Chemsex, Anxiety and Depression Among Gay, Bisexual and Other Men Who have Sex with Men Living with HIV

HIV has become a chronic rather than life-threatening condition due to significant advances in treatment [1]. However, despite significant improvements in efforts to end the epidemic, critical issues for people living with HIV remain. Quality of life in people living with HIV is known to be reduced, and they experience higher levels of psychological distress, including anxiety and depression [2]. Reduced levels of quality of life might be exacerbated in specific subgroups. Indeed, gay and bisexual men who have sex with men (gbMSM) face poorer outcomes related to their mental health when compared to their heterosexual counterparts [3]. This sexual orientation-related disparity in mental health has been attributed to the Minority Stress Theory [4]. The Minority Stress Theory posits that actual and perceived stigma, fear of rejection, internalised homophobia and concealing one’s sexuality all contribute to a higher prevalence of psychological distress.

Another difference between gbMSM and their heterosexual counterparts, which may contribute to psychological distress, is engagement in chemsex [5]. Chemsex is defined as drug use before or during sex with the specific intention to improve or prolong sex and has been described as a significant public health concern [6]. Some of the substances commonly associated with chemsex include but are not limited to; mephedrone, crystal meth and GHB/GBL [7]. These substances can be used independently or in combination, known as polydrug use. Chemsex has been most commonly observed among gbMSM [8]. Research indicates that gbMSM may be as much as three times more likely to partake in chemsex than their heterosexual counterparts [8], with multiple studies indicating gbMSM living with HIV are more likely to engage in chemsex [8]. Chemsex has also been linked to other risk-related sexual behaviours, including; transactional sex, group sex and fisting [3]. Drugs often linked to chemsex have been associated with psychological distress [8] with one study indicating that 25% of gbMSM engaging in chemsex self-reporting that it negatively impacted their mental health [9]. It has also been previously stated that there were higher rates of anxiety and depression among gbMSM chemsex users [9].

Data from the European Men Who Have Sex with Men Internet Survey (EMIS) [10] highlighted Amsterdam as an urban centre where participants reported the highest prevalence of chemsex use in the 4 weeks before completing the survey (59%). This study also showed an association between chemsex and living with HIV. Participants living with HIV had almost five times greater odds of engaging in chemsex [9]. This might, however, be an overestimation, as EMIS participants, in general, were younger, and more sexually active compared to the general gbMSM population [11]. Nevertheless, subsequent research has found that 20% of gbMSM in the Netherlands have reported a desire to change their behaviours related to drug use in general and chemsex in particular [12].

A 2019 systematic review of chemsex use indicated the practice is associated with various negative psychosocial impacts, including loss of friends and employment and reduced mental health [8]. Although much research to date has focused on the adverse outcomes associated with chemsex, it should be noted that not all research links chemsex to adverse mental health outcomes. Australian research indicates that one of the most ubiquitous chemsex drugs: GHB, is not associated with experiencing anxiety or depression [13].

The present study analyses the data from the online “Survey of Men and Sexuality” (SMS) [14]. We aimed to assess the prevalence of and associations between chemsex, anxiety and depression for gbMSM living with HIV. Research indicates that gbMSM living with HIV are more likely to partake in chemsex [8], this may be a volatile combination that requires further investigation. While much has been written about the possible relationship between chemsex and mental health, this study focuses specifically on gbMSM living with HIV to better understand the associations between chemsex use and the likelihood of experiencing anxiety and depression in this key population who are more likely to experience reduced mental health [2].

This study aimed to better understand the relationship between chemsex, anxiety and depression in gbMSM living with HIV. We found that engaging in chemsex, a behaviour traditionally thought of as high risk, was not associated with higher rates of anxiety and depression. Surprisingly, we found that engaging in chemsex was negatively associated with depression amongst gbMSM living with HIV in the Netherlands, such that people engaging in chemsex actually were less likely to qualify as potentially clinically depressed. Our findings contrast with the findings of previous research that has shown increased rates of psychological distress among gbMSM engaging in chemsex [5‐8, 21]. It has however been posited that not all chemsex is harmful [22]. Contemporary literature on the phenomenon often divides chemsex into two distinct categories, problematic and non-problematic [23]. Problematic chemsex has been described as chemsex leading to negative consequences impacting health and wellbeing either through recurrent STIs, negative social outcomes (e.g. job loss, relationship issues, financial distress) adverse mental health impact or addiction [21]. Non-problematic chemsex lacks these negative outcomes [21]. It should also be noted that the findings from this research do not stand alone. Previous Australian research looked relationships between mental health, sexual risk behaviour and drug use, found that men who used drugs including amyl nitrates, cocaine and GHB were less likely to show signs of depression [24]. This study also found no association between anxiety and this type of illicit drug use [24]. Our study adds to previous research showing that chemsex is not always associated with increased rates of anxiety or depression, extending current evidence to include findings from gbMSM living with HIV who may face unique challenges related to their mental health.

Harm reduction strategies have been identified as a method of preventing chemsex from becoming problematic and resulting in adverse outcomes [25]. A previous study in the Netherlands highlighted that sexual health services are well equipped to deal with chemsex, with 71% of sexual health nurses surveyed indicating that they address chemsex regularly or always during routine consultations with gbMSM. This allowed for the timely identification of problematic chemsex use and referrals to specialised chemsex-related healthcare [26]. The negative association may be related to the fact that over 96% (n = 345) of participants were engaged in HIV care and may have access to these supports.

Our study also showed that another traditionally high-risk behaviour, increased numbers of sexual partners, was associated with experiencing less anxiety and depression. This may reflect that gbMSM living with HIV who have higher numbers of partners can experience increased social connectedness [3], which has been described as a fundamental human need and has been linked to better outcomes for both mental and physical health [3]. The association between higher numbers of partners and lower rates of psychological distress may also reflect reversed causality or bi-directional influences. More specifically, participants who score in the depressive range may be more likely to socially isolate and be less likely to seek out sexual partners, as lower libido has been associated with depression in gay men [27]. These participants may then also be less likely to come into contact or engage in chemsex.

Our findings highlight that chemsex was not associated with increased rates of anxiety and depression and was, surprisingly, associated with lower rates of depression among gbMSM living with HIV and unrelated with rates of anxiety. It is, however, important to note that the interplay between chemsex and mental health is complex, as the variation in findings of previous research shows. Findings suggest that for the participating gbMSM living with HIV chemsex use may not have been problematic when focusing on anxiety and depression. It is however, possible participants experienced other negative psychosocial impacts not measured in this study. Further research would benefit from a more comprehensive collection of data regarding chemsex to allow for a thorough interrogation of how methods of consumption, frequency of use and other associated aspects of chemsex may or may not be associated with mental health outcomes among gbMSM living with HIV and engaging in chemsex.