Alcohol consumption and sexual risk-taking in adolescents
Barbara C. Leigh
In recent years, the public health field has seen an increasing amount of research devoted to adolescent sexual behavior. In 1983, 74 percent of women and 83 percent of men in the United States reported that they had engaged in sexual intercourse before their 20th birthdays (National Research Council 1987). A more recent survey found that 25 percent of 14- to 15-year-olds and 55 percent of 16- to 17-year-olds reported having had intercourse at lease once in their lives (Alcohol Research Group unpublished data 1991). Adolescents tend not to use contraceptives (Morrison 1985), and risks of unprotected intercourse include not only pregnancy but transmission of sexually transmitted diseases (STDs), including acquired immunodeficiency syndrome (AIDS).
The incidence of STDs is high among adolescents (Bell and Holmes 1984); it is estimated that one-fourth of STD victims are infected before leaving high school (Kroger and Wiesner 1981). The number of current AIDS cases among adolescents is relatively small (Miller et al. 1990); however, because the human immunodeficiency virus (HIV) causing this disease has a long incubation period, it is likely that many young adults who have a diagnosis of AIDS were infected with the virus as adolescents. Moreover, the proportion of AIDS cases attributable to heterosexual transmission is two to three times higher among adolescents than among adults (Goldsmith 1988).
Because the prospect of either a vaccine or a cure for AIDS remains remote, efforts to stem the spread of HIV infection have increasingly emphasized prevention. Public health research has focused on identifying individual and situational factors associated with sexual risk-taking behaviors (such as unprotected intercourse) that expose individuals to HIV. One of these factors is the use of alcohol or other drugs in conjunction with sex (Leigh 1990a; Stall 1989). Alcohol use and sexual activity often are initiated during the teenage years, and approximately one-half of both male and female adolescents report that they drank alcohol at the time of their first sexual encounters (Flanigan and Hitch 1986; Robertson and Plant 1988). If alcohol interferes with judgment and decision making, then its use in association with sexual activity might increase the likelihood of unprotected intercourse (Howard et al. 1988).
This article considers evidence regarding the relationship between alcohol use and sexual risk-taking in adolescents. For the purpose of this discussion, “sexual risk-taking” is defined as unprotected intercourse, with the recognition that protection against pregnancy and protection against AIDS and other STD s sometimes involve the use of different methods of contraception. First, we present findings from research on adolescents, along with a discussion of the limitations inherent in the research methods used to generate these data. Second, we consider certain characteristics of adolescents that may contribute to a relationship between drinking and sexual risk-taking, and highlight ways in which this relationship may differ for adolescents and adults. Finally, we present conclusions that may be drawn from this research, and suggest directions for future investigation.
REVIEW OF RESEARCH ON
Any discussion of research on the relationship between alcohol use and sexual risk–taking must take into account the limitations of research methods used. The ideal means for testing whether alcohol consumption causes a particular behavior is an experimental study in which alcohol is administered to one group and a placebo is given to a control group. Controlled laboratory experiments have been used to investigate the influence of alcohol on various physiological and psychological responses to sexual stimuli in adult men and women (see Crowe and George 1989 for review). However, it is impossible to design a controlled experiment to study the influence of alcohol on actual sexual behavior in a natural setting. Furthermore, because consumption of alcohol by minors in a laboratory setting is precluded by minimum drinking age laws, there are no such studies of alcohol-related sexual responses and behaviors in adolescents.
For these and other reasons, most research concerned with the connection between alcohol use and sexual activity has taken the form of correlational studies. In these studies, measures of individual drinking habits and sexual activities are collected (often by means of a survey), and the relationships between these measures are examined. Surveys of adolescents have found that sexually active young men and women are more likely to use alcohol than are those who have not yet had sexual intercourse (Coles and Stokes 1985; Mott and Haurin 1988; Zabin et al. 1986), and that there is a positive correlation between frequency of sexual activity and extent of alcohol use (Bentler and Newcomb 1986; Zucker et al. 1981). However, the statistical associations between these behaviors are not always strong, and these correlations may result from other factors, including personality characteristics (such as impulsivity or desire to flout social restraints), or a certain lifestyle that involves both drinking and sexual activity (Wilsnack 1984).
Similar correlational studies of adolescents have investigated the relationship between drinking habits and contraceptive use. Some studies have shown that young women who are heavy drinkers are less likely to use contraception than are lighter drinkers and abstainers (Jaccard 1987; Zucker et al. 1981). A more recent survey has shown that adolescents who are heavy drinkers are less likely to use condoms than are nondrinkers (Hingson et al. 1990).
An association between drinking behavior and the frequency of unprotected intercourse does not demonstrate that drinking has a direct impact on contraceptive use; correlational data are insufficient to infer cause. A relationship between drinking and sexual behaviors may involve a host of other variables. Both drinking and unprotected intercourse may be indicators of a constellation of general sensation-seeking or risk-taking activities (Adlaf and Smart 1983; Zuckerman 1979), or may indicate an inability to control impulsive behavior. In addition, correlational data do not establish whether drinking and sexual risk-taking took place on the same occasion. It is impossible to determine from such data whether heavier drinkers are less likely to use contraceptives in general, or whether they are less likely to use contraceptives during the particular sexual encounters during which they are drinking.
To address limitations of correlational studies, some investigators have used an event-specific technique in which survey respondents are asked a number of questions about specific sexual incidents and about the presence or absence of alcohol during these incidents. In one such event-specific study, Robertson and Plant (1988) found a strong relationship between drinking and nonuse of contraception at first intercourse in their sample of Scottish adolescents: only 24 percent of young women and 13 percent of young men who had been drinking at first intercourse reported using contraception, while 68 percent of young women and 57 percent of young men who had not been drinking reported contraceptive use (Figure 1). In a sample of young American women, Flanigan and Hitch (1986) found that only 34 percent of those who drank at the time of first intercourse used contraception. By comparison, 51 percent of those who did not drink used contraception.
Flanigan and Hitch (1986) also found that the connection between alcohol use and lack of contraception was particularly strong among women whose first intercourse was not planned (Figure 2). Of those women who planned intercourse, 67 percent of those who drank alcohol and 54 percent of those who did not drink reported using some method of birth control. Among women who did not plan intercourse, only 18 percent of those who drank reported using contraceptives, while 44 percent of women who did not drink used contraceptives.
Because the event-specific technique ensures that drinking and sexual activity are temporally paired in the incidents studied, the resulting data represent an improvement over data from correlational studies. However, this event-specific information does not necessarily take other confounding variables into account. A general predisposition to risk taking, for example, may influence both drinking and unprotected intercourse: risk takers may be more likely to drink on any given occasion and aloo may be more likely to engage in unprotected intercourse on any given occasion (Cooper et al. 1990). Knowledge about a specific occasion does not necessarily reveal whether these individuals are more likely to engage in unprotected intercourse when they are drinking than when they are not. Data on discrete events, while providing information on the co-occurrence of both alcohol consumption and high-risk sexual behavior, still do not provide compelling evidence that drinking causes sexual risk-taking.
A limitation of research n contraceptive use by adolescents, for purposes of investigating certain consequences of sexual risk-taking (such as transmission of AIDS), is that these studies often consider all contraceptives, including those that are ineffective as protection against sexually transmitted diseases. Although the condom is the method most commonly used by adolescents at first intercourse, its use by adolescents declines over time from the initiation of sexual activity, in favor of birth control pills (Morrison 1985). Furthermore, some research on adolescent contraceptive use relies on information obtained from clinic-based studies; because adolescents generally visit clinics to obtain birth control pills (Zelnik et al. 1981), these studies can implicitly emphasize the use of this contraceptive technique and thereby slant the body of knowledge concerning adolescent contraceptive attitudes and choices.
Much of the existing data on the relationship between alcohol use and sexual risk-taking comes from studies of adults and, particularly since the advent of the AIDS epidemic, from samples of male homo-sexuals. Correlational studies of adults suggest that the frequency of combining alcohol use with sexual activity is positively associated with the frequency of engaging in high-risk (in terms of AIDS infection) sexual behavior (see Leigh 1990a for review). However, studies of adults using the event-specific technique described above have yielded contradictory results, with some studies finding no relationship between drinking and unprotected intercourse (Doll 1989; Leigh 1990b; Temple and Leigh 1990), and others reporting weak relationships (Trocki and Leigh in press). These equivocal findings stand in contrast to the more robust findings from event-specific studies of adolescents discussed earlier. The following discussion focuses on adolescent characteristics that may contribute to the relationship between drinking and high-risk sexual activity, and that may explain why this relationship may be different for adolescents than for adults.
First, both drinking and sexual activity typically are initiated during adolescence, and because both are usually timed to occur when adults are absent, a natural pairing of these activities may result. Adolescents are novices in both realms; their decision regarding drinking and intercourse may reflect the limited knowledge and experience one might expect of beginners. At the same time, adolescents often are unable or unwilling to consider the consequences of risky behaviors, including the dangers intrinsic to alcohol and other drug use and the risks of unprotected intercourse such as pregnancy (Allgeier 1983; Cvetkovich et al. 1975) and AIDS infection (Price et al. 1985).
Second, adolescents’ perceptions of alcohol as a sexual disinhibitor may play a role in alcohol-related sexual activity. The belief that drinking loosens restraints and reduces inhibitions, including those associated with participation in sexual activity, is common among both adolesecents and adults (Goldman et al. 1987; Reinarman and Leigh 1987). Because adolescents may have somewhat more ambivalent feelings about engaging in sexual activity than do adults, the perceived power of alcohol as a sexual disinhibitor may be an especially important influence on adolescents’ decisions regarding participation in sexual activity and use of contraception. The possession and use of contraceptives, particularly among adolescent women, may indicate that sexual activity was planned (Byrne and Fisher 1983; Luker 1975); however, such planning is inconsistent with a cultural “‘sexual mystique’ [that] includes a strong preference for impulsiveness and spontaneity” (Gross and Ballew-Smith 1983, p.266). The desire to be “swept away” by sexual feelings, and perhaps to go so far as having unprotected intercourse, may be facilitated by alcohol consumption if adolesecents believe alcohol to be a sexual disinhibitor with the power to make one “lose one’s head.”
In addition, adolescent choices with regard to sexual activity may be influenced by the degree to which psychosocial and sexual identify have developed. Several authors have stressed the importance of the development of psychosocial and sexual identity on adolescent contraceptive use, suggesting that adolescents may be unable to accept the fact that they now have sexual motivations and interests. This inability to acknowledge their sexuality interferes with planning for intercourse; thus adolescents may engage in sexual activity before they are psychologically and emotionally equipped to make decisions about contraception (Cvetkovich et al. 1975; Jorgenson 1980; for a more complete review, see Morrison 1985). Furthermore, Cvetkovich and Grote (1983) have suggested that adolescents who engage in sexual activity before they are developmentally prepared for it may place themselves in situations in which they relinquish personal control (for example, by becoming drunk), thereby avoiding responsibility for their actions. In this way, the responsibility for having unplanned and unprotected sex is placed on the drink rather than on the drinker (see Coles and Stokes 1985).
Finally, alcohol-related sexual risk-taking may be part of a “problem behavior syndrome” that has been identified among adolescents (Donovan and Jessor 1985). Adolescent problem behaviors are those that are socially defined by adult norms as undesirable, such as delinquent behavior (for example, truancy or vandalism), alcohol and other drug use, and precocious sexual activity. Rather than assuming a causal relationship between specific behaviors (for example, between drinking and sexual activity), problem behavior theory postulates that these various activities are interrelated manifestations of a single underlying syndrome of unconventionality or tendency toward deviance (Donovan et al. 1991; Osgood et al. 1988). Research has demonstrated strong positive relationships among a variety of such behaviors in some adolescents (Donovan and Jessor 1985; Donovan et al. 1988; Jessor and Jessor 1977). One study of adolescents found that high-risk sexual activity was correlated with a variety of problem behaviors, including alcohol and other drug use and cigarette smoking (Biglan et al. 1990).
Because conventional standards for some of these behaviors change with age, problem behavior theory suggests that associations between some behaviors would be stronger for adolescents than for adults. Drinking and sexual activity are seen as inappropriate and undesirable for adolescents, but are more accepted for adults. If the observed relationships between alcohol use and sexual activity results from the fact that both are considered “deviant” for adolescents, then the association between them may weaken with increasing age (Osgood et al. 1988).
CONCLUSIONS AND CAVEATS
Considerable research has shown that the use of alcohol is correlated with early sexual activity, and a smaller body of work has suggested that the use of alcohol may be related to nonuse of contraception in adolescents. Much of this existing research is limited, in that some data come from small, nonrepresentative samples (such as groups of health clinic clients); specific contraceptive methods often are not distinguished; and cultural and ethnic differences have not been explored fully. We are far from being able to make definitive statements about the causal nature of any relationship between alcohol use and unprotected intercourse.
Some researchers have noted a “malevolence assumption” (Collins 1981) with regard to alcohol: the mere presence of alcohol in any sort of untoward event is seen as sufficient evidence to impute cause to the alcohol rather than to other possible factors. The assumption that alcohol use directly causes adolescents to engage in high-risk sexual activity is not conclusively supported by the available evidence. As Dr. Enoch Gordis, Director of the National Institute on Alcohol Abuse and Alcoholism, has explained, “… whether [high-risk] sexual behavior is a reflection of a general kind of behavior in adolescence, or whether the alcohol itself at the time of sex[ual activity] is related to the judgment at [the time]…we are not sure” (Addiction Research Foundation 1990).
In some ways, the societal acceptance of alcohol as a sexual disinhibitor may hinder the progress and application of research: if drinking itself is assumed to cause high-risk sexual behavior, then other possible factors contributing to the relationship between alcohol use and sexual risk-taking may not be explored.
In conclusion, we wish to stress the importance of understanding, not simply observing, the link between drinking and sexual risk-taking. It is unrealistic to propose a single explanation for this relationship. The search for explanations must encompass psychological, environmental, and cultural perspectives (see Leigh 1990a; Ostrow 1986; Stall et al. 1986), and further efforts must attend to research and theory from all of these disciplines. From a public health standpoint, a full understanding of these behaviors is important, given that one’s view of the cause of a problem determines one’s view of its solution. Thus, identifying whether the cause of alcohol-related sexual risk-taking lies with the individual, the alcohol, or the environment in which both exist is an important step in identifying appropriate strategies for intervention.
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BARBARA C. LEIGH, PH.D., is a scientist with the Alcohol Research Group, Medical Research Institute of San Francisco, Berkeley, California.
DIANE M. MORRISON, PH.D., is a research assistant professor, Center for Social Welfare Research, School of Social Work, University of Washington, Seattle, Washington.
Preparation of this manuscript was supported by National Institute on Alcohol Abuse and Alcoholism grant AA08564 (Dr. Leigh) and National Institute of Allergy and Infectious Diseases grant AI29507 (Dr. Morrison).
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