方法也只能走這麼遠。認為單一學科可以解決所有問題是不可能的。所以，這是一種多學科的性健康治療。應該有一位了解藥物並能夠駕馭這種精神疾病（例如精神病和過動症）的精神科醫生或成癮醫學醫師。
還必須有一位性學家來治療可能存在的任何性功能障礙。在聖路易斯醫院，60% 從事 chemsex 的患者表示，從事這種做法與他們在第一次使用藥物之前所注意到的性問題有關——但從未去看醫生。儘管如此，如果這些患者能夠見到性學家——他會治療這個問題——則這種藥物可能還沒有發揮作用。
還必須要有一個可以專注於降低風險的從業者。換句話說，能夠幫助患者於渴求時達到使用時所需之水平和隨時檢測以即時滿足需要的人，。
在實踐中，除此之外，有時還可以求助於藥物治療來控制渴望或合併症，這是一種基於性學的方法來為性功能障礙提供照護，甚至幫助人們學習如何喚起性慾或沒有藥物的色情幻想，以及基於成癮藥物或心理治療的方法，因為我們的一些患者在童年時期經歷過性虐待。最後，chemsex 只是外層——這個問題似乎只與性有關，但實際上，它涵蓋了廣泛的問題。不僅僅是性問題或與 chemsex 等藥物有關的問題。
Medscape：這種多學科治療的結果是什麼？
阿斯蘭：在我們結束之前，我必須指出且只說明患者，當他們得到照顧並得到適當的治療時，會改變他們的做法。 我們的一些患者，即使是那些在頻率方面更嚴重的病例，他們注射藥物的頻率——在 24 或 48 小時過程內每 30 分鐘一次，並伴有血栓形成、敗血症和膿腫等併發症——他們在治療幾個月後已經完全停止。 正如他們告訴我們的那樣，他們現在過著更適合他們的生活。 因此，我們這些從事醫療保健行業的人，我們必須組織起來，以一種能讓我們集中精力治療這些患者的方式去進行設置。本英文版譯自 Medscape 法語版
Patients Who Engage in Risky “Chemsex” Benefit From Appropriate Treatment
Marine Cygler / August 09, 2022 / Medscape
France — When it comes to chemsex, the findings of various international studies all agree: 20% to 30% of men who have sex with men (MSM) engage in this practice, which is becoming more and more prevalent. Chemsex combines sex, drugs, and smartphones, and physicians know very little about it. Dedicated consultations were instituted in the fall of 2019 at the Infectious Diseases Department at the Saint-Louis Hospital in Paris. It’s estimated that 1000 persons who were patients there practice chemsex.
Alexandre Aslan, MD, is one of the department’s physicians; he is also a sexologist and psychotherapist-psychoanalyst. At the ALBATROS International Congress of Addiction, which took place in the French capital in June, he presented the results of a study of patients who engage in chemsex and who regularly attend those consultations. Through this research, light is being shed on the phenomenon.
Medscape French Edition invited Aslan to discuss the issues connected with this practice.
Medscape: What exactly is chemsex, also known as party ‘n’ play (PnP)?
Aslan: Hearing the word “chemsex,” one would automatically think that it is what it sounds like it is: having sex while on drugs. That’s not really what it is. According to the definition that’s been published in the scientific literature, chemsex is a practice seen among men who have sex with men (MSM), where they take some very specific substances during sexual activity to sustain, enhance, or intensify the sexual experience, but also to “manage” issues related to intimacy, performance, and concerns about sexually transmitted infections (STIs). The substances are most commonly a cocktail of three drugs: GHB [gamma-hydroxybutyrate], cathinones, and crystal meth. In chemsex, smartphones play a central role as well, through the use of social networking and dating applications — those location-based apps that allow users to instantly find partners.
Medscape: In what ways does meeting through apps influence the sexual relationship and the use of substances?
Aslan: Because the plan to meet up for sex is being made through these kinds of apps, the promise to have sex is often implied — and this is before the individuals even meet up in real life. Let me explain. It’s not an encounter or a person that’s going to trigger sexual desire. Instead, it’s something within — the sexual “urge” inside of the individual — that’s going to drive them toward sexual activity. Now, finding yourself promising to have sex with someone — someone you don’t know, haven’t spoken to, and haven’t actually met — in an environment where it’s possible that you’ll meet several people and where the moments in which the sexual acts take place are predominantly characterized by pornography-related performance scripts: this can push you to take substances so you can “let go” and get to the point where you’re able to adapt to the requirements of the situation. Seeking to perform well and to not be overly inhibited, these individuals have found that this drug cocktail proves to be quite explosive, imparting a very strong capacity for experiencing excitement and even bringing about new sexual practices.
Medscape: Can you speak a bit about drug-enhanced sex?
Aslan: We sexologists consider it to be a very particular type of sex. People who engage in it feel that the sex is very intense, with unbelievable experiences, and that they have a deeper connection with their partner. In fact, it’s a type of sex where taking these substances does away with the very principles of sexual physiology — in other words, desire followed by excitement, plateau, orgasm, and resolution. Little by little, one’s sexual partner is no longer going to exist in the sex session, and the benefit is a succession of partners whose sole purpose is to keep the fire of excitement burning, an excitement that’s also reinforced by the substances taken. It’s “sex” under the influence rather than a sexual encounter linked to desire.
Medscape: What impact does it have on health?
Aslan: This practice brings with it numerous complications, such as STIs, but also physical injuries, as these sessions can last for 24 to more than 48 hours. There are also psychological complications, because these drugs can bring about depression, paranoia, self-harm, and even episodes of decompensation. And then, it should be noted that later on, the spotlight gets pulled away from the sex — the pretext from the very beginning — and shifts toward the taking of drugs: the individuals will no longer be able to separate the sexual encounter from the taking of drugs. Then, in a few years, there’s no longer the sexual encounter, only the taking of drugs. In the United States, between 2021 and 2022, there was a decrease in the number of deaths caused by heroin and prescription opioids. On the other hand, since 2020, the overdoses that have exploded in number are those related to fentanyl, nonprescription opioids, and stimulants — cocaine and methamphetamine, which can come back into the practices particularly through the seemingly “playful” arena of sex.
Medscape: How is it that things have gone from being a practice that’s under control to full-on drug addiction?
Aslan: You still have people who manage to keep things under control. But the kinds of drugs that are taken are highly addictive and compel the individual to take even more. It’s one big circle: the exciting sexual relationship itself, to which you add substances that cause even more dopamine to be released, and a smartphone screen with excitatory pornographic images on it all the time. In all the patients we see, we notice a trajectory that looks like the trajectory of every drug. When they’re at the beginning — in other words, the first year — after a first experience that they consider to be explosive, they may not return to the scene right away, and then they do return to it. They realize that it’s perhaps not as marvelous as the first time, but they’re going to give it another try. During this novelty phase, a strategy is pursued whereby they adapt and make adjustments in an attempt to feel again what they felt the first time. At the end of a year or two, they become disillusioned and they refocus on all activities having to do with drug use. Our hospital department conducted a survey where we asked detailed questions to over 100 individuals. It showed that people noticed the negative consequences that chemsex had on their work (60%), on their private lives and sex lives (55%), and on their relationships with friends and family (63%). This means that people are well aware of the negative effects that this practice has in very important areas of their lives. But even if they notice all of that, even if they resolve to have a certain number of sexual relations without drugs involved, these substances are so powerful in releasing a rush of dopamine that that very fact can sweep away any capacity the individual may have had to make a decision and stick to it, and they’re going to feel practically “compelled” to use. This is what’s called a craving.
Medscape: How do you identify patients who engage in chemsex among the patients in your infectious diseases department?
Aslan: As a rule, all patients admitted to our department are asked a series of questions. Do you use drugs to engage in sexual relations? Which drug do you prefer? How do you take it? Do you have a good time? Do you find that it’s good for you? Are you okay with how much you’re using? We also ask patients to tell us when they last had drug-free sex. It’s a very important question, because if we can identify someone who has had 10 or so partners a month but hasn’t had drug-free sex for over a month, we’ll try to steer the conversation to where they’ll come to think that it might not be such a bad idea to talk about it.
Medscape: Should a physician be asking younger patients whether they’re engaging in chemsex?
Aslan: Yes, but the physician has to be very careful. We often have a tendency to believe that we’re capable of speaking with our patients about relevant matters related to sex. We see ourselves as that kind of person, not to mention we’re open-minded. Now, as in all fields of medicine, we have to educate ourselves about how best to approach patients — in this case, about their sexual health. Because sometimes, despite our best intentions, we can do harm. The idea that we have of our own sexual behavior does not necessarily help provide counsel regarding another person’s sexual behavior, particularly when there are differences between the two. If you’re interested in the issue, you need to be trained on all the answers that could come up. There are training courses online. There’s a module on sexual health and chemsex at a site designed to give private practice physicians guidance about PrEP. It’s at least a place to start. This way, physicians will know what questions they can ask and when they should reach out to a specialist, such as a sexologist with training in these specific issues.
Medscape: What is the treatment based on?
Aslan: The traditional approach taken by addiction medicine physicians may not be comprehensive enough. Likewise, a sexologist’s approach alone can only go so far. It’s impossible to get by thinking that a single discipline can hold the solution, all the answers. So, it’s a multidisciplinary sexual health treatment. There should be a psychiatrist or addiction medicine physician who knows the drugs and is capable of navigating through this landscape of psychiatric comorbidities (such as psychoses and ADHD).
There also has to be a sexologist for the treatment of any sexual dysfunctions there may be. At Saint-Louis Hospital, 60% of patients who engage in chemsex said that engaging in the practice was related to a sexual problem that they noted — but never went to see a doctor about — before the first time they used. Be that as it may, it’s still the case that if these patients had been able to see a sexologist — who would have treated the problem — the drug may perhaps not have taken hold.
There also has to be a practitioner who can focus on risk reduction. In other words, someone capable of helping the patient get to the desired level of use where the craving, the need for instant gratification, can be kept in check.
In practice, one can sometimes, in addition to all of that, turn to medical treatments to manage the craving or medical comorbidities, an approach based on sexology to provide care for the sexual dysfunction or even to help the person learn how to evoke sexual or erotic fantasies without drugs, and an approach based on addiction medicine or psychotherapy, as some of our patients experienced sexual abuse in childhood. In the end, chemsex is just the outer layer — a problem that only seems to pertain to sex but that, in reality, covers up a wide range of issues. And not only sexual issues or issues that are related to drugs like chemsex is.
Medscape: What are the outcomes of this multidisciplinary treatment?
Aslan: Before we finish, I must point out and just state that the patients, when they’re cared for and when they’re provided with the appropriate treatment, change their practices. Some of our patients, even those with more advanced cases in terms of frequency, how often they’re injecting drugs — every 30 minutes over the course of 24 or 48 hours, with complications such as thrombosis, sepsis, and abscesses — they’ve completely stopped after several months of treatment. They now lead lives that, as they’ve told us, work better for them. So, those of us in the healthcare industry, we have to get organized and set things up in a way that will allow us to focus our efforts on treating these patients.
This article was translated from the Medscape French edition.