“Emptiness Filled with Love”: A Reflexive Thematic Analysis of Chemsex Trajectories Among Gay, Bisexual, and Other Men Who Have Sex with Men in Almaty, Kazakhstan Using a Life Course Framework

Chemsex (intentional psychoactive substance use to enhance sexual experiences) among gay, bisexual, and other men who have sex with men (GBMSM) is associated with HIV transmission and psychological distress. Limited research exists on chemsex trajectories in Eastern Europe and Central Asia, where structural homophobia and restrictive policies uniquely shape risks. This study identified chemsex engagement stages and examined how social, psychological, and structural factors influence transitions among GBMSM in Kazakhstan. A cross-sectional qualitative study was conducted in Almaty, Kazakhstan (July-September 2023). Twenty-one GBMSM who engaged in chemsex within 12 months participated in 60-90 minute semi-structured interviews. All participants used mephedrone and/or alpha-PHP. Deductive reflexive thematic analysis, guided by Life Course Theory, reconstructed chemsex trajectories from retrospective accounts. Four trajectory stages emerged: Initiation occurred through trusted networks in intimate settings, fulfilling emotional needs for connection. Maintenance involved self-imposed limits but declining satisfaction with sober sex. Escalation featured breakdown of protective boundaries and increased use despite consequences. Dependence involved loss of control, with substance use shifting from pleasure enhancement to withdrawal coping. Structural stigma constrained agency throughout all stages, while chemsex networks provided emotional safety unavailable elsewhere. Chemsex trajectories represent dynamic processes where substance use functions as emotional regulation and social survival strategies in high-stigma contexts, shaped by interactions between individual agency and structural constraints.