Work, Sex, and Substances: Differences in Self-Reported Chemsex Behaviors Between MSM Sex Workers and Digital Content Creators

Abstract Background Chemsex, the use of psychoactive substances to enhance sexual activity, may vary by occupational context. This study compared its prevalence, substance-specific patterns, and acquisition behaviors among two groups: male sex workers who have sex with men (MSM) and MSM who create sexually explicit digital content. Methods Cross-sectional web-based survey of HIV-negative U.S. MSM (N = 769) with verified platform profiles. Group differences were assessed using chi-square tests with Benjamini–Hochberg correction, and independent associations were examined using multivariable logistic regression. Results Sex workers reported higher prevalence of criminalized or controlled psychoactive substance use in occupational contexts than digital content creators (47.7% vs. 21.6%), with occupational group emerging as the strongest independent predictor of use (aOR = 3.36, 95% CI 2.41–4.69). Sex workers also reported greater use of poppers and erectile dysfunction medications more frequently obtained through unregulated acquisition channels. Conclusions Occupational context shapes distinct chemsex use profiles among MSM, underscoring the need for occupation-sensitive harm reduction and clinical outreach. Policy Implications MSM sex workers and digital content creators represent occupationally distinct populations with divergent substance use profiles. Harm reduction, clinical screening, and outreach should be tailored to the risk environments and substances characteristic of each group, rather than treating all MSM engaged in sexual labor as a single, undifferentiated population.