{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,8]],"date-time":"2026-10-08T22:46:31Z","timestamp":1791499591954,"version":"4.3.4"},"reference-count":37,"publisher":"Public Library of Science (PLoS)","issue":"5","license":[{"start":{"date-parts":[[2026,5,14]],"date-time":"2026-05-14T00:00:00Z","timestamp":1778716800000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["www.plosglobalpublichealth.org"],"crossmark-restriction":false},"short-container-title":["PLOS Glob Public Health"],"abstract":"<jats:p>Section 377 of the Pakistan Penal Code penalizes same-sex behavior with life imprisonment. There is a high degree of religious stigma against men who have sex with men (MSM) in Pakistan. The social and legal framework adds to the minority stress for MSM in Pakistan. We conducted a cross-sectional study aimed at examining the association of amphetamine-type stimulant (ATS) use with anxiety and depressive symptoms, and their association with suicidal ideation. Generalized Anxiety Disorder-7 (GAD-7), Patient Health Questionnaire-9 (PHQ-9), and Ask for Suicide Questionnaire-5 (ASQ-5) were used in this study. MSM were recruited from community organizations using convenience sampling from 5 July 2025\u20135 August 2025. A total of 735 participants identifying as MSM were included in the study. About 10.5% reported ATS use, and 25.4% reported SDU. The prevalence of moderate and severe anxiety symptoms was 12.45% and 14.4%, respectively. The prevalence of moderately severe and severe depressive symptoms was 9.4% and 8.4%, respectively. Around 26.8% of MSM included in the study were non-acute positive, and 6.8% were acute positive for the suicide screen. Having a homosexual partner and ATS use were associated with higher GAD-7 score, \u03b2\u2009=\u20091.044 (BCa 95% CI 0.083 to 1.919, p\u2009&lt;\u20090.05) and \u03b2\u2009=\u20095.523 (BCa 95% CI 3.932to 7.257, p\u2009&lt;\u20090.001), respectively. ATS use was also associated with an increased PHQ-9 score, \u03b2\u2009=\u20096.258 (BCa 95% CI 4.418 to 8.207, p\u2009&lt;\u20090.001), ATS use, PHQ-9, and GAD-7 increase suicidal ideation with the odds ratios of 3.76 (95% CI 1.788 to 7.721), 1.166 (95% CI 1.106 to 1.229), and 1.152 (95% CI 1.093 to 1.214), respectively. Overall, ATS use was high among MSM and associated with the symptoms of anxiety, depression, and suicidal ideation. Comprehensive mental health screening and harm reduction programs for ATS use should be provided to MSM in Pakistan.<\/jats:p>","DOI":"10.1371\/journal.pgph.0006370","type":"journal-article","created":{"date-parts":[[2026,5,14]],"date-time":"2026-05-14T17:45:16Z","timestamp":1778780716000},"page":"e0006370","update-policy":"https:\/\/doi.org\/10.1371\/journal.pgph.corrections_policy","source":"Crossref","is-referenced-by-count":1,"title":["Sexualized drug use, anxiety, depression, and suicidal ideation among men who have sex with men in Pakistan: Results of a multi-center cross-sectional survey"],"prefix":"10.1371","volume":"6","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-9168-5911","authenticated-orcid":true,"given":"Usman","family":"Ali","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Syed Azhar","family":"Ali","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0002-5447-4802","authenticated-orcid":true,"given":"Syed Raza Haider","family":"Tirmizi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tanzil ur","family":"Rehman","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tehseen","family":"Azar","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Babar","family":"Yasin","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Aftab Tawab","family":"Siddiqi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2026,5,14]]},"reference":[{"key":"pgph.0006370.ref001","unstructured":"Map of jurisdictions that criminalise LGBT people. 2023. https:\/\/www.humandignitytrust.org"},{"key":"pgph.0006370.ref002","article-title":"Pakistan blocks five dating apps including Tinder and Grindr","author":"GN Peshimam","year":"2020","journal-title":"Reuters"},{"issue":"2","key":"pgph.0006370.ref003","doi-asserted-by":"crossref","first-page":"227","DOI":"10.1080\/10538720.2021.1948941","article-title":"Abuse and violence experienced by gay men living in pakistani cultural context: an interpretative phenomenology analysis","volume":"34","author":"A Pervez","year":"2021","journal-title":"J Gay Lesbian Soc Serv"},{"key":"pgph.0006370.ref004","doi-asserted-by":"crossref","first-page":"41","DOI":"10.1177\/1363460716633393","article-title":"Outing the Pakistani queer: pride, paranoia and politics in US visual culture","volume":"20","author":"M Charania","year":"2016","journal-title":"Sexualities"},{"key":"pgph.0006370.ref005","doi-asserted-by":"crossref","first-page":"849","DOI":"10.1348\/014466609X485025","article-title":"Coping with potentially incompatible identities: accounts of religious, ethnic, and sexual identities from British Pakistani men who identify as Muslim and gay","volume":"49","author":"R Jaspal","year":"2010","journal-title":"Br J Soc Psychol"},{"key":"pgph.0006370.ref006","unstructured":"Pakistan AIDS strategy IV 2021-2025. 2020."},{"key":"pgph.0006370.ref007","unstructured":"Integrated biological and behavioral surveillance of HIV in Pakistan: Round 5 - 2016-17. 2017."},{"key":"pgph.0006370.ref008","unstructured":"Ali U. National HIV stigma index. 2024."},{"issue":"3","key":"pgph.0006370.ref009","doi-asserted-by":"crossref","first-page":"212","DOI":"10.1521\/aeap.2015.27.3.212","article-title":"Correlates of internalized homonegativity among black men who have sex with men","volume":"27","author":"K Quinn","year":"2015","journal-title":"AIDS Educ Prev"},{"key":"pgph.0006370.ref010","doi-asserted-by":"crossref","first-page":"101579","DOI":"10.1016\/j.copsyc.2023.101579","article-title":"Minority stress theory: application, critique, and continued relevance","volume":"51","author":"DM Frost","year":"2023","journal-title":"Curr Opin Psychol"},{"key":"pgph.0006370.ref011","doi-asserted-by":"crossref","DOI":"10.3390\/jcm13061812","article-title":"Sexualized drug use and chemsex among men who have sex with men in Europe: a systematic review and meta-analysis","volume":"13","author":"M Coronado-Mu\u00f1oz","year":"2024","journal-title":"J Clin Med"},{"key":"pgph.0006370.ref012","doi-asserted-by":"crossref","DOI":"10.3390\/ijerph20032751","article-title":"Understanding sexualized drug use: Substances, reasons, consequences, and self-perceptions among men who have sex with other men in Spain","volume":"20","author":"D \u00cdncera-Fern\u00e1ndez","year":"2023","journal-title":"Int J Environ Res Public Health"},{"issue":"7","key":"pgph.0006370.ref013","doi-asserted-by":"crossref","DOI":"10.2196\/17894","article-title":"Influence of social media on sexualized drug use and chemsex among Chinese men who have sex with men: observational prospective cohort study","volume":"22","author":"Z Wang","year":"2020","journal-title":"J Med Internet Res"},{"issue":"1","key":"pgph.0006370.ref014","doi-asserted-by":"crossref","DOI":"10.1002\/jia2.26054","article-title":"Prevalence of sexualized drug use and risk of HIV among sexually active MSM in East and South Asian countries: systematic review and meta-analysis","volume":"26","author":"L Nevendorff","year":"2023","journal-title":"J Int AIDS Soc"},{"key":"pgph.0006370.ref015","unstructured":"Apcom. A qualitative scoping review of sexualised drug use (including Chemsex) of men who have sex with men and transgender women in Asia. 2021."},{"key":"pgph.0006370.ref016","unstructured":"The hidden crisis: The causes and consequences of sexualised drug use (\u2018chemsex\u2019) amongst key populations in Pakistan. 2022."},{"key":"pgph.0006370.ref017","doi-asserted-by":"crossref","first-page":"81","DOI":"10.1016\/j.eclinm.2019.09.014","article-title":"Mental health outcomes associated with of the use of amphetamines: a systematic review and meta-analysis","volume":"16","author":"R McKetin","year":"2019","journal-title":"EClinicalMedicine"},{"key":"pgph.0006370.ref018","volume-title":"Diagnostic and statistical manual for mental disorders (DSM-V TR)","year":"2022"},{"issue":"7","key":"pgph.0006370.ref019","first-page":"779","article-title":"Prevalence of depression and subjective job stress among men who have sex with men and transgender community health workers in Pakistan","volume":"33","author":"U Ali","year":"2023","journal-title":"J Coll Physicians Surg Pak"},{"issue":"8","key":"pgph.0006370.ref020","first-page":"1166","article-title":"Urdu translation and validation of PHQ-9, a reliable identification, severity and treatment outcome tool for depression","volume":"68","author":"S Ahmad","year":"2018","journal-title":"J Pak Med Assoc"},{"issue":"10","key":"pgph.0006370.ref021","first-page":"1536","article-title":"Urdu translation and validation of GAD-7: a screening and rating tool for anxiety symptoms in primary health care","volume":"67","author":"S Ahmad","year":"2017","journal-title":"J Pak Med Assoc"},{"issue":"7","key":"pgph.0006370.ref022","article-title":"Urdu-language translation and validation of the ask suicide-screening questions (ASQ) tool: a focus on connotation and context","volume":"16","author":"KI Afzal","year":"2024","journal-title":"Cureus"},{"issue":"11","key":"pgph.0006370.ref023","article-title":"Prevalence and predictors of depressive symptoms among people living with HIV in Pakistan; country-wide secondary data analysis from National Stigma Index Study","volume":"4","author":"U Ali","year":"2024","journal-title":"PLOS Glob Public Health"},{"issue":"1","key":"pgph.0006370.ref024","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0316853","article-title":"Screening for anxiety in patients with cancer: Diagnostic accuracy of GAD-7 items considering lowered GAD-7 cut-offs","volume":"20","author":"M Grapp","year":"2025","journal-title":"PLoS One"},{"key":"pgph.0006370.ref025","doi-asserted-by":"crossref","first-page":"606","DOI":"10.1046\/j.1525-1497.2001.016009606.x","article-title":"The PHQ-9","volume":"16","author":"K Kroenke","year":"2001","journal-title":"J Gen Intern Med"},{"issue":"6","key":"pgph.0006370.ref026","doi-asserted-by":"crossref","first-page":"590","DOI":"10.1111\/ceo.12358","article-title":"Understanding and checking the assumptions of linear regression: a primer for medical researchers","volume":"42","author":"RJ Casson","year":"2014","journal-title":"Clin Exp Ophthalmol"},{"issue":"9596","key":"pgph.0006370.ref027","doi-asserted-by":"crossref","first-page":"1453","DOI":"10.1016\/S0140-6736(07)61602-X","article-title":"The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies","volume":"370","author":"E von Elm","year":"2007","journal-title":"Lancet"},{"key":"pgph.0006370.ref028","unstructured":"Drug use in Pakistan. 2013."},{"issue":"9","key":"pgph.0006370.ref029","doi-asserted-by":"crossref","first-page":"983","DOI":"10.29271\/jcpsp.2023.09.983","article-title":"Assessment of acceptability of pre-exposure prophylaxis for HIV prevention among men who sex with men and transgender community in Pakistan","volume":"33","author":"U Ali","year":"2023","journal-title":"J Coll Physicians Surg Pak"},{"key":"pgph.0006370.ref030","unstructured":"Integrated biological and behavioral surveillance (IBBS) among key populations at high risk of HIV in Bangladesh. 2021."},{"key":"pgph.0006370.ref031","article-title":"Factors, practices and health needs of men who have sex with men, transgender and female sex workers engaged in sexualized drug use in Pakistan","author":"U Ali","year":"2025","journal-title":"AIDS Care - Psychol Socio-Med Aspects of AIDS\/HIV"},{"key":"pgph.0006370.ref032","doi-asserted-by":"crossref","DOI":"10.1017\/S2045796024000210","article-title":"Mental health and help-seeking in Czech sexual minorities: a nationally representative cross-sectional study","volume":"33","author":"M Pito\u0148\u00e1k","year":"2024","journal-title":"Epidemiol Psychiatr Sci"},{"issue":"10","key":"pgph.0006370.ref033","doi-asserted-by":"crossref","first-page":"3206","DOI":"10.1007\/s10461-023-04041-z","article-title":"Chemsex, anxiety and depression among gay, bisexual and other men who have sex with men living with HIV","volume":"27","author":"DJ Field","year":"2023","journal-title":"AIDS Behav"},{"issue":"1","key":"pgph.0006370.ref034","doi-asserted-by":"crossref","first-page":"38","DOI":"10.1186\/s12991-022-00414-1","article-title":"What is the global prevalence of depression among men who have sex with men? A systematic review and meta-analysis","volume":"21","author":"E Nouri","year":"2022","journal-title":"Ann Gen Psychiatry"},{"issue":"10","key":"pgph.0006370.ref035","doi-asserted-by":"crossref","first-page":"1294","DOI":"10.29271\/jcpsp.2025.10.1294","article-title":"The effect of emotional intelligence and employment on the psychological well-being of HIV key population workers","volume":"35","author":"U Ali","year":"2025","journal-title":"J Coll Physicians Surg Pak"},{"issue":"11","key":"pgph.0006370.ref036","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pgph.0002348","article-title":"Suicidal ideation, plan, and attempt among men who have sex with men in Nepal: findings from a cross-sectional study","volume":"3","author":"K Paudel","year":"2023","journal-title":"PLOS Glob Public Health"},{"issue":"1","key":"pgph.0006370.ref037","article-title":"Capacity needs of Pakistani psychiatrists to deliver community-sensitive mental health services to sexual minority men","volume":"6","author":"U Ali","year":"2026","journal-title":"PLOS Glob Public Health"}],"container-title":["PLOS Global Public Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pgph.0006370","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,5,14]],"date-time":"2026-05-14T17:45:26Z","timestamp":1778780726000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pgph.0006370"}},"subtitle":[],"editor":[{"given":"Prashanth Nuggehalli","family":"Srinivas","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2026,5,14]]},"references-count":37,"journal-issue":{"issue":"5","published-online":{"date-parts":[[2026,5,14]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pgph.0006370","relation":{},"ISSN":["2767-3375"],"issn-type":[{"value":"2767-3375","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,5,14]]}}}