Chemsex in Lisbon? Self-Reflexivity to Uncover the Scene and Discuss the Creation of Community-Led Harm Reduction Responses Targeting Chemsex Practitioners

This essay is based in a self-reflexive collective process and intends to present the chemsex scene in Lisbon and harm reduction responses implemented to address the needs of chemsex practitioners. The analysis considered professional experiences, participant observation, literature review of the relevant data in Portugal and autoethnographic data from a chemsex practitioner and peer educator. This essay aims to present the community-led creation of a transdisciplinary collaborative network able to assess and respond to chemsex-related risks in Lisbon. Specifically, we aim to: (i) present the chemsex scenes in Lisbon; (ii) discuss the setting up and preliminary results of a collaborative network and harm reduction responses targeting chemsex practitioners. The work implemented in Lisbon demonstrates that chemsex is a global trend with localized idiosyncrasies that must be addressed when designing local tailored interventions. It also reiterated that harm reduction organizations are in a privileged position to detect, monitor and respond to emerging trends at local level. Moreover, the work implemented in Lisbon demonstrated that transdisciplinary collaborative networks, involving communities—chemsex practitioners, gay-friendly and queer venues and collectives—and professionals working in the fields of intersection of chemsex (drugs, sexual health, mental health, gender diversity, gender-based violence), can be effective in the local early detection and response to chemsex-related risks.


Introduction
At different moments in history, drug use among queer 1 men was connected with "new drugs" and emerging informal drug markets, and hypervisibilized to produce moral panic about specific drugs and sexual practices. Scientific literature and literary journalism analyzing the harms of cocaine use in Portugal in the beginning of 20th century, narrated the alleged role of this drug in generating sexual deviance and promiscuity, particularly between two specific groups of users: women and queer men (Coelho, 1931;Marques da Silva, 1926).
Other cocaine enthusiasts are the countless homosexuals who, to the shame of this country, swarm in the numerous clubs and dance halls of the specialty. Drunkards of cocaine, disgustingly dressed in feminine clothes, made up and grotesque, constitute one of the most chilling signs of the decadence of a race. 2 (Coelho, 1931, p. 115) In those times, a double alterity was created, focusing on the uses of "other" drugs (cocaine) by queer men, socially perceived as otherness. Therefore, cocaine panic contributed to increase social stigma and discrimination against queer people. In addition, negative views regarding non-heteronormative gender roles and sexuality reinforced social alarm and prohibitionist approaches toward drug use.
For 48 years, Portugal lived under an ultraconservative dictatorship. After 1974's Democratic Revolution, a kind of queer renaissance happened in Lisbon: new gay-friendly bars, nightclubs with drag shows and saunas opened, mainly in the city's central district of Príncipe Real (Afonso, 2019). These hedonistic, libertarian and creative landscapes offered safer spaces and risk-taking zones for experimenting and affirming gender and sexual identities. In this vibrant Lisbon nightlife, there were also reports of drug use among queer people, demonstrating "( . . . ) the part drugs play in the forging of queer sociabilities and practices of queer and trans world-making" (Pienaar et al., 2020a, p. 2). Drug use, sexuality and self-expression intermingled in Lisbon nightscapes of the late 1970s and the early 1980s: At night, the use of drugs and alcohol was particularly high. Sex seemed to have no taboos, bisexuality was natural, and hook up in the end of the night was the norm. (Marques, 2017, p. 32) The environment was ( . . . ) relaxed, somewhat fun, there was music, so people were dancing, or drinking, having a drink . . . ( . . . ) some blokes drank a lot, because when they would be in that [inebriated] state they would get the courage to say or do things they would not do otherwise. ( . . . ) Although it was a conditioned freedom, these were spaces of liberty. (Afonso, 2019, p. 178) In 1984, the death of António Variações, a queer pop star and part of Lisbon's queer subculture and nightlife, marked the emergence of AIDS-phobia and AIDS panic in Portugal, and the (re)pathologization of queer men (Marques, 2017). An unknown, lethal, and transmissible disease renewed ostracism, brought fear to and of queer sex, and emptied the venues (Afonso, 2019). HIV brought a long-term change in the way sociability, intimacy and sexuality are constructed and constricted, particularly among queer communities, people who use drugs, and those living with HIV.
In 2012, in the scope of the national discussion and alarmism around the new psychoactive substances (NPS) phenomenon in Portugal, one of the most sensationalist newspapers published a piece with the title "legal high kills in gay sex" (Correio da Manhã, 2012), beginning a biased public association between MSM (men who have sex with men) and NPS. In 2017, after the Portuguese National Health Agency mentioned that chemsex could be the cause of the recent hepatitis A outbreak, the first media description of chemsex was published in a large circulation newspaper in Portugal. The article highlighted weekend "parties," "multiple partners," having "all kinds of sex," using drugs that "stimulate desire, all you can think about is sex," prolonged sex until "exhaustion," and the transmission of hepatitis A (Horta, 2017).
Similar to other countries, in Portugal sexualized drug uses among MSM communities are not new. Although not all MSM use drugs, "( . . . ) drugs have been a significant component in the subcultural practices and spaces of pleasure upon which urban gay identity has been built" (Race, 2011, p. 36). In this sense, it is relevant to contextualize and analyze chemsex as a continuity of queer historic and cultural processes of building safer social spaces, sociability, intimacy and experimenting/enacting gender/sexual identities (Pienaar et al., 2020a(Pienaar et al., , 2020bRace, 2009Race, , 2011. Moreover, Portugal is not an exception regarding the social reactions to sexualized drug uses among queer communities, and more recently to chemsex. In different moments in history, specific drug use patterns among these communities were negatively amplified resulting in the (re)stigmatization, (re)pathologization and (re)marginalization of their sexualities and identities, and aggravating sex and drugs-related risks and harms (Hakim, 2019;Race, 2009). However, this social alarmism is not based in epidemiological and scientific evidence. In Portugal, few studies focused on sexual health of MSM revealed evidence of the use of chems (gamma-hydroxy butyrate-GHB, cathinones and methamphetamine) and other drugs and sexualized drug use among MSM (EMIS Network, 2019;Meireles et al., 2015;Schmidt et al., 2016;Sialon II, 2016). However, the drug use patterns of queer communities and evidence-based healthcare are absent from the major technical literature about drug use in Portugal, namely the annual report published by the General Directorate for Intervention on Addictive Behaviours and Dependencies (SICAD). In addition, the ground-breaking Portuguese Decriminalization law 3 (SICAD, n.d.) reduced problematic drug use and drug-related harm, increased access to drug treatment, decreased criminal justice overcrowding (Hughes & Stevens, 2010) and reduced the legal and health-related costs of illicit drug use (R. Gonçalves et al., 2015). A network of harm reduction services and programs were created (needle and syringe exchange, low-threshold substitution programs, drop-in centers and shelters, contact units and outreach teams) being marginalized contexts and nightlife/festival environments the main settings intervened. However, similarly to other drug responses, harm reduction approaches remained blind to gender, sexual, ethnical and citizenship status diversity. In a recent mixed-method study (Pinto et al., 2021), respondents from 26 harm reduction teams working in the drug field (from a total coverage of 32 projects co-funded by SICAD in 2019), considered that tailored services for queer people who use drugs were "scarcely available" (54.5%) or "not available" (27.3%) but "very much needed" (57.9%). In 2019, the first paper about chemsex published in Portugal (Sousela, 2019) pointed out the risks of chemsex for sexual health and mental health, highlighting that "a multidisciplinary approach based in harm reduction and treatment responses is crucial for the individual, collective and public health" (Sousela, 2019, p. 46). Yet to our knowledge, until 2019 there were only two healthrelated services directed to chemsex practitioners, both in Lisbon. A Pre-Exposure Prophylaxis (PrEP)prescription and sexually transmitted infections (STI) screening services, reserved to public hospitals and implemented in November 2017, specified sexualized drug uses as criteria to access. In addition, a collaboration between an addiction treatment team and a Sexology unit (including one of the authors of this essay), both within the public health system, offered Chemsex-specific clinical assistance from March 2018 to March 2020.
In this essay we present the chemsex scene in Lisbon and tailored responses designed to support people engaged in chemsex. We expect to contribute to a global analysis of chemsex and mapping of its local expressions by focusing in Lisbon where little research has been published. Most scientific research on chemsex is based in Anglo countries. This may establish an "Anglocentric" perspective that overlooks the scenes and practices in other locations where the criteria for chemsex may differ. The uncovering of localized practices, behaviors, agents, drugs, and technologies that emerge in a specific socio-political, economic and moral background may build a more complex, nuanced and comprehensive understanding of chemsex and its evolution in a historical and cultural context. This decentralization may also be relevant for the exchange of best practices that may increase competence in the detection, monitoring, and response to chemsex-related harms. This analysis offers an interdisciplinary self-reflexive perspective based in our experiences as harm reduction and health professionals, and [in one case] as a chemsex practitioner and peer educator. Firstly, we describe the chemsex scene in Lisbon, having as reference the internationally established definitions of this concept. Secondly, we share the process of creating a community-led chemsex-focused collaborative network in Lisbon. This transdisciplinary approach implemented capacity-building activities, chemsexspecific materials and services, and an integrated referral among organizations working in the fields of drugs, sexual health, mental health, sexual and gender diversity, and sexual violence. In the absence of specific funding to respond to chemsex-related harms, this network is a counterpublic health measure (Race, 2009) where harm reduction and participatory approaches are used as effective means to implement an alternative to the neutrality of public health responses. Finally, we will also discuss the impact of the Covid-19 pandemic in the chemsex scene and in the continuity of this work.

Method
Chemsex scenes and practices in Portugal remain under-researched. To the best of our knowledge, no earlier studies addressing chemsex prevalence, motivations, contexts and related harms was implemented in Portugal. In this sense, this analysis offers a preliminary contribution to fill this gap and present the chemsex scene in Lisbon. This essay also describes a community-led collaborative effort to respond to chemsex-related needs, based on cultural competence, a trustful referral network, and tailored harm reduction.
This analysis is based in a self-reflexive process informed by: (a) a literature review focused on drug use among MSM and queer communities in Portugal; (b) qualitative data resulting from the participant observation of discussion groups and capacity building activities implemented in the scope of the collaborative network; (c) autoethnographic inputs of one of the authors, who's been practicing chemsex for more than 5 years, and formally a peer educator since 2020. Finally, all four authors concur with process data and professional perceptions from tailored harm reduction projects, namely individual psychological support and harm reduction counseling (Consulta Kosmicare) and a peer-led counseling and support group (ChemTalks). In the absence of a specific funding to analyze chemsex in Portugal and specifically in Lisbon, the use of the data collected while building-up of a community-led integrated response was the only source of credible and updated information to analyze the scene locally. Moreover, the use of multiple sources (literature review, autoethnography and participant observation) allowed us to fill the gaps, contextualize the data and to weigh anecdotal evidence.
The authors of this essay coordinated and participated in the creation of a collaborative network of services to respond to chemsex in Lisbon. The creation of this community-led process was based in two discussion groups with professionals working in the fields of harm reduction and drug treatment, sexual health and STI prevention, mental health, gender and sexual diversity (LGBTI 4 ) and genderbased violence, sexual violence targeting male survivors, queer collectives and representatives of gayfriendly venues. The first discussion group was implemented in September 2019 with the aim of uncovering the chemsex scene in Lisbon as well as the chemsex related risks and harms and specific needs of people who engage in these sexualized drug uses. The second discussion group was held in December 2019 and was focused on the discussion and validation of a harm reduction leaflet targeting chemsex practitioners (Figure 1). Due to the lack of consent from all the participants, these discussion groups were not recorded. Since the discussion groups were in Portuguese, all the references in this essay were translated to English. The data presented is based on participant observations of inter-group interactions and discussions during these events and notes written down at the time. In addition, the authors of this paper also led capacity building activities (a 7-hour training course and a 7-hour cycle of webinars both focused on chemsex) targeting professionals working in the fields of intersection of chemsex. Data from the participant observations of these activities was also used in this analysis.
In this collective reflection, autoethnography was included as a valid method of "doing research" by considering "ethnography produced by an 'insider' or 'native' observer of his or her own cultural milieu" (Marak, 2015, p. 8). By "co-producing" research with those involved in the scenes and practices, it was possible to combine public health and user perspectives, and provide a collective, inclusive and subculturally grounded analysis of chemsex in Lisbon. One of the co-authors contributed to this essay with notes from his personal diary, describing his experiences and the chemsex scene in Lisbon (the diary excepts will be identified through the reference "CP autoethnographic notes-N"). His notes were written in English, therefore they are presented in the essay as he wrote them. Now 30 years old he identifies as a queer and gay man. He was born and grew up in Lisbon, participating in nightlife environments from his adolescence which included experimenting with drugs. He moved to London in 2014 and there began participating in chemsex scenes. In 2019, he returned to Lisbon and is collaborating as a peer educator at the NGO GAT. 6 Together with the psychiatrist co-authoring this essay, in April 2020 they implemented the first harm reduction and peer-led mutual support group designed for people who engage in chemsex in Portugal.
Through this collective self-reflection we aim at creating a preliminary analysis of chemsex scenes and practices in Lisbon, the heterogeneity of actors involved, the evolution of community-based efforts and intervention processes toward the creation or transition to chemsex-sensitive responses, and finally the impact of Covid-19. We expect this paper to contribute to the contemporaneous discussions regarding chemsex, specifically by providing data about local harm reduction approaches to respond to chemsex-related risks and harms.

Chemsex in Lisbon?
In the early 2010s, activists and harm reducers in Western Europe signaled that queer people, specifically gay men and MSM, were using "new" psychoactive substances-GHB, mephedrone, methamphetamine, ketamine-to ease, intensify, and dilate their sexual practices and experiences, a phenomenon they named chemsex (Stuart, 2019). Chemsex has since been defined as a gay and MSM-specific sexualized drug use pattern, resulting from the combination of several elements. Among these: the impact of generational traumas (e.g., the impact of HIV epidemic, external and internalized heterosexism); technological advances and the emergence of dating mobile applications (app) and its impact in the gay hook-up culture; the appearance of new drugs with effects that were considered interesting for sexual performances (chems a vernacular term to define GHB, methamphetamine and mephedrone) and idealized homonormativity (Bourne et al., 2014(Bourne et al., , 2015Florêncio, 2021;Hakim, 2019;Stuart, 2019). "Like all subcultures, chemsex cultures are social worlds brought together not only through shared consumer choices, language and rituals but also through shared spaces (whether virtual or physical) and narrations about themselves" (Florêncio, 2021, p. 9). It acts also like a pedagogy that allow the reproduction of MSM subcultures and communities of practices that express social meanings, pleasure seeking and risk taking behaviors, unsafety and ethics of care.
In this section, by using autoethnographic citations and information from our professional experiences and participant observations, we present the sexualized use of chems in Lisbon having as reference the international definitions of chemsex.
Sexualized drug uses already existed in Lisbon. Still, compared to other western-based cities chemsex seems to be a more recent and still emerging practice.
Before the three chems [GHB/GBL, mephedrone, methamphetamine], there were already sexualized uses of cocaine and MDMA. (CP autoethnographic note_1) I lived in London during 2014 and 2019, and it was there that I began using chems and participating in chemsex scenes. In 2017, I came for a few months to Lisbon, and saw a scene that was recent, smaller and less expressive. (CP autoethnographic note_2) These descriptions are consonant with the perception of the stakeholders who participated in the two discussion groups. In comparison to what was observed or heard from its main Western European scenarios (the United Kingdom, the Netherlands, Germany, France, Spain), it was inferred that chemsex practices in Portugal involved a smaller number of people and seemed to be less problematic. The emergence of chemsex in Portugal accompanied wider cultural and drug use globalization processes, but also two factors specific to MSM: Lisbon's growing appeal to gay tourists in the 2010s (or Gaytrification as defined by Costa & Pires, 2019), 7 and the experience of many Portuguese MSM as migrants or tourists within those countries.
According to our sources the predominant chems used are Bloom (local street name for cathinones) and GHB (known as "G"), together with other drugs such as ketamine, MDMA, cocaine and poppers in a polydrug use pattern. Viagra (sildenafil, an erection drug) is also used to enhance and prolong sexual practices. At this point, it is interesting to note that Bloom was one of the commercial names used for cathinones when smart shops were open, and the term became familiar throughout Portugal. After the Decree-Law 54/2013 was implemented in Portugal, the production and commercialization of 159 NPS were prohibited and their use decreased substantially among the general population. However, it seems that these drugs continued circulating among more marginalized groups, specifically among MSM and queer people. For this reason, it is not surprising that cathinones continue to circulate with the previous commercial name and packaging aesthetics previously used to advertise them in grey markets.
In a focus group implemented in Lisbon, in November 2015, in the scope of the project "NPS in Europe, 8 gal] . . . and use a substance, I dońt know the name but it is a substance they inject to increase sexual pleasure. (Vavrincicova et al., 2016, p. 28) The chemsex scene in Lisbon was hidden and difficult to understand even among organizations working directly with gay men and MSM. This may be related with the fact that these organizations were not working in the drugs field or not asking their client directly about these practices, the scene was small-scale and emergent or even that chemsex practitioners were not in contact with services or not talking about their sexualized drug uses with professionals. This absence of information about the use of NPS among this group was also evident in a Trendspotter study focused in Portugal in 2018. "One of the limitations of this study is that it was not possible to update the knowledge at this level [chemsex] from experts, in the absence of additional sources" (Lavado et al., 2018, p. 16).
Regarding the profile of people who engage in chemsex in Portugal, In Portugal, chemsex practitioners do not use the concept chemsex. They call it chems, and advertise chems on Grindr. In contrast with London's "chemsexer" homonormative profile, most Portuguese chemsex practitioners never heard about chemsex or do not define their sexualised drug uses as chemsex. The chemsex scene in Portugal is more fluid, there are more transgender on Grindr searching for chems or chemsex partners. Additionally, the chemsex practices in Portugal seem to be more private and hidden than in London. (CP autoethnographic note_4) People who engage in chemsex in Lisbon appear unfamiliar with the concept of chemsex. Instead, they use chems in their search for partners or even in their search for people with drugs to participate in the sessions they are organizing. Stardust et al. (2018) also found that chemsex practitioners in Sydney use different references and terms to define and search for chemsex encounters, reinforcing the need to engage with these communities in order to understand the slang and social meanings they build around their sexualized drug use practices. Furthermore, according to our sources, and similarly to what is described by other authors (Hakim, 2019;Race, 2015;Stardust et al., 2018), hook-up mobile applications play a crucial role in mediating the organization and access to chemsex sessions in Lisbon. According to Race (2015), these "online hook-up devices" are central infrastructures in the mediation of the sexual encounters and in producing and reproducing gay sexual cultures. "These devices and practices are participating in the construction of a specific sphere of sociability and amiable acquaintance among men in urban centers that prioritizes sex as a principle mechanism for connection and sociability" (Race, 2015, p. 271). In addition, according to Santos (2020) these apps also (re)produce a homonormative culture that is exclusionary and prioritizes young, white cisgender men, with toned and muscular bodies (Santos, 2020). However, according to our sources, in Lisbon there are also transgender and non-binary people participating in these scenes, and searching for chemsex hook-up using these apps. In this sense, and considering the data we have, we cannot assume that in Lisbon chemsex scenes and sexualized uses of chems are MSM-exclusive. Chemsex is a cultural construction that congregates slightly different forms of sexualized drug uses, group dynamics, settings, motivations and risks. Santoro et al. (2020) identified four different types of chemsex sessions: "anonymous sessions," "chill-sex," "chemsex in saunas or in other sex or premise venues" and "semi-closed parties among networks of friends." They concluded that there are different forms of practicing chemsex, and variations in the sex dynamics, characteristics of the participants (e.g., age), patterns of drug use and different levels of care and exposure to risk. The risk is higher in anonymous and transactional chemsex scenes. In Lisbon, according to our sources, despite some sessions taking place in saunas and other types of sex clubs, but also in nightlife venues, chemsex tends to be hidden and private, and the participants may be defined as hard to reach. Most chemsex encounters are held in residential settings, usually hosted by someone who lives alone and can afford to pay for the substances for the guests. In anonymous and disengaged drug use contexts, just like many of the chemsex scenes reported in Lisbon before and especially during the Covid-19 pandemic, there's a higher risk of increased substance dosages, unattended adverse effects, and lack (or even denial) of assistance in accessing emergency care. Furthermore, the generalized disapproval of drug use by friends, queer peers, and family members, reinforces the stigma and pushes chemsex to clandestinity. In early 2018, sexual health and drug interveners and clinicians close to the MSM community noticed an increase in episodes of medical emergencies related to GHB and cathinones, and in users asking for help to deal with their chems-use and related harms. Problematic chemsex cases led to the creation of a synergy between the therapeutic fields of addictology 9 and sexology 10 to create a tailored clinical intervention (the first project in Portugal with such characteristics).
At Lisbon, global chemsex scenes are not merely being reproduced locally. Instead there is a localized subcultural construction around sexualized uses of chems. At this point, considering that chemsex was defined having the London scene as reference, it is worth asking: is that original definition a good representation of chemsex cultures emerging elsewhere? Should we even use the term "chemsex" to define the Lisbon chems' scene? According to Hibbert et al. (2021), it is more suitable to use local definitions of chemsex to understand the social meaning of these practices in a specific localization, instead of using a universal definition that can be exclusionary and contribute to obscure the cultural-specific practices that emerge locally. However, we believe that the use of the term "chemsex" in scientific and professional spheres can be helpful in the identification and discussion of global and local cultural sexualized chems' use patterns. From our side, the existence of international definitions and discussions around chemsex enabled us to look at the scenes at Lisbon and identify a subculture around chems that we recognize and define as chemsex. In addition, the international evidences was crucial to inform us in the design and implementation of community-based responses to support people who engage in chemsex.
It's worth noting that despite the scene in Lisbon being more recent and, at the moment, not as problematic and prevalent as in other European cities, we felt it was crucial to respond to the emerging risks and harms related to this practice. With this in mind, in 2019 we began a community-based collaborative work led by services working in the drugs, sexual and mental health, that resulted in a chemsex-aware and trustful referral network and in two specific harm reduction responses targeting people who are challenged or impacted by their chemsex practices. This collaborative work was crucial to shed light on the local chemsex scenes in Lisbon, mobilize resources and inform the design of community-led tailored responses targeting chemsex practitioners. The process of building this network and some considerations regarding its relevance to respond to chemsex-related risks in Lisbon is discussed in the next section.

Creation of a Collaborative Community-Led Network in Lisbon
Chemsex has become a frequent topic concerning health risks among MSM, regarding medical emergencies, interpersonal violence, sexually transmitted infections, anxiety or depressive syndromes, and drug addiction (Bourne et al., 2015;Silva et al., 2019;Stuart, 2019). Qualitative research and grounded expertise have pointed out pre-existing sexual health and mental health difficulties, connected with minority stress, sexual and gender normativity, sex work and/or living with HIV, that could be inflaming both the interest for chemsex and the challenges posed by it (Bourne et al., 2014(Bourne et al., , 2015. All of these are critical issues and it is crucial that chemsex practitioners find appropriate support when facing these challenges. We also considered the intersectional character of chemsex when designing a community-based tailored approach to provide or refer to diverse health interventions adjusted to the continuum of risks and harms experiences by people who engage in chemsex. As in many countries, in Portugal funding available to promote prevention and harm reduction in the fields of sexual health, drug use with at-risk populations (MSM, people who use drugs, transgender, sex workers) tends to be managed by different governmental organizations. 11 This atomized and segregated funding logic obstructs the creation of specific and tailored interventions addressing intersecting topics as chemsex. The creation of a specific response targeting chemsex practitioners in Lisbon was a bottom-up process based in a transdisciplinary collaborative network among different civil society organizations, collectives, and other key-stakeholders. The work implemented was based in participatory methods, including and considering the perspectives and perceptions of several stakeholders in building a common and culturally grounded knowledge about chemsex in Lisbon and discussing tailored intervention approaches targeting people who engage in chemsex.
Harm reduction was the core approach guiding the perspectives and intervention strategies designed to respond to chemsex in Lisbon. By using this framework, we intentionally address potential risks and harms related to chemsex, but also the consumers' embodied experiences of intoxication and "the pleasures, benefits and transformative value of drug use" (Pienaar et al., 2020a, p. 155). The consideration and acknowledgment of the beneficial aspects of chemsex for consumers counterbalances the hegemonic media and clinical perspectives that describe this practice as inherently deviant and selfdestructive (Hakim, 2019;Race, 2015). As discussed before, the risks related to chemsex are undeniable. However not all people who engage in this practice experience harm. For some the use of drugs can be a solution to escape oppressive norms surrounding sexual orientation and/or desire, produce gender and sexual liberation and/or to enhance sex, erotic desire and pleasure (Pienaar et al., 2020a;Race, 2009Race, , 2015. By considering pleasure and benefits, harm reduction is a counterpublic health approach (Race, 2009), since it moves beyond abstinence-only and other intervention responses that conceptualizes the search for pleasure as a threat to health and safety. Alternatively, this approach values and legitimizes pleasure as a valuable and legitimate experience in sexual practices and drug use. By integrating these experiences in the promotion of safety practices, they tend to be more effective and responsive than conventional risk-centered public health responses.
In April 2019, Kosmicare 12 found drug use practices that were specific to MSM and queer scenes, and felt the need to adapt their intervention. The use of cathinones and GHB was apparently uncommon in the mainstream and even underground club and festival scenes. However, they were the central drugs to the chemsex scenes and queer raves, putting Lisbon's queer communities in the role of "early adopters of drug trends" (Measham et al., 2011, in Bourne et al., 2015. Kosmicare moved to adapt their practices, and to produce chemsex-specific harm reduction contents and services. It's worth noting we found differences in the "more traditional" cisgender gay and MSM scenes and queer scenes. In both contexts the use of GHB and, particularly, dealing with G intoxication was challenging and identified as a key-area for our intervention. Each group had a contrasting view of GHB use. While more traditional gay scenes used repressive, "G-exceptionalism" and zero-tolerance policies toward G, banning its use and expelling its users, queer scenes were aligned with care and harm reduction (Blanchard, 2020). In their harm reduction work in Australia, ACON Rovers found the same contrasting reactions to GHB problems in queer environments (D. M. Gonçalves et al., 2016). Considering that repressive approaches increase the risks regarding GHB dosing, this project began implementing a volunteer team of "drug rovers" circulating in queer dance parties in order to detect and care for people facing drug-related difficulties. Kosmicare's approach to respond to GHB challenges was based on harm reduction awareness among the staff and patrons of gay and queer scenes. A specific training for managers and professionals working in "more traditional" gay scenes was planned to suggest them the implementation of harm reduction and care strategies in their venues, but this activity was suspended due to Covid-19 pandemic. In queer scenes, Kosmicare participated in two peer education activities during the parties, the first in December 2019 discussed harm reduction, intoxication, and crisis management. The second in January 2020 was focused on GHB-related harms and harm reduction. These talks aimed to increase the harm reduction and crisis management competency among the staff and participants. It's worth noting that these talks were advertised in the line-up to each party (before the first music began) demonstrating the willingness of the events' organization to implement harm reduction principles. Kosmicare's ongoing inclusion of specific responses for queer people who use drugs has increasingly signaled it as a queer-friendly organization in Lisbon. This promotes the access of clients to other services, namely drug checking, allowing the early detection of new drugs in the scenes. In the past year, Kosmicare's drug checking laboratory received samples submitted as mephedrone (4-MMC) and metaphedrone (known as 3-MMC), some of them from queer users. In this sense, this work allowed us to reach hidden and hard-to-reach groups and promote access to chemsex-aware community-based health and social services.
In early 2019, Kosmicare 12 established a strategic partnership with CheckpointLx, 13 a communitybased STI screening and diagnostic center for MSM by GAT, an NGO focused in HIV and hepatitis C prevention and treatment. Kosmicare then led a participatory process, already described, in order to characterize chemsex in Lisbon, collectively reflect about harm reduction needs, and design a harm reduction campaign focused on chemsex.
From there, a broader chemsex collaborative network evolved: ChemsexLX. 14 In addition to Kosmicare and CheckpointLx, it included partnerships formed during this previous process: two NGOs working in the fields of gender diversity and gender-based violence, 15 an NGO supporting men that survived sexual violence, and a representative from the city council. A new partner also joined the initiative: the abovementioned clinical program by addictologists and sexologists. 16 Through a transdisciplinary approach, interinstitutional liaison, and peer representation, Chem-sexLX encompasses the fields of sexual health, drug use, gender and sexual diversity, gender-based violence, queer leisure environments, and queer subcultures. ChemsexLX aims: (a) to raise awareness among people who engage in chemsex of the risks related to chemsex; (b) to monitor the evolution of chemsex scenes in Lisbon; (c) to promote harm reduction among chemsex practitioners; (d) to develop an integrated referral network of services able to respond to these consumers needs, including safer drug use and safer sex materials, drug checking, psychological support and harm reduction counseling (regarding drug use, sexual practices, and mental health), STI screening, diagnosis and treatment, mental health support, and clinical interventions; (e) to allow chemsex practitioners to use those services in an easy, client-centered way, through mutual referrals; and (f) to allow these clients to access non-chemsex-specific services that may be of use, such as legal counseling regarding LGBTQIA-phobic or HIV-phobic discrimination, support for victims of violence, and mental health support adjusted to minority stress.
ChemsexLX members wrote several articles for a queer-oriented online newspaper, highlighting major aspects about queer sexualized drug use, chemsex, risk reduction, and available resources. It is important to clarify that the dissemination strategy of the chemsex campaign and dissemination of the leaflet (Figure 1), posters, and informative contents, was targeted. The campaign reached its intended audience and, as much as possible, only them to avoid the risk of creating alarmism, and consequently, to aggravate the stigmatization and marginalization of non-heterosexual groups.
ChemsexLX also implemented capacity-building activities targeting health and social professionals, regarding chemsex and the needs of people who engage in chemsex. First held on March 2020 as a 1-day course, and later adapted to the Covid-19 pandemic as a series of webinars throughout June 2020. Each dealt with different topics, specifically: (a) an introduction to the concept of chemsex; (b) chemsex-responsive harm reduction and treatment practices in the fields of drugs and sexual health; (c) chemsex and sexual violence; and (d) chemsex during the Covid-19 pandemic. A total of 76 professionals, from different areas intersecting chemsex participated in these training activities. Each activity had trainers from the ChemsexLX network, experienced in the topics being discussed. More than uniquely presenting chemsex as a problematic practice, and the challenges to the intervention in the drugs and health field, these capacity building activities embraced a gender-aware, cultural-sensitive and comprehensive perspective to destigmatize the practice and its users.

Chemsex Throughout the Covid-19 Pandemic
The Covid-19 pandemic hit Portugal in March 2020, the date of the country's first lockdown, (for most activities) of 4 months. Some harm reduction outreach services were suspended for a few weeks. Others were converted to remote interventions through phone and video calls. In April 2020, after an interruption of 3 months, the abovementioned clinical response for chemsex was reorganized, and reopened via remote appointments. GAT Intendente, a sexual health clinic also from GAT that caters to sex workers and undocumented migrants-some of them engaging in chemsex-responded to a sudden mental health crisis among sex workers by providing free psychiatric appointments by one of the co-authors. From May 2020, all harm reduction services reopened, namely visits for counseling and STI testing.
Lockdowns, the loss of economic and spatial autonomy, the closer contact with families of origin, the return to less cosmopolitan locations, among other factors, have burdened MSM and queer people since the beginning of the Covid-19 pandemic (Gato et al., 2020;Sousa et al., 2021). Almost all sociability and community venues, such as bars, nightlife clubs, queer saunas, Pride rallies, and queer parties and events, were temporarily or permanently shut down from March 2020. Nightclubs and nightlife bars, together with MSM and queer venues and events, remained mostly closed until October 2021. Throughout the pandemic, collectives, activists, and other queer people created and sustained online support, online sociability, and basic economic support networks. Such resilience resonates with previous processes of identity and community building through collective action (Carneiro, 2009;Pienaar et al., 2020b). On the other hand, the pandemic expanded discussions in Portuguese society regarding mental health, including within the queer community, albeit online. During the lockdowns, chemsex in private residences were the only offline spaces allowing for MSM and queer people to meet each other in a queer-, sex-, and drug-inclusive way. Chemsex' main elements remained available: drugs (to some, without the requirement of paying for them), people interested in doing it, private residences, "hook-up" apps, and most importantly, free time (or flexible working schedules). It provided pleasures, relaxation, socializing with peers, eroticism and self-satisfaction that, for some, seemed otherwise unreachable throughout the pandemic, but especially during the lockdowns .
A characterization in Portugal during the first months of the pandemic, revealed that chemsex practitioners frequently engaged in group practices, were on PrEP, did not use condoms, and were tested for Covid-19 . Methamphetamine and sexualized stimulant injection became more popular throughout 2020 and 2021. Their emergence was first observed by chemsex-oriented services in late 2019. Because it's expensive and hard to find, the use of methamphetamine seems to reproduce class-based power imbalances in the scene, where some consumers in a subordinate relationship with those who can afford for this drug. That was also noted in the autoethnography: After years living in Lisbon and spending brief periods in Portugal, I returned definitely to Lisbon in September 2019. The scene was different. More people participating in chemsex and searching for chems on Grindr. It's still rarel, but there were also more people using methamphetamines, mainly those with more money since here they are very expensive and harder to find. Street dealers are not selling this drug and there is a strong dependency on a few dealers, only accessible by personal contacts or on Grindr. (CP autoethnographic note_3) Chemsex residential contexts are, by definition, hard to reach for harm reduction services. Their predominance during this pandemic made harm reduction in chemsex even more dependent on raising awareness and promoting skills among people who engage in chemsex, both for self-care and for informing and supporting peers. ChemsexLX facilitated the emergence of interinstitutional collaborations for a broad harm reduction response during the pandemic: (1) from July 2020, GAT trained a harm reduction intervener who is, to our knowledge, the only one doing peer work with chemsex practitioners in those residential settings; (2) in September 2020, Kosmicare enrolled a psychiatrist involved in the abovementioned chemsex-specific clinical unit, so that people who engage in chemsex could find specific an web-based psychological support and harm reduction counseling; (3) in May 2021, the two started ChemTalks, an online peer-led and support group for sharing experiences, reflecting about the scenes and discussing harm reduction strategies. ChemTalks were publicized through its parent organizations, GAT and Kosmicare, and also in an online newspaper for LGBTI people. Interested persons could contact ChemTalks through email to arrange a counseling session with the psychiatrist. After discussion of their concerns, each chemsex practitioner was directed to the most suitable resources, including ChemTalks. Until the end of November 2021, nine people contacted ChemTalks, six of them decided to join ChemTalks, and nine sessions were held, lasting 1 hour each.
From September 2020 to November 2021, Kosmicare provided counseling to 15 MSM (aged 21 to 51, eight of them migrants), a total of 21 appointments. They reached out through Kosmicare's email address and social media, CheckpointLx, their interest to join ChemTalks, and, in two cases, a therapist who knew about this service. They were concerned about their use of cathinones (n ¼ 9), injection of stimulants or slamming (n ¼ 6), methamphetamine (n ¼ 4), GHB (n ¼ 4), and ketamine (n ¼ 1), and self-reported sexual compulsivity (n ¼ 1). Support mainly consisted of information about chems and harm reduction strategies-including Kosmicare's drug checking service and collecting harm reduction kits at the drop-in-managing a psychoactive crisis or unwelcomed effects, and improving their mental health. One of them wished to prepare for a first experience with GHB; another reached out just after an overdose with GHB. Some were informed about and referred to the DiverGENTE clinical unit (n ¼ 9), GAT resources for sex workers (n ¼ 1), GAT's mutual support group for MSM who live with HIV (n ¼ 1), and ChemTalks (n ¼ 4).
Additionally, after the training for professionals working in the fields of drugs, sexual health, gender diversity and gender-based violence, we received contacts from colleagues asking for support to deal with specific chemsex-related cases in their care. One such professional with long experience dealing with people who use drugs acknowledged she was able to support one chemsex practitioner because of the knowledge and competence acquired during the training provided by Kosmicare and ChemsexLx.
In this sense, the ChemsexLx network was a bottom-up initiative that undoubtedly identified specific needs of people engaged in chemsex and to develop specific, integrated and articulated community-based responses to support them. It is relevant to add that the creation of this response was not planned-in the beginning the idea was merely to implement a tailored harm reduction campaign targeting chemsex practitioners-but evolved with the uncovering of the scene and the articulation of the diverse stakeholders.
At Kosmicare, apart from specific harm reduction and psychological support for chemsex practitioners, it was essential to create a trustful referral network, with services able to respond to several chemsex-related needs. And, above all, to have a cultural sensitive approach to these sexualized drug uses.
Additionally, this experience in Lisbon was also very relevant since it contributed to highlight that drug use is not a neutral field. Integrated interventions must acknowledge the diversity of profiles, drug use patterns, social determinants and subcultural dimensions of people who use drugs. This community-led organized process was also important to raise awareness of governmental institutions for chemsex. In this sense, in October 2020, the General Directorate for Intervention in Addictive Behaviours and Dependencies (SICAD) organized a webinar about "Chemsex interventions in Lisbon," 17 with the participation of three of us. After this webinar, SICAD invited three representatives of ChemsexLx (including two of the authors of this essay) to prepare a certified 21 hour training course under the topic "Gender and sexual diversity in Addictive Behaviours and Dependencies," 18 including a module about chemsex. This training course was held online in June 2021 and 24 professionals (from a total of 28 registrants) working in the drugs field completed the training.
The integrated intervention implemented in Lisbon was effective in the detection of chemsex scenes and emerging risk-taking behaviors and in creating tailored responses that are increasingly recognized by those engaged in chemsex as trustful and helpful. By allowing honest conversations about chemsex in a non-judgmental environment, our intervention demonstrated that harm reduction is better able to respond effectively to chemsex than generic health services (Bourne et al., 2015).
The work in Lisbon has similarities with other chemsex harm reduction projects in, specifically by combining interventions at individual and community levels and emphasizing subculturally grounded risk reduction, harm minimization and peer education (D. M. Gonçalves et al., 2016;Stardust et al., 2018). Similarly to ACON's intervention in Sidney (Stardust et al., 2018), our approach was also multidimensional, integrating direct client services for those who are struggling with their chems' use or chemsex experiences; raising awareness and health promotion activities and a wider partnership with other organizations. We believe the innovation of our approach was the creation of a transdisciplinary collaborative network. A collective dialogue, capacity-building and mutual referral process is better able to detect and monitor new trends among gay men, MSM and other queer communities, and respond to their diverse and intersecting needs. Bourne et al. (2015) suggest that tailored interventions to respond to chemsex-related risks must integrate sexual health and drug education. We consider this the beginning of an intersectional work that must be wider. In chemsex, issues regarding masculinity, sexual and gender diversity, sexual violence and other forms of gender-based violence, mental health must be considered. These are intrinsically related with risk-taking behaviors, self-determination and cultural (re)production of social and sexual environments.
This experience showed that even in the absence of specific funding or governmental support, civil society is able to respond to emerging trends at the local level. Lacking a tailored response, the community-based collaboration in the intersecting fields of chemsex can be effective to respond to the needs of chemsex practitioners.
Finally, considering the continuity of the ChemsexLx collaborative network, there are several areas to invest in the future. Slamming is a growing trend, and an increasingly segregated practice in Lisbon chemsex scenes. There is also the need to explore GHB regarding the increasing number of intoxication and emergency situations. In this sense, it is relevant to produce harm reduction materials and contents addressing these uses (e.g., leaflets with safer drug use information, specific material for safer injection and for dosing). Peer education can also be a powerful approach to promote safer drug uses and care practices among these communities. Therefore, the work implemented by the harm reduction and mutual support group can be a powerful tool to promote peer-led education in chemsex scenes. However, in the absence of a specific funding, the investment in this field is an additional effort and these organizations and professionals struggle to dedicate time and resources to this work and to justify these investments in the scope of the priorities of the funding they receive. "Local authorities, particularly those with large populations of gay and bisexual men, need to consider joint commissioning structures across public health areas for gay men engaging in chemsex so that the acute harm reduction needs of this population do not fall between the gaps of current commissioning practice" (Bourne et al., 2015, p. 15).

Conclusion
In this essay, we described the chemsex scenes in Lisbon having as reference the international definitions of chemsex. In Lisbon, the scene was detected later and seems to be smaller and less problematic. Similarly to what happens in other cities, in Lisbon, the hook-up culture, the use of chems (particularly cathinones and GHB), the use of apps to search for chemsex partners and chems are also central. However, in Lisbon there are also transgender and non-binary people engaging in chemsex, in contrast to traditional description of chemsex scenes and practices as MSM-exclusive. Additionally, there are sex workers and migrants who engage in these scenes and are looking for help due to their problematic chemsex patterns. In this sense, it is important to embrace an intersectional approach and implement cultural-sensitive care and user centered approaches to respond to chemsex.
Additionally, the traditional chemsex definition doesn't represent the diversity of sexualized drug use patterns we found MSM and queer communities in Lisbon. Several studies contributed to expand our knowledge regarding sexualized drug use among gay men and MSM. More research is necessary to understand sexualized drug use among non-heterosexual women, transgender and non-binary people (Hibbert et al., 2021).
In this essay, we also presented the experience of Kosmicare in creating specific services targeting people engaged in chemsex and a collaborative network to establish cultural-sensitive, chemsexresponsive and integrated responses to the needs of these users. In the absence of specific funding and governmental responses, this bottom-up community-led initiative was the local strategy to detect and monitor chemsex scenes and to fill the gap to support to chemsex practitioners. From our perspective, this was a necessary and worthwhile experience that we believe can be reproduced in other contexts, through the mapping and collective capacity-building toward chemsex-sensitive services. However, this was the beginning of an intervention that must be continued and expanded, creating harm reduction materials and contents, and peer-led initiatives able to promote safer chemsex practices. It also highlighted the role of civil society in the early detection of emerging trends and problematic practices, and its innovative and flexible character in designing and implementing bottom-up approaches. However, civil society is not enough to respond to complex and intersectional issues due to their chronically underfunded and precarious situation.
Finally, chemsex remains an under-researched area in Portugal. More studies are needed to understand the scenes, patterns, motivations, risks and harms related with this practice. Sexual orientation is a relevant social determinant of health (Logie, 2012). The aggregation of data should consider heterogeneity among non-heterosexual groups (Wicki et al., 2021). In addition, Mereish and Bradford (2014) demonstrated that substance use disparities are more nuanced if the analysis considers the intersection of sexual orientation; gender and raciality. They found racially diverse non-heterosexual women at greater risk than heterosexual and non-heterosexual women. In Portugal, Portuguese or migrant Afrodescendants and Brazilians are racialized due to the complex decolonization processes. However, they tend to be excluded from central geographies of the cities, social and sexual environments. In this sense, future research and community-based work should consider analyzing chemsex, sexualized and non-sexualized substance use and health disparities through an intersectional lens, to guarantee equity in the access to healthcare and social services and contribute to implementing inclusive and transversal approaches.

Acknowledgments
This paper resulted from a collective work resulting from contributes from several organizations, collectives and individuals. We want to thank our colleagues from Kosmicare, GAT-Checkpoint Lx, GAT-Intendente, Casa Qui, ILGA, Quebrar o Silêncio, DICAD-ARS/NORTE, Lisbon Municipality, Trombeta Bath, Claro. We also want to thank Steve Chapman (Isomer Design) for the generous English revision. Finally yet importantly, we want to express our gratitude to David Stuart for all his devoted work and advocacy, and for giving us insightful feedback to our leaflet and campaign strategy.

Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The chemsex harm reduction campaign, a collaborative network in Lisbon, was coordinated by Kosmicare and resulted from a cofounding from the General Directorate for Intervention on Addictive Behaviours and Dependencies (LVT/LX/076/32C/02) and Lisbon Municipality.

ORCID iD
Cristiana Vale Pires https://orcid.org/0000-0003-4172-0787 Notes 1. Queer, a derogatory slur commonly used to refer to "strange," "odd" or "eccentric" people, was reclaimed in later years to affirm gender and sexual diversity, non-conformity to social and cultural conventions, political and public resistance, and disidentification with other sexual identities, such as gay (Cascais, 2004). For some, Queer names the experience of not "passing" as a cisgender heterosexual and the pride in it (Halkitis, 2019).
In this text, we use the term queer as an inclusive umbrella term for the non-heterosexual and non-cisgendered community. 2. By using this quote, we aim to denounce the historical continuity of a degrading and biased narrative about drug use in social spaces by gay men and other queer communities. We recognize that this quote can be triggering for those impacted by homophobia and transphobia, so we state clearly our profound criticism toward the assumption of this statement. 3. Law n.30/2000, of 29 November.