Contents lists available at ScienceDirect International Journal of Drug Policy journal homepage: www.elsevier.com/locate/drugpo Chemsex and mental health as part of syndemic in gay and bisexual men Perry N. Halkitis a, ⁎ , Stuart N. Singer b a Rutgers School of Public Health, Rutgers University, Center for Health, Identity, Behavior & Prevention Studies (CHIBPS), RWJ Medical School, Rutgers University, Graduate School of Applied and Professional Psychology, Rutgers University, School of Public Affairs and Administration, Rutgers University, United States b Center for Health, Identity, Behavior & Prevention Studies (CHIBPS), United States ARTICLE INFO Keywords: Chemsex Gay and bisexual men Non injection drug use Mental health Sexual behaviors Syndemic Resilience HIV STIs ABSTRACT A commentary is provided on the study reported by Garrett Prestage and his colleagues, which examined the relations between mental health states, non-injection drug use and sexual risk behaviors in a cross-sectional sample of 3,017Australian gay and bisexual men. We provide a summary of the findings in relation to the extant literature on the interconnectedness of these behaviors and health states and interpret the findings in this regard, noting both strengths and limitations. We couch our commentary in a theory of syndemics for considering how these associations may manifest and for informing both research and practice. While the data from this in- vestigation posit risk they also point to strength and suggest the application of a resilience framework for ad- dressing the health needs of gay and bisexual men. In this special issue on chemsex and its associated risks, Garrett Prestage and his colleagues examine the relations between mental health states, non-injection drug use (NDU) and sexual risk behaviors in a cross-sectional sample of 3,017Australian gay and bisexual men (GBM). The investigative team found relatively high levels of anxiety as well as licit and illicit drug use, but no significant associations were found between poor mental health and drug use, or between mental health and sexual risk behaviors. With the exception of tobacco use, which was associated with increased anxiety and depression, other drug use was only associated with anxiety and depression when it was considered problematic or dependent, either by the user or by others. Further, use of erectile dysfunction medications (EDMs), which GBM often use to enhance sexual pleasure, often in combination with me- thamphetamines in the context of sex partying, was associated with decreased anxiety and depression, and higher self-esteem. Contrary to the hypotheses set forth by Prestage et al., sexual risk behavior also was not associated with either depression or anxiety; in fact, the practice of any anal intercourse was associated with higher self-esteem, and group sex was more commonly practiced by GBM with higher self-esteem and lower levels of depression and anxiety. Poor mental health states were associated with social isolation, including less social support, being less socially engaged with other gay men, and a self-perception of being “feminine,” which researchers conclude may drive social isolation in social and cultural contexts that may favor particular forms of mascu- linity. Poor mental health states were also associated with discrimina- tion and marginalization, including less education, lack of employment, lower socioeconomic status, and cultural or ethnic minority status. However, the work provides a clean snapshot of drug use and sex risk behaviors as wel as mental health in Australian men at present. These findings are considered below in relation to the extant literature and with regard to a theory of syndemics, which provides a lens through which to understand the complex relations that exist between drug use, mental health burdens, and sexual risk taking in GBM. The study undertaken by Prestage et al. adds to the growing tome that identifies the complex and intricate synergies that exist between non injection drug use and sexual risk in gay and bisexual men in Australia and globally. In fact, non-injection drug use is a health dis- parity experienced by the LGBTQ population (Graham et al., 2011). Throughout the course of the HIV crisis, non-injection drug use has been scrutinized in GBM (Halkitis et al., 2011; Stall & Purcell, 2000) and implicated in the ongoing transmission of the virus (Koblin et al., 2006; Ostrow et al., 2009) and other sexually transmitted infections (STIs) (Hirshfield, Remien, Humberstone, Walavalkar, & Chiasson, 2004), and HCV which has shown to be sexually transmitted in GBM (Witt et al., 2013). Non injection drug use is more prevalent in GBM than injection drug use (Voetsch et al., 2012) but comparable to in- jection drug use as a driver of HIV incidence (Strathdee & Stockman, 2010). While the extant literature on drug use prior to the HIV crisis is more limited, Martin et al. (Martin, Dean, Garcia, & Hall, 1989) documented the high rates of alcohol use in the population. In this regard, the work of Prestage and his colleagues is situated in a long tradition of research scrutinizing the impact of non-injection drug use https://doi.org/10.1016/j.drugpo.2018.04.002 Received 30 January 2018; Received in revised form 30 March 2018; Accepted 4 April 2018 ⁎ Corresponding author. E-mail address: perry.halkitis@rutgers.edu (P.N. Halkitis). International Journal of Drug Policy xxx (xxxx) xxx–xxx 0955-3959/ © 2018 Elsevier B.V. All rights reserved. Please cite this article as: Halkitis, P.N., International Journal of Drug Policy (2018), https://doi.org/10.1016/j.drugpo.2018.04.002