Sex,Methamphetamine,and a Surge in Syphilis Among Women and Men Who Have Sex With Women: A Call to Diversify Research Addressing Sexualized Drug Use

Abstract

Globally rates of syphilis have been increasing since 1990 and, historically transmission has predominated among gay, bisexual, and men who have sex with men (GBMSM). In the past decade, transmission has increased among women and men who have sex with women (MSW). This led Australia to declare syphilis a communicable disease of national significance in August 2025. In this commentary, we consider the implications of these developments on conceptions of sexualized drug use (SDU) and research in this field. To date, discourses surrounding SDU have often focused on GBMSM and the culturally specific practice of chemsex. Yet emerging data outlining an association between methamphetamine use and syphilis transmission across populations may warrant a more inclusive SDU research agenda. In reflecting on this topic, we acknowledge that while the association between methamphetamine use and syphilis transmission may stimulate additional research on SDU, there are drawbacks associated with this research focusing on sexually transmitted infections (STIs) alone. We look to the literature on GBMSM and chemsex as a blueprint for a potential research agenda on SDU as practiced by women and MSW. Chemsex research was initially spurred by concerns regarding HIV transmission, however, this body of work has expanded over time to traverse domains of health and wellbeing, service delivery, evaluation and critical theory. We suggest that a similarly diverse body of empirical, applied and critical research on SDU is required to shape culturally appropriate, interdisciplinary services that meet the varied information and support needs of women and MSW who use drugs in sexual contexts.

Overview

This commentary was prompted by the Australian Chief Medical Officer's declaration of syphilis as a communicable disease of national significance (Kidd, 2025). It was also spurred by emerging data indicating an association between syphilis acquisition and recent methamphetamine use among women and men who have sex with women (MSW) (Kidd et al., 2019; Sisnowski et al., 2025). In light of this evidence, we consider the need to diversify and broaden research into sexualized drug use (SDU).

Our commentary is comprised of four key subsections. The first section provides an overview of evidence denoting an association between syphilis acquisition and recent methamphetamine use. Within this section we also briefly comment on theories that attempt to account for associations between drug use and sexually transmitted infections (STIs). The following section describes how research and services addressing SDU have predominantly focused on gay, bisexual, and men who have sex with men (GBMSM) and the culturally specific practice of chemsex. In this section, we note that much research on chemsex (as practiced by GBMSM) has been driven by concerns regarding HIV transmission. The third section of our commentary shows that increasing syphilis notifications among women and MSW reporting methamphetamine use has incited some preliminary attention in research, clinical guidelines, community-based responses, and policy. In this section, we outline an imperative for research that explores syphilis transmission among people who use methamphetamine while highlighting the potential for an exclusive focus on STIs to reinforce stigma. We conclude our commentary with an outline of the multiple realms of contemporary chemsex scholarship. In doing so, we suggest that chemsex research offers a useful blueprint for a diverse body of research addressing SDU as practiced by women and MSW.

To compile this commentary, we drew on the collective expertise of the authorship team comprising researchers with backgrounds spanning clinical services, lived/living experience representation, peer-led programs, harm reduction, sexual health, Aboriginal and Torres Strait Islander populations, drug use, qualitative methods, and critical chemsex studies. This expertise was supplemented by a desktop review of peer-reviewed and grey literature addressing syphilis notifications, SDU, and chemsex. Our commentary has also been informed by engagement with public health practitioners across Australia and consultation with the Australian Injecting and Illicit Drug Users League (AIVL). AIVL is Australia's national peer-led peak organization representing a network of peer-based harm reduction programs and organizations.

The specific drugs used in the context of sex and terminology used to describe this practice are variable and often geographically determined (Murphy et al., 2024; Stuart, 2019). As will be discussed throughout our commentary, research on this subject has prioritized the sexualized use of methamphetamine and gamma-hydroxybutyrate specifically among GBMSM and has often used the term chemsex to denote this phenomenon (Strong et al., 2022; Stuart, 2019). Several scholars, however, question the centrality of chemsex and GBMSM to discourses on sex and drugs (Azbel, 2023; Giacalone et al., 2023). Researchers highlight that people of all sexualities and genders use a range of drugs to enhance sex and often use terminology of SDU when describing this practice (Anderson & Norman, 2025; Freestone et al., 2022; Hibbert et al., 2019; Íncera-Fernández et al., 2022; Poulios et al., 2024). With acknowledgement that the terms chemsex and SDU are contested, dynamic, and sometimes interchangeably applied (Poulios et al., 2024), we broadly align the term chemsex with crystal methamphetamine and gamma hydroxybutyrate use among GBMSM. We use the term SDU when referring to a wider range of drugs, used in sexual contexts among people of all sexualities and genders, including women and MSW.

Methamphetamine, Syphilis, and New Populations

Syphilis is an STI that can also be transmitted vertically during pregnancy (Daniels et al., 2024). Syphilis can be asymptomatic and if undetected and untreated, it can develop into secondary or tertiary infection (Peeling et al., 2023). In severe cases, late-stage syphilis may cause blindness, organ failure, brain infections, or death (Australian Department of Health and Aged Care, 2024; World Health Organisation, 2024). When transmitted congenitally, syphilis may result in stillbirth or infant death (Peeling et al., 2023).

The potential severity of syphilis underscores concerns surrounding the persistent rise in syphilis notifications across high income nations over the past 30 years (Tao et al., 2023). Although syphilis continues to disproportionately impact GBMSM (King et al., 2024), rapid increases in syphilis notifications across several nations globally have been observed among women and MSW (Carter et al., 2023; Kidd et al., 2019; King et al., 2024; Public Health Agency of Canada, 2020).

In light of increasing rates of syphilis transmission, cases of congenital syphilis, and cases of infant death, the Australian Chief Medical Officer declared syphilis a communicable disease of national significance in August 2025 (Kidd, 2025). This declaration followed evidence of an overall 200% increase in infectious syphilis notifications between 2014 and 2023, with a seven-fold increase in syphilis notifications among women specifically who now represent 20% of new case notifications (King et al., 2024). This outbreak has particularly affected remote Aboriginal communities (Pérez Chacón et al., 2024). The syphilis notification rate among Aboriginal and Torres Strait Islander people in 2023 was almost five times as high as among non-Indigenous people, and congenital syphilis notification rates among Aboriginal and Torres Strait Islander infants were more than 20 times higher than among non-Indigenous infants (King et al., 2024).

Syphilis Notifications and Recent Methamphetamine Use

Syphilis notification data from several countries increasingly demonstrates that a significant portion of those newly diagnosed with syphilis report recent methamphetamine use (Harney et al., 2025; Kidd et al., 2019; Raval et al., 2022; Shaw et al., 2019). In the Australian state South Australia, 26% (n = 108) of people diagnosed with syphilis between July 2022 and September 2023 reported either injecting or non-injecting drug use in the past 12 months (Sisnowski et al., 2025). Among this group, methamphetamine was the drug most commonly reported and overall, women and heterosexuals diagnosed with syphilis had higher odds of reporting drug use than GBMSM (Sisnowski et al., 2025). In 2018 and 2019, among a sample of 2759 people diagnosed with syphilis in Alberta Canada, nearly half (41.8%, n = 1153) reported non-prescription stimulant use at any point in their lifetime (Raval et al., 2022). In the United States’ National Notifiable Diseases Surveillance System, 16.6% (n = 456) of women and 13.3% (n = 482) of MSW with syphilis in 2017 reported methamphetamine use within the past year, an increase from 6.2% and 5.0% respectively in 2013 (Kidd et al., 2019). Monitoring of congenital syphilis notifications in the United States similarly demonstrates that those reporting recent methamphetamine or other drug use are more likely to give birth to an infant with syphilis and are also more likely to have received inadequate pre-natal care (Daniels et al., 2024; Plotzker et al., 2022). Although a seemingly high proportion of people diagnosed with syphilis report recent methamphetamine use, the reliance on self-report to collect these data, stigmas surrounding drug use, the perception that reporting drug use may negatively impact care or bare other negative consequences may mean that methamphetamine use is under-reported in these datasets (Kidd et al., 2019; Pearce et al., 2020).

Evidence on syphilis notifications arising from routine public health monitoring concurs with findings from several discrete studies conducted among people who use methamphetamine. For example, multiple studies conducted among GBMSM (Guerra et al., 2020; Jennings et al., 2021) and people of all sexualities and genders (Liao et al., 2013; Ye et al., 2022) have recorded higher odds of infectious syphilis among people who use methamphetamine.

Theorizing Associations Between Methamphetamine Use and Syphilis Transmission

Syphilis is a bacterial infection usually passed on via contact with an infectious lesion during anal, vaginal, or oral sex (World Health Organisation, 2024). Unlike hepatitis C and HIV, syphilis is not a bloodborne STI and is rarely passed on via shared injection equipment or drug use paraphernalia (Arora et al., 2016; Price et al., 2025; World Health Organisation, 2024). This raises a question as to why methamphetamine use and syphilis cluster together? Because no studies have provided clear evidence of a causal pathway between methamphetamine use and syphilis transmission, it is important to emphasize that evidence of any association is observational (Bryant et al., 2018; Digiusto & Rawstorne, 2013). It has long been well known that STIs disproportionately impact people who use drugs (Murali & Jayaraman, 2018; Price et al., 2025; Reno et al., 2020) and several theories have been mounted in an effort to explain this association.

A social determinants lens on STI transmission among people who use drugs, and in turn, syphilis transmission among people who use methamphetamine, frames the phenomenon as a byproduct of poor environmental conditions, social and economic disenfranchisement, and inequitable systems (Rubin, 2024). When describing surges in syphilis among people who use methamphetamine, researchers may also refer to the interplay between social determinants and syndemic theories (Liao et al., 2014; Liao et al., 2013; Rubin, 2024; Singer et al., 2006). These theories suggest that environmental, structural, and social inequalities give rise to the simultaneous experiences of multiple adverse health outcomes which then compound each other (Ferlatte et al., 2018). For example, in an Australian context, elevated rates of methamphetamine use and STI transmission among remote Aboriginal communities may be mutually associated with compounding factors such as intergenerational trauma, insufficient access to health care, lack of health care capacity, lack of employment, and experiences of ongoing stigma and discrimination (Sivak et al., 2023; Ward et al., 2020).

Moreover, the pharmacological effects of methamphetamine, especially its libido enhancing properties, have been considered in relation to syphilis transmission (Rubin, 2024). People who use methamphetamine often do so for the express purpose of enhancing sex (Cheng et al., 2010; Hammoud et al., 2020). There is a large and growing body of research that documents associations between methamphetamine use and a range of social practices which may carry risks for STI transmission, such as condomless intercourse (Schmidt et al., 2019; Zule et al., 2007), engagement with a greater number of sexual partners (McKetin et al., 2018), and sexual episodes that last for longer than a day (Cheng et al., 2010). Equally, the few studies that have been conducted among women and MSW engaged in SDU suggest that women and MSW who use methamphetamine have more casual sex partners, report reduced condom use, and engage in prolonged sexual episodes (Cheng et al., 2010; Íncera-Fernández et al., 2022; McKetin et al., 2018; Zule et al., 2007).

Finally, the mechanism underlying this association may be hypothesized with reference to bio-medical risk factors. For example, long-term methamphetamine use is known to heighten certain physiological vulnerabilities to syphilis, methamphetamine use reduces immune function (Salamanca et al., 2015) and may also lead to dry mucosal membranes or microtears that enable syphilis to be easily transmitted during sex (Shoptaw & Reback, 2007).

Theories (such as those outlined above) that attempt to explain associations between drug use, sexual practices, and disparate health outcomes have faced substantial critique among critical chemsex scholars. In brief, such theories are critiqued for pathologizing practices, positioning people as vulnerable rather than agentive and eschewing pleasure in favor of risk (Bryant et al., 2018; Pienaar et al., 2018; Race et al., 2017). Moreover, theories that rest solely on biomedical reasoning or that suggest the pharmacological effects of substances cause STI transmission have been described as overly deterministic (Race, 2009). Notably Bryant and colleagues remind us that while methamphetamine may facilitate sexual exploration and pleasure, it is important to avoid perpetuating the suggestion that the pharmacological effects of methamphetamine cause STI transmission. This slippage fails to account for the social, material, and contextual variations of methamphetamine use (Bryant et al., 2018). Relatedly, research that situates “risky” drug use or sexual practices in the realm of individual choice, or individual susceptibility has been critiqued for neglecting examination of macro-level structural conditions (Hakim, 2019). Overall critiques of behavioral risk frameworks, bio-medical and pharmacological causality suggest that associations between drug use and STIs are not stable and linear but instead relational, emergent, and situated within complex assemblages (Race, 2009; Race et al., 2017).

A Prevailing Focus on GBMSM and Chemsex

SDU as practiced by women and MSW remains relatively unexplored in comparison to chemsex as practiced by GBMSM, with notable exceptions (Azbel, 2023; Cheng et al., 2010; Íncera-Fernández et al., 2022). To date, most research, media, and policy discourses surrounding methamphetamine use and sex have focused on the social practices and experiences of GBMSM (Flynn, 2015; Home Office, 2017; Møller & Hakim, 2021; Tomkins et al., 2018).

In part, the principal focus on chemsex among GBMSM to discourses surrounding sex and drugs may be explained by the seemingly high proportion of GBMSM who use drugs such as methamphetamine to enhance sex (Tomkins et al., 2018). In Australia, cross-sectional surveys conducted among a sample of the general adult population found that approximately 1% reported methamphetamine or amphetamine use within the previous 12 months (Australian Institute of Health and Welfare, 2024). By comparison, surveys conducted among convenience samples of GBMSM consistently report rates of approximately 8% of GBMSM using methamphetamine in the past 6 months (Broady et al., 2025). A cohort study exploring drug use among Australian GBMSM reported that over 80% of GBMSM who had used methamphetamine did so for the explicit purpose of enhancing sex (Hammoud et al., 2020).

The role of HIV must also be considered. GBMSM are at heightened risk of HIV transmission (World Health Organisation, 2025) and concern about the link between chemsex and HIV has incited significant attention on the phenomenon, been leveraged to fund chemsex research and services and overall reified a focus on GBMSM specifically (Drysdale et al., 2020; Grov et al., 2020; Murphy et al., 2024; Pakianathan et al., 2018; Pienaar et al., 2018). Although a direct causal pathway between HIV transmission and chemsex is far from clear (Bourne et al., 2015a; Bryant et al., 2018), studies, policies, and discourses surrounding chemsex often explicitly focus on associations between chemsex, HIV risk behaviors, and HIV transmission (Heritage & Baker, 2022; HM Government, 2017; Maxwell et al., 2019). This said, over the last 10 years the uptake of PrEP among GBMSM, alongside high coverage of HIV treatment and retention in HIV care, appears to ameliorate HIV risk for some GBMSM who practice chemsex (Hammoud et al., 2020; Hammoud et al., 2018b). Alongside these advances in biomedical prevention, chemsex research has diversified its focus. We outline and consider the implications of this development in a later section of this commentary.

Syphilis-Driven Imperatives for Expanding SDU Research

Just as concerns associated with HIV prompted attention on chemsex among GBMSM, associations between methamphetamine use and syphilis transmission has prompted preliminary attention to the ways in which drugs are being used during sex by women and MSW (Gorman, 2019; Kidd et al., 2019; Liao et al., 2013). In this section, we consider both the rationale for, and drawbacks associated with researching associations between syphilis acquisition and methamphetamine use.

There is a clear rationale for researching associations between methamphetamine use and syphilis transmission. For one, it is particularly important to understand the epidemiology of syphilis and prioritize the groups most impacted for primary prevention and screening. This imperative is heightened by the fact that syphilis can be fatal, but when detected early it is easily treatable. Studies report 90–100% treatment success rates when early-stage syphilis is treated with a single intramuscular injection of penicillin (Clement et al., 2014).

Australian commentators have advocated for clinical guidelines to list drug use (particularly methamphetamine and gamma-hydroxybutyrate) as a standalone indicator for syphilis screening in asymptomatic, sexually active people (Sisnowski et al., 2025). While certain public health strategies now prioritize syphilis prevention, testing and treatment for people who use drugs specifically (Government of Western Australia Department of Health, 2021; U.S. Preventive Services Task Force, 2022), ongoing research is required to inform future policy development and guide the adaptation of clinical guidelines.

This research is particularly key in a context where screening and biomedical prevention technologies are evolving. These advances may offer benefits for groups at elevated syphilis risk; however, research is required to inform how these programs are implemented. For example, there is growing evidence regarding the use of doxycycline as both a post-exposure prophylactic (Doxy-PEP) and pre-exposure prophylactic (Doxy-PrEP) for syphilis and other bacterial STIs (Grant et al., 2020). In the IPERGAY trial Doxy-PEP resulted in an approximately 73% relative reduction in syphilis diagnoses among GBMSM and transgender women (Molina et al., 2018). As a result, guidelines from the Centres for Disease Control in the US now recommend intermittent Doxy-PEP use for GBMSM and transgender women who report a heightened syphilis risk (Bachmann et al., 2024). Doxy-PEP may also be appropriate for people who use methamphetamine, but suitability must be weighed against risks associated with anti-microbial resistance (Kong et al., 2023). Moreover, acceptability among women and MSW who use methamphetamine warrants further investigation.

Drawbacks of a Narrow Focus on STI Risk

Although evidencing associations between methamphetamine use and syphilis transmission may incur benefits, a body of critical chemsex research highlights the negative impacts of discourses which place too much emphasis on associations between drug use and STI risk (Drysdale et al., 2020; Pienaar et al., 2020). Notably, accounts that overwhelmingly problematize practices of chemsex or SDU may disenfranchise people who engage in it by perpetuating stigma (Drysdale et al., 2020; Weatherburn et al., 2017). Furthermore, studies that focus on STI risk alone position participants as vulnerable rather than agentive (Bryant et al., 2018) and eschew the vigilance and care of those who routinely employ harm reduction strategies to extend experiences of pleasure while mitigating risk (Drysdale et al., 2021). When such studies underline relationships between social practices and STIs, they risk reinforcing notions of individual deviance and responsibility and give rise to reductive media coverage and public health strategies that attempt to induce compliance with social norms via stigmatizing rhetoric (Brown, 2018; Digiusto & Rawstorne, 2013).

In the case of syphilis, sensitivities around stigma are particularly significant (Kidd et al., 2019) and may be strongly felt by people who use drugs when having sex. People who combine sex and drugs are often subject to multiple intersecting stigmas associated with drug use, sexual identity, STI, HIV, or hepatitis C status, injecting behaviors and sexual practices which others may deem adventurous, risky, or unusual (Freestone et al., 2025a; Freestone et al., 2025b; Treloar et al., 2021). The detrimental impact of these stigmas may reinforce the anticipation of discrimination within healthcare services (Freestone et al., 2025a) and the onwards disenfranchisement from supportive social networks (Treloar et al., 2021). Given these sensitivities, work must be undertaken to undo rather than perpetuate stigmas, which has implications for research which is conducted at the intersection of drug use and sexual health. The evolution of research focused on chemsex and GBMSM may provide useful lessons on research that is both productive and is conscious of unintended effects.

Drawing Inspiration From the Breadth of Contemporary Chemsex Research

So far, we have outlined evidence of an association between syphilis acquisition and recent methamphetamine use. We have described the literature's prevailing focus on GBMSM and chemsex and we have considered the imperative for further research on the association between methamphetamine use and syphilis. In this final section, we draw attention to a diverse and growing body of chemsex research focused on GBMSM with the intention of indicating the potential for a similarly diverse research agenda focused on SDU as practiced by women and MSW.

We conceptualize contemporary chemsex research along three axes: (1) empirical research on chemsex and health and wellbeing, (2) applied research on tailored and inclusive chemsex services, and finally (3) critical and cultural chemsex studies. In turn, we suggest that research on SDU among diverse populations must similarly encompass three axes and meaningfully engage people with lived-living experience at all stages (Australian Injecting and Illicit Drug Users League, 2025).

Chemsex Health and Wellbeing

Empirical research exploring chemsex, health and wellbeing now traverse multiple domains that extend beyond associations with STI or HIV transmission risk. Empirical chemsex research has investigated acute harms, such as overdose, accidents, and emergencies (Bourne et al., 2015b; Freestone et al., 2023; Hammoud et al., 2018a). Other studies have examined impacts on mental health (Bohn et al., 2020; Tomkins et al., 2018), and outcomes associated with employment and other components of psychosocial wellbeing (Hegazi et al., 2017; Kurtz, 2005). Several studies have also examined chemsex and sexual wellbeing and have explored a bi-directional relationship between drugs and sex, an inability to have sex without drugs and experiences of sexual distress or sexual violence (Drückler et al., 2021; Evers et al., 2020; Freestone et al., 2025b). With acknowledgement of these potentially adverse experiences, empirical research on chemsex and wellbeing emphasizes that not all who engage in chemsex experience harm and in fact many people experience benefits (Lunchenkov et al., 2024). For example, studies conducted among GBMSM living with HIV engaged in chemsex have demonstrated that the practice may be associated with positive mental health outcomes, which may be attributed to experiences of community and peer connection afforded by chemsex participation (Field et al., 2023; Power et al., 2018). Further, with regards to sexual wellbeing, studies have demonstrated that the sexualized use of drugs can facilitate, gratifying, exploratory, and ultimately beneficial sexual experiences (Freestone et al., 2022; Pienaar et al., 2020).

In sum, empirical chemsex research has enabled a nuanced understanding of the numerous ways in which chemsex shapes wellbeing. This body of literature has informed our understanding of the concerns facing those engaging in chemsex as well as the experiences that are most associated with morbidity and the sub-groups who may be at highest risk of experiencing drug-related harm, such that we can target them for supportive programs and services.

Research on Chemsex Services and Interventions

The realm of applied research on tailored and inclusive chemsex service delivery is slim by comparison to empirical work, with only a handful of studies on services and interventions having been conducted (Íncera-Fernández et al., 2025). Peer interventions for GBMSM who use crystal methamphetamine have been favorably evaluated against outcomes associated with crystal methamphetamine use and mental health (Burgess et al., 2018; Reback et al., 2019; Reback et al., 2012). Peer-reviewed and grey literature make reference to peer-led chemsex outreach education, peer-led chemsex counselling, group programs, and peer-led training programs for health services, with a range of these interventions delivered across Europe, Asia, and Australia (APCOM, 2021; Controlling Chemsex, 2024; Freestone et al., 2025a; Mainline, 2022; Pires et al., 2022; Stardust et al., 2018; Strong et al., 2022). In the context of services delivered by those with clinical qualifications, the literature highlights that chemsex talk therapies are delivered across both mainstream general population health settings and within tailored and community-led health services (Freestone et al., 2025b). Commentators have also outlined that chemsex services should be interdisciplinary and address matters relating to drug use and sex, be LGBTQ +  inclusive, affirm autonomy, and adopt a posture of openness and non-judgement (Gaudette et al., 2022; Graf et al., 2018; McGaughey et al., 2023). A handful of clinician-led, talk-based therapies tailored for GBMSM using methamphetamine have been favorably evaluated against outcomes spanning sexual health and methamphetamine use outcomes (Knight et al., 2019).

This body of applied research has significantly advanced our ability to meet GBMSM engaging in chemsex where they are at and hold lessons for designing and delivering services for other populations engaged in SDU. To be acceptable and accessible, such programs and services need to be delivered by trusted parties, in the spaces and places where chemsex is occurring and where the potential for harm can be actively addressed.

Critical Chemsex Studies

Counter to perspectives that frame chemsex as a phenomenon which needs to be examined for its detrimental impacts on health and wellbeing, or as a practice which must be addressed by tailored services, critical and cultural chemsex studies invite a pluralistic understanding of the phenomenon. Chemsex scholarship has emerged at the interstices of sociology, cultural studies and media studies, and this body of work is often drawn together by feminist and queer theoretical orientations towards power, identity, and affect (Møller & Hakim, 2021; Pienaar et al., 2020). A recent review of critical chemsex studies authored by Møller and Hakim (2021) suggested that research in this area operates along three domains. The first focuses on public health, with a range of critical studies aiming to move the field beyond risk-based perspectives on chemsex. The second are studies that examine the cultural dimensions of chemsex and explore the discursive, sociopolitical, and economic contexts in which the practice has emerged. Finally, the third element of critical chemsex studies highlights how chemsex interplays with pleasure and the role it plays in shaping gay identity, intimacy, social connections, and chemsex “scenes” (Drysdale, 2021; Møller & Hakim, 2021).

This domain of research has made explicit the social and cultural forces that shape engagement in chemsex and the structural conditions that both help and hinder in terms of addressing harm. Critical and cultural chemsex studies have problematized what at times has been a highly pathologizing discourse about chemsex, which as we have outlined is a key issue of concern in the context of methamphetamine use, syphilis, and other populations.

In sum, we propose that research spanning health and wellbeing, service delivery, and critical theory, offers potential to explore salient questions regarding the benefits and harms associated with SDU as practiced by women and MSW. Such research must be informed by lived/living experience at all stages (Australian Injecting and Illicit Drug Users League, 2025) and may guide the commissioning, design and delivery of programs and services that extend beneficial experiences and mitigate harms while also illuminating the cultural forces and structural conditions that shape SDU practices.

Conclusions

Syphilis disproportionately impacts people of all sexualities and genders who use drugs (Price et al., 2025). In this commentary, we have noted emerging associations between methamphetamine use and syphilis notifications among women and MSW. We argue that increasing rates of syphilis among women and MSW who use methamphetamine highlight a need to diversify perspectives, research, and services surrounding SDU, which to date have largely focused on chemsex and GBMSM. Research on associations between methamphetamine use and syphilis may usefully guide public health priorities, programs, and services; however, there are drawbacks associated with exclusively examining SDU from the vantage of STI risk. Looking to a body of evolving chemsex research, we suggest that an exclusive focus on STI risk behaviors and STI transmission may invite slippages towards erroneous narratives that suggest methamphetamine use causes the transmission of syphilis or other STIs. Such narratives suggest that those who practice SDU are responsible for the spread of disease while positioning people and communities as reckless and vulnerable, rather than responsible and agentive. The trajectory of research and practice in the chemsex field, which initially focused on HIV but expanded over time, offers useful guidance to researchers and service providers working in the field of SDU as practiced by people of all sexualities and genders. While HIV retains centrality to many chemsex discourses, the field now extends to scholarship traversing domains of health and wellbeing, service delivery, evaluation and critical theory, each of which have usefully shaped thinking and informed practice.