Why Gay Saunas Operate the Way They Do

The culture inside a gay sauna didn’t appear from nowhere. It developed over decades in response to specific pressures that shaped how men who have sex with men socialised, found each other, and managed risk.

For much of the twentieth century, sex between men was criminalised in the UK, and even after partial decriminalisation in 1967, the social and legal environment remained hostile well into the 1990s and beyond. Bathhouses and saunas became spaces where men could meet with a degree of privacy and anonymity that pubs, clubs, and public spaces couldn’t offer.

That history shaped two features of sauna culture that still define it today. The first is discretion: many venues have unmarked entrances, strict phone bans, and policies designed to protect the identity of every visitor. The second is what some venues call the “code of silence” — the convention that most communication, including the negotiation of sexual interest, happens non-verbally.

This wasn’t a stylistic choice. It was a practical adaptation to environments where being overheard or identified could have serious consequences.

Understanding this context matters because it explains why saunas feel different from other social or sexual settings. The quietness, the reliance on body language, the emphasis on anonymity — these aren’t arbitrary customs. They’re the architecture of a venue designed to let men be themselves safely. Modern UK saunas operate in a very different legal climate, but the culture retains its roots. These are places where discretion and respect for others’ privacy are foundational, not optional.

It’s also worth understanding that a gay sauna is two things at once. It’s a wellness facility — showers, steam rooms, dry saunas, jacuzzis, and usually a café or lounge area — and it’s a sexualised environment where men may seek sexual contact with other men. Neither purpose overrides the other. You’re not obligated to do anything sexual simply by being there, and nobody is obligated to treat it as purely recreational. Your visit is defined by what you choose to do, not by what the venue makes available. For a detailed guide to what each room and facility is designed for, see Gay Sauna Facilities Explained: What Every Room Is For.

The Unwritten Rules and Why Each One Exists

Every sauna has its own house rules, usually displayed at reception or in the changing area. The conventions below are broadly consistent across UK venues, and what makes them easier to follow is understanding the reasoning behind each one rather than memorising them as a list.

Hygiene is the most universal expectation. You’ll be asked to shower before using any communal wet area — steam rooms, saunas, jacuzzis — even if you showered at home before arriving. This isn’t about doubting your cleanliness; it’s a practical measure to keep shared water and surfaces sanitary for everyone. Sitting on your towel rather than directly on wooden or tiled benches is standard, and in many venues it’s compulsory for saunas. If you engage in sexual activity, showering again before returning to communal areas is both considerate and widely expected.

Phone and camera rules are strictly enforced in almost every UK venue. Using your phone in changing areas, wet areas, or play areas is typically prohibited outright, and taking photographs or video can result in immediate removal and, in serious cases, a report to the police. Beyond venue policy, covert recording of someone engaged in a private act is a criminal offence under Section 67 of the Sexual Offences Act 2003, which covers voyeurism. The Data (Use and Access) Act 2025 has since made it a criminal offence to create non-consensual intimate images of another person — including through AI — strengthening the legal framework further.

The phone ban exists to protect every visitor’s right to anonymity. Many men who visit are not out to their families, friends, or workplaces. Others work in roles where being identified in a sexual setting could have professional consequences. The simplest way to comply is to put your phone in your locker when you arrive and leave it there until you leave.

Towel etiquette functions as a subtle form of communication. Most venues provide a towel with your entry fee, and wearing it around your waist is the default. The towel acts as a kind of baseline: keeping it on signals that you’re comfortable but not necessarily inviting contact, while how and where you wear it (or don’t) can indicate different levels of openness. If you’re unsure, keeping your towel on until you’ve had time to observe how others use the venue is a reasonable approach.

Conversation norms vary by area within the venue. Cafés and lounges are the most openly social areas — normal conversation, introductions, and relaxed chat are all common, and many men use these as a low-pressure way to get comfortable before moving elsewhere. Changing rooms tend to be more functional; brief, practical exchanges are fine, but long or loud conversations can feel intrusive. Steam rooms and dry saunas are usually quieter, and it’s worth reading the room before talking at length. Dark rooms and private play areas are generally not places for conversation that draws attention to what others are doing. If you need to discuss boundaries, safer sex, or logistics with someone, it’s better to do so in a more neutral area first.

Private and public play areas follow different but equally important conventions. If a venue has private cabins, those are intended to offer seclusion — looking over walls, peering through gaps in doors, or knocking uninvited violates that privacy. Public play areas are where sexual activity may be visible to others, but being in a public area does not mean anyone can touch you without consent. The distinction between “visible” and “available” is important.

The Non-Verbal Consent Framework

In most everyday sexual contexts — dates, hookups arranged through apps, encounters that begin with conversation — consent is negotiated at least partly through words. In a sauna, the primary language of consent is non-verbal. This can feel unfamiliar, but it follows a clear and logical structure once you understand how it works.

The process is sequential and incremental. Each step functions as a checkpoint where both people can opt in or opt out before anything escalates further.

The first stage is eye contact. If you notice someone you’re interested in, you look at them. If they’re interested, they’ll hold your gaze rather than looking away quickly. Sustained, mutual eye contact — not a passing glance, but a deliberate look that’s returned — is the first signal of potential interest. If they break eye contact immediately, look away repeatedly, or don’t engage, that’s a signal to move on.

The second stage adds warmth. A relaxed smile, combined with that sustained eye contact, moves the interaction from “I’ve noticed you” to “I’m open to more.” If the smile is returned, that’s a second positive signal. If their expression stays neutral or they look away, the answer is probably no.

The third stage is proximity. If eye contact and a smile have been exchanged, one of you may move closer — sitting nearer on a bench, shifting position in a steam room, standing at a closer distance. This should be gradual and should leave the other person room to move away if they choose to. Moving directly into someone’s personal space without these earlier signals is not an approach; it’s an imposition.

The fourth stage involves light, non-sexual touch — a hand placed briefly on a shoulder, a foot making contact in a jacuzzi, a casual brush of a leg. The key word is “non-sexual”: this stage is about testing whether physical proximity is welcome, not about initiating sexual contact. If the other person reciprocates with similar touch, leans into it, or moves closer, that’s a positive signal. If they pull away, move their body, or remove your hand, that’s a clear signal to stop.

Only after these stages have been navigated — and only if each one has been met with a reciprocal response — does escalation towards sexual contact become appropriate. Even then, consent continues to operate on an ongoing basis. It can be given for one thing and not another, and it can be withdrawn at any time. At any point where you’re uncertain whether the person is genuinely engaged or merely tolerating contact, the correct response is to pause or stop.

This sequential model exists for a practical reason: it allows two people to negotiate interest and boundaries without either one needing to make a grand, vulnerable declaration. Each step is small enough that opting out carries minimal awkwardness. A system where saying “no” is easy is a system where saying “yes” means something.

Peer-reviewed research consistently supports what experienced sauna visitors already know: non-verbal behaviours are the dominant mode of consent communication among men who have sex with men. Beres, Herold, and Maitland (2004), in a study published in Archives of Sexual Behavior, found that participants in same-sex relationships reported using non-verbal behaviours significantly more frequently than verbal behaviours to indicate consent. Two decades later, Webber et al. (2024) confirmed this finding in a scoping review of thirty studies on GBTQ men’s consent practices, noting that the same pattern of non-verbal-dominant consent communication remains prevailing among MSM.

When to Break the Silence and Use Words

Non-verbal communication works well for the early stages of an encounter — establishing mutual interest, gauging comfort, and initiating light contact. But there are specific moments where words become important, and using them is a sign of confidence and respect, not a disruption of the atmosphere. The “code of silence” is a cultural convention, not a rule.

Before penetrative sex, a verbal check-in is strongly advisable. Agreeing on what both people want, discussing safer sex (condom use, PrEP status), and confirming that the encounter is heading somewhere both people are comfortable with is far easier to do with words than with gestures. This conversation doesn’t need to be long or formal. “Want to go somewhere more private?”, “Are you into this?”, “I’ve got condoms — are we using one?” are all short, direct, and clear.

When moving to a private cabin, stating what you’re open to — and what you’re not — before the door closes avoids misunderstandings that are harder to resolve once things are under way. “I’m up for oral but not into anal” or “I’m happy to play but I don’t kiss” are the kind of boundaries that are much easier to set verbally than to communicate through body language in a dark, enclosed room.

When something feels ambiguous — when you genuinely can’t tell whether the other person is interested or simply being polite, when body language signals are mixed, when you sense hesitation — asking a simple question resolves the ambiguity immediately. “Is this alright?” or “Do you want to carry on?” gives the other person an explicit opportunity to say yes, no, or suggest something different.

The situations where words are most needed are precisely the situations where relying solely on body language carries the most risk. Using your voice when it matters is a sign that you understand the environment well enough to know when non-verbal cues aren’t sufficient.

Signals of Interest vs. Signals of Disinterest

Reading body language in a steam room or a dimly lit corridor is not the same as reading it across a well-lit bar. Signs that someone is likely interested include: eye contact that is held deliberately and returned more than once; a genuine, relaxed smile directed at you; movement towards you when they had other options for where to sit or stand; open body language — facing towards you, arms relaxed, posture engaged rather than closed off; and reciprocal touch, where they respond to light contact by maintaining it or initiating their own.

Signs that someone is likely not interested include: breaking eye contact quickly and not returning it; turning their body away from you or angling their shoulders in the opposite direction; moving to a different seat, bench, or area shortly after you approach; neutral or one-word responses to any conversation you attempt; and pulling away from touch, removing your hand, or physically creating distance.

Brief eye contact without any particular expression, sharing a bench in a crowded steam room because it’s the only available seat, polite small talk about the facilities — these are not invitations, but they’re not refusals either. They’re simply people using a shared venue. Interpreting neutral behaviour as interest is one of the most common missteps, particularly for men who are new to the environment.

When you genuinely can’t read the situation, default to the lighter end of interaction. If that’s returned, take one further step. If it isn’t, or if the response is ambiguous, treat it as a “not now” and move on. Missing a possible connection is always preferable to making someone feel uncomfortable or pressured.

How to Decline — And Why You Don’t Owe an Explanation

Being approached by someone you’re not interested in is a normal, frequent part of being in a sauna. It doesn’t require a complicated response, and it certainly doesn’t require an apology or an excuse.

The simplest verbal declines are also the most effective: “No thanks”, “Not for me”, “I’m just here to relax tonight.” These are complete sentences. They don’t need to be followed by a reason, a justification, or a softening phrase like “maybe later” — unless you genuinely mean it. Offering a vague “maybe” to be polite often creates more confusion than a clean, brief “no.”

Non-verbal declines work in the earlier stages of an interaction. Breaking eye contact, turning your body away, relocating to a different area — these are well-understood signals among experienced sauna visitors.

In a sexualised environment, the instinct to soften refusals can be genuinely risky, because staying still, tolerating unwanted contact, or saying nothing can be misread as passive consent. Vague responses — saying “maybe in a bit” when you mean “no,” smiling apologetically, staying put rather than moving away — leave the other person waiting, watching, and eventually re-approaching. A clean “no” ends the interaction for both of you. It might feel blunt, but it’s the most respectful thing you can do — for them and for yourself.

Withdrawing consent after something has already started is equally valid. You might begin an encounter and then feel differently — about the person, about the activity, about the situation. That’s your right at any point. “I want to stop,” “I’ve changed my mind,” or “I’m going to leave it there” are all clear ways to communicate this. You don’t need to explain further.

How to Handle Being Told No

Rejection in a sexual context can sting, and pretending otherwise would be dishonest. But understanding why rejection is a routine, healthy, and structurally necessary part of how saunas function can make it considerably easier to handle.

In a venue where many men are present, many are making and receiving approaches, and most encounters don’t progress beyond the first couple of stages. This is by design. The whole system of incremental, non-verbal negotiation exists precisely so that most “nos” can happen early, quietly, and with minimal awkwardness. A declined glance, a turned shoulder, a brief “not for me” — these aren’t personal attacks. They’re the filtering mechanism that allows a room full of strangers with different tastes, moods, and intentions to coexist without constant friction.

The correct response to being turned down is brief and physical: acknowledge it (a small nod, a quiet “no worries”), and then move away. Not to the other end of the same bench — away. Give the person their personal space and give yourself a reset. Don’t follow them. Don’t hover nearby. Don’t return to try again ten minutes later unless they’ve given you a clear, new signal of interest.

If you realise you’ve misread a signal — you touched someone who wasn’t interested, you moved closer to someone who was trying to create distance — a short apology is the right response. “Sorry, I misread that” communicates self-awareness and respect. Say it, step back, and let the interaction end there. Don’t argue about whether the signals were clear. Learning from the moment and adjusting your behaviour is what makes you a more considerate visitor over time.

When Someone Doesn’t Take No for an Answer

If you’ve said no — verbally or through clear body language — and the person persists, that’s no longer an awkward moment; it’s a boundary violation, and you have every right to escalate. Repeat your refusal firmly and audibly. If they continue, move away from them physically. Then speak to a member of staff: tell them what happened, where it happened, and describe the person as clearly as you can.

Reporting matters even when the incident feels minor. A single instance of persistent unwanted contact might seem manageable on its own, but staff can only identify patterns of behaviour if they receive multiple reports. The man who ignored your “no” may have ignored someone else’s before you, and may do so again after. Reporting creates a record that protects not just you but the people who come after you.

A venue where men feel safe saying “no” is a venue where “yes” carries real weight. Every time you handle rejection gracefully, you contribute to an environment where consent is meaningful rather than pressured. That benefits everyone in the building, including you.

Different areas within a sauna carry different conventions, and understanding what each one is designed for helps you choose the right one for what you’re comfortable with.

Dark rooms are purpose-built areas where sexual activity is expected rather than incidental. Some venues state explicitly that entering a dark room implies consent to anonymous, non-penetrative sexual contact. Even where that convention applies, it does not mean you’ve consented to everything that could happen in that room. Consent still operates on a per-person, per-act basis. Under Section 74 of the Sexual Offences Act 2003, consent requires agreeing by choice while having the freedom and capacity to make that choice. Your physical location in a building doesn’t override that.

You can enter a dark room, experience contact you’re not comfortable with, and leave immediately. Leaving is withdrawing consent, and it doesn’t require an explanation. If you’re not sure what a specific venue’s conventions are for their dark room, ask staff before you go in — that’s a perfectly reasonable question, and they’ll have answered it a hundred times before.

Glory holes typically carry an implied consent convention for specific anonymous sexual contact. If you use one, understand what that convention involves, and know that you can stop and walk away at any point.

Private cabins are designed for seclusion — looking over walls, peering through gaps in doors, or knocking uninvited violates that privacy. Public play areas mean your activity may be visible to others, but “visible” does not mean “available.” Being in a public area does not give anyone permission to touch you without your consent.

The bottom line across all areas: choose the one that matches your comfort level, and know that consent applies everywhere regardless of the room you’re standing in. For a comprehensive walkthrough of what each room and facility is designed for, see Gay Sauna Facilities Explained: What Every Room Is For.

Chemsex, Alcohol, and What UK Law Actually Says

Some UK gay saunas serve alcohol. Some visitors arrive having used recreational drugs. Chemsex — the use of specific drugs (most commonly GHB/GBL, mephedrone, and crystal methamphetamine) to facilitate, enhance, or prolong sexual activity — is a reality in parts of the MSM community, and its presence in or around some sauna settings is documented. None of this is a reason to avoid saunas, but it is a reason to understand how intoxication affects consent, both legally and practically.

Under Section 74 of the Sexual Offences Act 2003, consent is defined as agreeing by choice while having “the freedom and capacity to make that choice” (legislation.gov.uk). The critical word is “capacity.” A person who has consumed alcohol or drugs is not automatically unable to consent — the law recognises that people can make valid decisions while under the influence of substances.

The Court of Appeal addressed this directly in R v Bree [2007] EWCA Crim 804, clarifying that voluntary intoxication does not automatically negate capacity to consent. But the principle is clear: when intoxication reaches the point where a person can no longer understand what is happening, weigh the decision, or communicate their choice, they have lost the capacity to consent. At that point, any sexual activity with them is, in law, non-consensual. The Crown Prosecution Service guidance on this point is explicit: prosecutors are directed to consider whether the complainant had the capacity to consent, taking into account the effect of alcohol or drugs on their ability to make a free choice.

If you’re in a sauna and considering a sexual encounter with someone who has been drinking or using substances, the question to ask yourself is not “have they technically said yes?” but “are they in a state where their yes is meaningful?” If there’s genuine doubt, the answer is to wait. For detailed guidance on chemsex support services and what to do if substance use complicates your visit, see What to Do After Your Gay Sauna Visit.

Recognising When Someone Cannot Consent

In practical terms, there are observable indicators that someone may have lost the capacity to consent. These include slurred or incoherent speech, difficulty maintaining balance or coordination, confusion about where they are or who they’re with, inability to respond coherently to simple questions, and drifting in and out of consciousness. Any one of these should be treated as a reason not to engage sexually with that person.

If you encounter someone in a sauna who appears to be in this state, the appropriate response goes beyond simply not engaging with them yourself. If you’re concerned about their safety — because they’re in a vulnerable position in a play area, because they appear to be losing consciousness, because someone else seems to be taking advantage of their state — alerting staff is the right thing to do. Venue staff are trained to manage situations involving intoxicated visitors and can arrange appropriate support, from helping the person to a safe area to calling emergency services if necessary.

Inside the Venue: Reporting to Staff

If someone crosses your boundaries, start with directness. “Stop,” “No,” and “I don’t want this” are clear, unambiguous statements. Move your body away from the person. If you can leave the area, do so. You don’t need to stay and explain, negotiate, or give them a second chance.

Once you’re away from the situation, speak to a member of staff. Tell them what happened, where it happened, and describe the person involved as clearly as you can. Reputable venues take these reports seriously. Depending on the severity, staff may speak to the individual, issue a warning, remove them from the venue, or — in serious cases — contact the police.

If you witness someone else being harassed or in obvious discomfort, a simple intervention — “He said no” or “Are you alright, mate?” — can interrupt the situation. Whether or not you intervene directly, you can also inform staff and point out who was involved. Bystander action is one of the most effective tools for maintaining a safe environment, and it doesn’t require confrontation; it requires attention and a willingness to act.

After You Leave: External Support and Reporting

For more serious incidents — anything that felt like assault, anything that left you feeling unsafe or violated — support exists beyond the venue. A survey of over 600 LGBTQ+ people conducted by LGBT HERO found that 76% of respondents had experienced sexual assault, violence, or abuse; among those, 80% had been groped or touched without consent, and 68% had their sexual boundaries ignored. More than one in five (21%) had been sexually assaulted in an LGBTQ+ venue. These are not marginal figures, and knowing your options is genuinely important.

Galop is the UK’s specialist LGBT+ anti-abuse charity. Their national helpline (0800 999 5428) is staffed by people with specific experience supporting LGBT+ survivors of sexual violence, domestic abuse, and hate crime. They can talk through what happened, explain your options, and help you decide what steps, if any, you want to take next. Details of current hours are available at galop.org.uk.

SurvivorsUK runs the National Male and Non-Binary Survivors Helpline for men, boys, trans and non-binary people who have experienced sexual abuse at any time in their lives. You can reach them by phone on 0808 801 0332 (Monday to Friday, 10am to 12pm), by webchat at survivorsuk.org (Monday to Sunday, 12pm to 8pm), or by text and WhatsApp on 0786 003 1252 (Monday to Sunday, 12pm to 8pm). Their service is confidential.

NHS Sexual Assault Referral Centres (SARCs) are available across the UK and provide medical, practical, and emotional support to anyone who has been raped or sexually assaulted. You can access a SARC without reporting to the police, and they can carry out a forensic examination if you choose. You can find your nearest SARC through the NHS website or by calling 111.

The 24/7 Rape and Sexual Abuse Support Line, operated by Rape Crisis England and Wales, is available to all victims and survivors aged 16 and over, including men. You can call free on 0808 500 2222 at any time, day or night, or start a free online chat through their website.

Whether or not to report to the police is your decision. The reasons for under-reporting are well-documented and specific to MSM: fear of being outed, distrust of the police rooted in historical criminalisation, minimisation, shame, and concern about not being believed. These barriers are real. You have the right to report, and you have the right not to. What matters is that you know the option exists and that support is available regardless of which path you choose.

A sexualised environment does not reduce your right to consent. Being in a sauna, being naked, being in a dark room, having been interested in sex earlier in the evening — none of these things diminish the seriousness of what happened to you if your boundaries were crossed. If something felt wrong, it matters.

Attending a sauna with someone you know changes the dynamic in ways that are worth thinking about before you arrive rather than improvising on the night. The most important conversation happens before you walk through the door. If you’re attending with a partner, discuss in advance what you’re each comfortable with: are you there to play together, to play separately, to explore with others, or simply to enjoy the facilities? What would you each want to happen if one of you is approached by someone else? Is there a signal for “I’d like to leave”? These aren’t prescriptive questions with right answers — they’re questions where any answer is fine as long as both people agree on it beforehand.

The environment inside a sauna is designed for spontaneity with strangers, and it’s not a great setting for complex negotiations between people who already know each other and have feelings at stake.

Inside the venue, couples and groups should be mindful of how they use communal areas. Forming a tight, inward-facing cluster in a steam room or jacuzzi can make solo visitors feel excluded or unwelcome, even if that wasn’t your intention.

If you and your partner are open to others joining, make that clear to each other first, then communicate it to others through the usual non-verbal signals or, better yet, through a brief verbal invitation. If you prefer to keep things between the two of you, private cabins are the appropriate choice. Using a public area and then objecting to others showing interest is a mismatch between the area you’ve chosen and the boundary you’re trying to set.

For a dedicated treatment of how to approach this decision, including the pre-visit conversations worth having, see Going Alone vs. Going With a Friend to a Gay Sauna: How to Decide.

Although the principles covered in this guide are consistent across UK gay saunas, the atmosphere and culture of individual venues can differ considerably. Some saunas are sociable and community-oriented, with a busy café, regular events, and a crowd that treats the place as much as a social club as a sexual one. Others are quieter, more anonymous, and more heavily focused on cruising and sexual encounters. Neither type is better or worse; they serve different needs and suit different preferences.

When you arrive at a venue for the first time, give yourself time to observe before deciding how to behave. Notice how men use the café area — is it a lively social hub or a quiet waiting room? Pay attention to how loud or quiet the steam rooms and wet areas are. Watch how people move through the building: are they lingering and socialising, or moving purposefully between play areas? Notice how staff interact with visitors. These cues will tell you more about the venue’s culture in ten minutes of observation than any amount of online research.

Many men try more than one venue over time, and this is worth doing. There’s no obligation to commit to a single venue, and experiencing more than one gives you a better sense of the range available and where you feel most comfortable. For venue-specific details including location, facilities, and opening times, visit the UK Gay Sauna Directory.

Everything in this guide — the etiquette, the consent framework, the advice on substances and reporting — connects to a single underlying principle: respect for the shared nature of the venue and the people in it.

A gay sauna works well when the men inside it look after themselves, pay attention to how their behaviour affects others, and accept that not everyone is there for the same reason. It works badly when individuals treat their own desires as the only thing that matters, when silence is exploited rather than respected, and when the vulnerability inherent in a sexualised environment is treated as an opportunity rather than a responsibility.

These venues serve a purpose that goes beyond recreation. For men who are not out, who lack access to other queer social environments, who are exploring their sexuality for the first time, or who simply want somewhere their desires are treated as normal rather than exceptional, a well-run sauna offers something genuinely valuable: somewhere you can be yourself without explanation.

Good etiquette is not a restriction on your enjoyment. It’s the foundation that makes enjoyment possible — for you and for every other man in the building. When people feel able to say yes and no freely, when privacy is protected, when hygiene is maintained, and when boundaries are respected, anxiety drops and trust rises.

You don’t need to be experienced to belong in a sauna. You don’t need to be confident, or attractive by any particular standard, or sure of what you want. You need to treat others — and yourself — with respect. Over time, the rest follows.

Beres, M.A., Herold, E. & Maitland, S.B. (2004). Sexual Consent Behaviors in Same-Sex Relationships. Archives of Sexual Behavior, 33(5), 475–486.

Crown Prosecution Service. Rape and Sexual Offences — Chapter 6: Consent. cps.gov.uk.

Data (Use and Access) Act 2025. legislation.gov.uk.

Howley, I. (2025). We Need to Talk About Consent. LGBT HERO. lgbthero.org.uk.

R v Bree [2007] EWCA Crim 804.

Sexual Offences Act 2003, s.67 (Voyeurism). legislation.gov.uk.

Sexual Offences Act 2003, s.74 (Consent). legislation.gov.uk.

Webber, V., McCready, S., Young, C., Dietzel, C., Eaton, A.D., McKie, R.M., Lowe, D.J. & Numer, M. (2024). Are Queer Men Queering Consent? A Scoping Review of Sexual Consent Literature Among Gay, Bisexual, Trans, and Queer Men. International Journal of Sexual Health. PMC11323870.