Chemsex, HIV and gay men: an object relations perspective

There is growing concern and controversy surrounding the rise of ‘chemsex’ – the use of psychoactive drugs during sex – among gay men. Concern centres on public health implications and the social costs of treatment, while the controversy relates to its psychological origins and appropriate interventions. Chemsex promotes disinhibition, confidence, libido and a sense of belonging; yet carries significant risks including sexually transmitted infections, mental illness, and death. Its use is often interpreted as a response to the historically homonegative social context of being gay, and the traumatic impact of the HIV pandemic. Although new HIV therapies may reduce fear of infection, research suggests that an HIV diagnosis remains traumatic for gay men, reinforcing anxiety about social acceptance. Chemsex can be understood at both individual and social levels through Fairbairn’s object relations theory. The social context may be conceptualised as a dynamic of libidinal and anti-libidinal social forces or ‘bad objects’, with the HIV pandemic symbolising a ‘traumatic release of bad objects’. For some gay men, this context precipitates release of repressed bad object relations rooted in early homophobic familial and communal experience. This fosters identification with bad objects and acceptance of the ‘burden of badness’. Such dynamics create an ‘internal saboteur’, which directs aggression towards the object and the self for being exciting and needy, respectively. Thus, gay intimacy may be unconsciously sabotaged or permitted only with punitive consequence. This pattern appears in a growing subgroup of gay men who seek intimacy through the potentially damaging route of chemsex, as illustrated in a case vignette. The article encourages debate around formulation, intervention and resource. Therapies, while being affirmative, should not only support clients in addressing negative beliefs and social stigma, but also aim to integrate repressed bad object relations and associated feelings.