Drugs and sex (including chemsex) and compulsive sexual behaviour: a clinical view

The relationship between drugs and sex is not new, and it is not, at face value, a problem. People have been using substances to enhance sexual experience for as long as both have existed. In modern recreational life, particularly among younger adults, exploration of substances and exploration of sexuality have often run alongside each other. That is true across generations and across populations, and the starting position in the work we do with men around this is to acknowledge it openly rather than pretend it is not the case.

Many of the men I see for the first time on this subject will say something like this. I've had the best sex of my life using drugs. The sex I had on certain substances completely changed what I thought sex could be. It allowed me to feel adventurous, excited, free. I felt connected in ways I had never felt sober. That is real. It is not the part of the story that gets reported in the media or in most therapeutic models. But it is the part that explains why the men I see started, and why they kept going.

I am not glamorising sexualised drug use. There are real and often severe consequences when it goes wrong, and I will get to those. But to understand why men become caught in patterns that hurt them, you have to understand first what those patterns were originally giving them. Drug use in sex usually starts as enhancement. As a way to reduce inhibition. As a way to push past shame or self-consciousness. As a route to connection that felt unreachable any other way. Recognising that, and not skipping over it, is the first move in doing this work honestly.

In over ten years working in NHS sexual health services, across compulsive sexual behaviour, drugs and sex (including chemsex), and what some clinicians call sex addiction, and across the outcomes we have now published in peer-reviewed work, I have come to think that the way this territory is usually treated in healthcare misses the point for most of the men I see. This piece is about why, and about what works better.

When it stops feeling like a choice

The men I see do not typically arrive at my clinic the first time they have used drugs in sex. They arrive much further down a road than that. They arrive at the point where what once felt like enhancement, or fun, or freedom, has started to take from them more than it gives.

The shift is not usually dramatic. It tends to be a slow erosion across months or years. The consequences accumulate in different places. Physically, the long comedowns and the toll on sleep and the body. Psychologically, the anxiety, the low mood that builds on the rebound days, the sense of something being wrong that has not yet been named. Socially, the friendships that begin to drift because the lost weekends, missing important events, making excuses to avoid plans and prioritise sex and using. Financially, the cost of substances, of paid sex, of the rolling hotel rooms. Relationally, the partner who can feel that something is being held back. Professionally, the missed mornings and the disengaged afternoons, the eventual inability to keep up.

And then a moment comes, often, where a man realises that what he has been doing is not actually something he is choosing any more. It is something that is happening to him. That moment is hard to describe in the abstract. It lands differently for different men. But when it lands, the question changes. It is no longer I do this and I enjoy it and I should be able to stop whenever I want to. It is I cannot remember the last time this felt like a free choice.

What most treatment gets wrong

The dominant treatment framework for drugs and sex, in mainstream healthcare and in most popular writing, runs through the lens of addiction. The behaviour is named as the problem. The treatment is the elimination of the behaviour. Twelve-step programmes, abstinence-based interventions, models that derive from substance use treatment in other domains, all share the same underlying assumption: that the way out is to stop.

There is real validity to part of this picture. Substances do have pharmacological effects on the brain. Habituation and tolerance are real. The neurochemistry of repeated drug use, particularly the substances commonly involved in drugs and sex (including chemsex), does create patterns that can feel and behave very much like addiction.

But for most of the men I see, treating their behaviour purely through the addiction lens does not work, and I have come to think it can at times, actually do harm.

Treating their behaviour purely through the addiction lens does not work, and I have come to think it can at times actually do harm.

The reason is this. Drugs entered these men's sexual lives because they were doing something for them. Because they wanted to explore something. Because they had anxiety, or shame, or self-consciousness, or performance pressure, or body worries that made approaching sex sober feel impossible. Because they wanted access to a depth of connection with other men, or with women, that they had never been able to reach without something to soften the edges. The drugs were a solution, even if the solution eventually became its own problem.

Asking these men simply to stop, without addressing any of the underlying drivers that brought them to substances in the first place, almost always fails. Either the man refuses, because he can sense, often without being able to articulate it, that something he genuinely needs is being asked to be abandoned. Or he attempts abstinence and finds himself relapsing, sometimes catastrophically, because the original problem the drugs were solving is still there, untreated. Or he disengages from treatment entirely, because the clinician's prescription does not match his actual experience.

What can often be labelled addiction is, for many of the men I see, more accurately described as an adaptive coping mechanism that has stopped serving them. They found a solution that worked, in some senses, very well. The solution then began to cause its own harm. But the underlying reason the solution was reached for has not gone away, and will not go away through behavioural removal alone.

What drugs were actually doing

For most of the men I see who use drugs in sex, there is a pattern under the behaviour that becomes visible only when you slow down enough to look at it.

For some, the drugs are answering anxiety. The feeling that they cannot perform, or cannot be desirable, or cannot be in their own body, without something to take the edge off. Sober sex is exposing in ways that feel intolerable. Drugs reduce the exposure.

For some, the drugs are answering shame. The sense that the sex they want, or the body they have, or the way they are wired sexually, is somehow wrong. Drugs lift the censor and let the man briefly access parts of his own sexuality that he otherwise treats as off-limits.

For some, particularly though not exclusively for gay and bi men, the drugs are answering loneliness. There is a depth of connection in drugs and sex (including chemsex) that many of the men I see have never accessed sober. Long conversations, philosophical and political, that suddenly feel possible at three in the morning. A felt sense of being known by other men, of being inside something rather than alongside it. Of course, this can be argued to be artificial, and of course there are real questions about whether it is sustainable or genuine. But the question that emerges from these men is more interesting than that. Why is this only available to me on drugs? Why does deep connection in a sexual space feel out of reach in the rest of my life?

If you do not understand what the drugs have been giving the man, you cannot help him let go of them. You are asking him to abandon something that, however costly, was the only access he had to something he needed.

If you do not understand what the drugs have been giving the man, you cannot help him let go of them.

Two men I have been thinking about

The cases described in this essay are anonymised. Initials and identifying details have been changed throughout. Some are composites.

To make this concrete, here are two men whose work has stayed with me.

J.N. A man in his late twenties who identifies as gay. He came onto the gay scene in his early twenties, primarily through dating apps. He had not had long-term relationships before that. Drugs entered his sexual life relatively early, and they did not feel, at the time, like a problem. He enjoyed going to chillouts with other men. The conversations were interesting. They went beyond sex, into philosophy, politics, identity, the shape of their own lives. He felt connected to other gay men in a way he had not previously experienced. And then sex would happen, and the connection would deepen further. From his point of view, in those years, this was not addiction. This was discovery.

By the time he came to my clinic, drugs had started taking more from him than they were giving. He was using more often than he wanted. His work was being affected. He had lost contact with his older friendships from school and university because they did not understand the world he now lived in, did not know where he disappeared to on long weekends, did not understand the comedowns. His social world had narrowed to people he used with. He used to play sports; he had stopped, because he was usually too depleted on the days the clubs met. He wanted to take up other activities; he could not, for the same reason. And when he tried to think about sex without drugs, the idea felt alien to him. It felt impossible. The version of sex he had built his adult life around did not exist sober.

K.R. A man in his early forties, heterosexual. He had been in a series of long-term relationships through his twenties and thirties, and across that whole period had occasionally used sex workers, almost always alongside cocaine. The combination felt liberating to him. Transactional, exciting, freeing. He had also used cocaine with long-term partners, and again it had felt elevating, like a way of pushing the edges of what he and his partner could do together.

What he noticed over time was that without cocaine, sex became difficult to approach. The confidence he had felt in his twenties to walk up to a new partner had quietly evaporated. By the time he came to my clinic, he was newly single, back on the dating scene, and his cocaine use had increased both socially and sexually. The cycle had become almost stereotyped. A night out. A few drinks. A few lines. An attempt to meet someone. If it did not work, the temptation to go online, contact a sex worker, find a hotel, use more. He felt trapped between two things he could not reconcile. He enjoyed the power and control of the transactional encounters. He also wanted intimacy. He wanted connection. He could no longer find a way to do either without the substance, and he could feel something of his earlier sexual self being lost in the process.

What it sounds like when it stops being a choice

I have been told two things by two different men that I think capture this moment better than anything I can write about it from a clinician's position.

One man, gay, said this to me. He had been trying to work out for himself when his pattern had crossed a line.

> "I realised this was a problem when I started to sleepwalk my way into sexual encounters. I came home from work, I sat at home, I had some dinner. I was on my own. I thought I was just going to go to bed. I opened the laptop. The next thing I knew I was in a cab. I had picked up drugs and I was going round to a guy's house. There was almost a moment where I did not remember setting up the encounter. I did not remember spending the hour on Grindr. I did not remember sending pictures. I did not even remember getting his address. I just became conscious as I was arriving at the door with the drugs in my hand."

Another man, heterosexual, said this.

> "I used to really enjoy taking drugs. I knew why I was doing it. But then one day I woke up. On my own, in my flat. Half a gram left, still using. There was no one there. There was not even any sex. It was not a choice. I felt like I needed to finish the drugs. I do not know why."

Both of these men are describing the same thing in different forms. The line gets crossed when the man can no longer remember why he is doing what he is doing. The behaviour becomes automatic. The conscious self, the part that can choose, has gone offline. What is left is the pattern, running on its own.

That is the moment I have come to listen for when men describe their use to me. Not the frequency, not the amount, not even the consequences. The moment when the choice goes missing.

Not the frequency, not the amount, not even the consequences. The moment when the choice goes missing.

Why I work this way

In the work I do with men in this territory, I do not start from abstinence. I do not start from the position that the behaviour must stop. I do not even, in the early sessions, treat the behaviour as the central problem.

I do not start from abstinence. I do not start from the position that the behaviour must stop.

I start from a different question. What has this been bringing you? What do you think you have been looking for in it? Who do you want to be sexually?

Early on in the programmes I run, those questions are often met with blank faces. I don't know who I want to be sexually. That is not evasion. That is the truth. Many of the men I see have spent so long using drugs to navigate sex that they have never had to answer the question. The substance was convenient. It meant they did not have to think about it. You could say, fairly, that drug use in sex for some of these men became the way of avoiding the harder underlying question of what kind of sexual life they actually wanted.

So we work backwards from there. Not from behaviour reduction, but from preferences. From values. From boundaries.

Not from behaviour reduction, but from preferences. From values. From boundaries.

What kinds of sex feel good to me? What turns me on, when I am not on anything? What kind of man do I want to be in a sexual space? How do I want to treat other people in sex, and how do I want them to treat me? What do I actually find pleasurable, as opposed to what I have learnt to perform? These questions sound straightforward. They are not. For many of the men I see, they are the hardest questions in the work. But they are also the only questions that lead anywhere sustainable.

Once a man has begun to develop some answer to those questions, even a partial answer, the conversation about substance use becomes possible in a way that it was not before. He can begin to look at the behaviour through the lens of his own values. Is this behaviour serving the kind of sexual life I want? Where does it fit, where does it not? And from that frame, he can make decisions about substance use that he can actually sustain. Some men decide to stop using altogether. Some decide to keep using but to change the context, the frequency, the partners, the boundaries. Some decide they want to be able to access certain kinds of sex sober that they have only ever accessed on drugs. Different men reach different conclusions. They reach them themselves, from their own frame, which is why they hold.

That is the work that matters. Pushing for abstinence first, before any of that frame is in place, almost always fails. The man does not have anything to fall back on. The drugs were doing something. If you take them away without replacing what they were doing, the pattern reasserts.

What change actually looks like

To return to the two men.

The first man, the gay man whose drug use had narrowed his life, did not stop using by the end of treatment. He did not need to. What he did was change the relationship to it. He worked out the contexts in which substance use felt aligned with the values he was developing for himself, and the contexts in which it did not. He worked out who he wanted to be using with, and around. He worked out when he wanted to be sober, particularly in encounters where the connection he wanted was emotional and not just sexual. Drugs remained part of his social life and part of his community connections at the end of the work, in a measured way. What he reclaimed was time, friendships outside the scene, the ability to play sports, the ability to think about sex sober without recoiling from it. The relationship to substances had been re-set rather than removed.

The second man, the heterosexual man with cocaine and sex workers, ended up making a different decision. He came to the conclusion that cocaine was no longer doing for him what it had once done. The fun, the sociability, the elevation, had drained out of it. What was left was a use that disconnected him from the sexual confidence he had previously valued in himself. Through the work, he focused on rebuilding that confidence. On finding ways to approach new partners that did not depend on substances. On being honest about the cost the sex workers had been having on him, financially and otherwise, and what he had been chasing in those encounters that he could begin to find in different ways. By the end of the work, his use had dropped substantially and his pattern had changed. The change had come, but not by being prescribed at the start.

Neither of these arcs would have been reachable through an abstinence-first frame. The first man would have refused. The second would have stopped, and relapsed, and felt himself a failure for it, because the question of who he actually wanted to be sexually would not yet have been addressed.

When this approach is not the right call

There are situations where the approach I am describing is not the right first move.

The first is when current substance use is severe enough that day-to-day functioning is affected. If a man's drug use is at a level where it is difficult to sustain attention through a session, hold a conversation, or get through the time between sessions without using, then specialist substance use treatment needs to come first. Therapy that works on meaning, values, and underlying drivers requires a baseline of stability that very heavy current use can make impossible. This is not a moral judgement. It is a sequencing question. Get the stability first, then the deeper work becomes possible.

The second is when there are immediate safety concerns. Patterns of use that involve significant risk to life, severe and untreated mental health difficulties alongside use, or active risk of harm to self or others, all need targeted clinical intervention first. The values-based, slower work I am describing is not a substitute for crisis care when crisis care is what is needed.

The third is when a man arrives genuinely committed to abstinence as his chosen path from the start. Some men have already done the underlying work for themselves, by whatever route, and have arrived at the clear preference to stop. In that case my job is not to slow them down with an exploratory frame they no longer need. It is to support what they have decided.

The frame I have described is for the men in the middle. The men who are caught. The men who can sense that something has gone wrong and that something needs to change, but who do not yet know what they actually want their sexual lives to look like. That is the majority of the men I see, and that is the territory most underserved by current treatment.

If you are thinking about this for yourself, or for someone in your life

If you are reading this and recognising yourself, or recognising someone in your life, a few things are worth knowing.

The first is that you do not have to commit to stopping before you ask for help. The most common reason men do not come forward is that they believe asking for help means being told they have to give up the behaviour, and they are not yet ready for that, even though they sense something needs to change. You can come into a conversation about this still using. You can come in still wanting to use. A clinician worth seeing will work with you from where you actually are, not from where they think you should already be.

The second is that the questions to ask of a potential clinician matter. Do you work from an abstinence-only frame, or are you open to working with someone who is not ready to stop? Do you understand drugs and sex (including chemsex) as a clinical area, or are you treating it as general addiction? What does the first few sessions actually look like in your practice? If a clinician's answers to those questions sound rigid, prescriptive, or moralising, they may not be the right fit. The best work in this territory is done by clinicians who can sit with the complexity of what drugs have been doing for you without either glamorising it or condemning it.

The third, if you are a partner or friend trying to support a man in this position, is that ultimatums almost never work. Demanding stoppage, threatening consequences if the behaviour continues, or trying to police use directly, will usually push the man away from help rather than toward it. The thing that actually tends to help is making space for the conversation about what the substances and the behaviour have been doing for him in his life, rather than what they are taking from him. That conversation, more than any direct pressure to stop, is what allows him to begin to see his own pattern.

The fourth is that change is rarely linear. Men who come through this work do not usually arrive at a clean endpoint. Their relationship to substances and to sex evolves over time, sometimes through more than one cycle. That is not failure. That is what change in this territory actually looks like, for most of the men I have worked with.

What this work is really for

There is a particular kind of clinical orthodoxy in this field that says drugs in sex must be eliminated, and that anything short of elimination is a compromise. I do not work that way, and the men I see do not respond to that frame.

What I work toward, with the men who come to my clinic, is the recovery of choice. Not necessarily the elimination of the behaviour, but the recovery of the consciousness behind it. The recovery of the question why am I doing this. The recovery of the answer.

Not the elimination of the behaviour, but the recovery of the consciousness behind it.

Some men, having recovered that, choose to stop using. Some choose to keep using in particular contexts, with particular care, under particular boundaries. Some choose something in between. What they share is that the choice is theirs again, and that they have done the work to know what they actually want their sexual lives to look like.

That is what the work is for. Not abstinence as a moral position. Not behaviour change as the goal. The restoration of someone's ability to recognise their own pattern, and to decide, with intent, what they want it to look like next.

Dr Michael Yates is a Clinical Psychologist, EFS-ESSM Certified Psychosexologist and COSRT-registered Sex and Relationship Therapist. He is Lead Clinician and Psychology Service Lead at 56 Dean Street, part of Chelsea and Westminster Hospital NHS Foundation Trust.