‘Chemsex’ then and now – towards a ‘6Ws’ model for functional analysis and configurational assessment that embraces phenotypic diversity

Background: Distinguishing problematic from non-problematic chemsex, or placing experience on a continuum of severity, generates limited information about why similar drug use can lead to different experiences and support needs. We propose considering how the circumstances of an encounter work together and change over time.Method: This think piece presents a selective conceptual synthesis of chemsex research and assessment approaches, informed by minority stress theory, drug, set and setting, functional analysis, and addiction science. Empirical studies inform the domains and the proposed relationships between them.Results: Six questions (who, what, why, with, where and when) describe the person, substances, functions, relationships, settings and timing within a changing chemsex configuration. Digital activity may connect these through partner contact, planning and support, and is an important emerging consideration. Three fictional vignettes illustrate different responses to comparable exposure. The person and therapist could each map the configuration, compare accounts and identify a focus for formulation and therapy.Conclusions: Assessment should determine how pleasure, protection and harm arise through interacting circumstances. The six Ws direct attention to these relationships and to differences between the person’s and therapist’s accounts. Participatory development and longitudinal evaluation are needed to establish whether this approach improves shared understanding, decisions and care.