Alcohol, drugs, and adolescent sexual behavior.

Subst Use Misuse Downloaded from informahealthcare.com by Karolinska Institutet University Library on 01/29/15 For personal use only.

The International Journal of the Addictions, 27(2), 129-146, 1992

Alcohol, Drugs, and Adolescent Sexual Behavior Lee Strunin, PhD Ralph Hingson, ScD School of Public Health Boston University Boston, Massachusetts

Abstract In a 1990 Massachusetts-wide random digit-dial telephone survey of 16- 19 year olds, 66%reported sexual intercourse of whom 64%had sex after drinking and 15 % after other drug use. Thirty-seven percent always used condoms. Forty-nine percent were more likely to have sex if they and their partner had been drinking, and 17% used condoms less often after drinking. Fewer, 32%,said they would be more likely to have sex if they and their partner had used drugs, with 10%less likely to use condoms after drug use. Since so few adolescents consistently use condoms, the greatest risk for HIV, sexually transmitted diseases, and unwanted pregnancy is the increased likelihood of having sex after drinking or drug use, not the decreased likelihood of condom use after drinking and drug use.

INTRODUCTION Unprotected sexual intercourse among adolescents contributes to infection with the Human Immunodeficiency Virus (HIV), other sexually transmitted diseases (STDs), and unwanted pregnancy. Despite substantial increases in reported knowledge about how HIV is transmitted, the adolescent population in the USA remains at “high risk” for HIV infection. Currently there have been over 186,000 129

Copyright 0 1992 by Marcel Dekker, Inc.


130

STRUNIN AND HINGSON

cases diagnosed and over 100,000deaths from AIDS in the USA (Centers for Disease Control, 1990). One-fifth of all cases have been in the 16-29 year old age group (Centers for Disease Control, 1990). Because of the long latency period of the disease, many in this group contracted HIV during adolescence. Although AZT and other treatments are prolonging the lives of AIDS patients, there still is no cure. Approximately one million persons in the USA are infected with HIV, and it has been estimated that 150,000-200,000 will die from AIDS in the next 2 years (Anonymous, 1991). Given these projections, AIDS will soon be the leading cause of death in the 16-29 year old age group. Adolescents are also at “high risk” for other sexually transmitted diseases. Each year teenagers comprise one-quarter of all STDs nationally (Aral and Holmes, 1984), and in Massachusetts the number of STDs among adolescents has doubled since 1985 (Massachusetts Department of Public Health, 1990). Other sexually transmitted diseases of most concern are chlamydia with an estimated 3-5 million cases annually (Haberberger et al., 1985; Washington et al., 1987), gonorrhea with an estimated one million cases annually (Rice et al., 1987), genital herpes with an estimated current prevalence of 20 million cases and 500,000 new cases annually (Hillard et al., 1984), condylomata, and other manifestations of Human Papilloma Virus. Not only is morbidity associated with these sexually transmitted diseases, but having been infected with a sexually transmitted disease increases the likelihood of HIV infection. A study of adolescent pregnancy and childbearing in the USA by the National Academy of Sciences reported that more than one million teenage girls in the United States become pregnant each year, just over 400,000 have abortions, and almost 470,000 give birth. The majority of these teenagers are unmarried, under 18 years of age, and most are poor. The consequences of early unintended pregnancy and birth are likely to be most severe among young adolescents and those from the most socially and economically disadvantaged backgrounds (Hayes, 1987). Although condoms can protect one from contracting HIV, other STDs, and unwanted pregnancy, many individuals who have this knowledge continue to engage in unprotected sexual intercourse. In a 1988 Massachusetts-wide random digit-dial telephone survey of 1,773 16-19 year olds, most adolescents knew the major modes of HIV transmission but their sexual and drug use behaviors continued to put them at risk for HIV infection (Hingson et al., 1990a, 1990b). Among the 61 % of adolescents who reported having had sexual intercourse in the past year, only 3 1% of them reported that they always used condoms and 32% sometimes used condoms. Other studies of adolescents’ condom use have found that although sexually active males and females report knowing that condoms prevent the spread of sexually transmitted diseases, they did not find an association between knowledge and increased condom use (Kegeles et al., 1989; Goodman and Cohall, 1989; Rickert et al., 1989).

ALCOHOL, DRUGS, AND ADOLESCENT SEXUAL BEHAVIOR

131


REASONS FOR UNPROTECTED SEXUAL INTERCOURSE Explanations for why adolescents have unprotected sexual intercourse despite the attendant risk of HIV infection, STDs, and pregnancy have utilized psychological models and psychosocial theories such as the Health Belief Model (Jam and Becker, 1984), the Theory of Reasoned Action (Fishbein and Ajzen, 1975), and the Social Learning Theory (Bandura, 1984). The Health Belief Model suggests that people who have engaged in a rational cost benefit analysis believe that they are susceptible to HIV infection; that the consequences of infection would be severe; that measures such as condom use, safe sex practices, fewer sex partners, and/or sexual abstention are effective in preventing transmission; and that barriers to adopting safer practices (e.g., cost/embarrassment) are minimal and may change their behavior. Research based on the Health Belief Model has shown many of these beliefs to be predictive of adopting preventive behavior to avoid HIV infection (Becker and Joseph, 1988). However, even those studies supportive of the Health Belief Model concerning AIDS have been able to explain only a small part of the variance in condom use. One reason may be because the studies did not also consider other beliefs about sexually transmitted disease or pregnancy (Hingson et al., 1990b; Strunin et al., 1990a). Further, partners’ beliefs are important: sexual intercourse and IV drug use needle sharing are engaged in by two or more persons. According to the Theory of Reasoned Action, the importance of the desire to please friends or partners as well as what respondents believe are partners or friends’ preferences can also influence the likelihood they will engage in preventive behavior (Fishbein and Ajzen, 1975). Social Learning Theory suggests that social reinforcement for behavior and anticipation of reinforcement or rewards for behavior based on observation of others and modeling of behaviors observed in others can also influence behavior (Bandura, 1984). If persons believe sex will be less likely if condoms are discussed because others tell them this, or if they have encountered resistance from a partner when they wanted to use a condom, then they may be less likely to attempt to use condoms. The concept of self-efficacy is also important because if people have confidence that they can successfully persuade others to use condoms, then they may be more likely to use them. Similarly, if people feel they know how to effectively use condoms without slippage or breakage, then they may be more likely to use them.

ALCOHOL AND DRUG USE AND UNPROTECTED SEXUAL INTERCOURSE All of these theories imply that people weigh the costs and benefits of condom use and make decisions about their use in light of these judgments. However, adolescents’ sexual encounters are frequently not planned, and alcohol and drug use


132

STRUNIN AND HINGSON

can affect all these judgments and influence sexual behavior. In a careful review of experimental studies of the effects of alcohol on sexual behavior and performance, Crowe and George (1989) concluded that while alcohol disinhibits sexual arousal, at higher doses or after chronic “heavy use” it suppresses response. Further, while suppression is physiologic in nature, disinhibition is both phannacologic (the result of cognitive impairment) and psychologic (the result of socially learned expectancies). It has long been known that “heavier” drinkers and drug users are more likely to engage in unprotected sex (Plant, 1990). Numerous hypotheses could be advanced to explain this behavior. According to Problem Behavior Theory (Jessor and Jessor, 1977), “heavy” drinkers and drug users may be more likely to be risk takers in general and hence less likely to use condoms. Drinking and drug use may occur in settings where strangers meet in hopes of sexual encounters. Consequently, they may be reluctant to ask new partners to use condoms if they think their asking will break the spontaneity of sex and in turn reduce the likelihood that it may occur (Plant, 1990). Alcohol and drug use, particularly in combination with condoms, may interfere with sexual pleasure and orgasm. Alcohol may compromise the rational cost benefit analysis implied in the Health Belief Model and disinhibit those otherwise inclined to use condoms (Hingson et al., 1990b). Alcohol and drugs may reduce a person’s sensitivity to the desires of others that condoms be used, or if one partner has been drinking the other partner may not feel they can be persuasive in encouraging the use of condoms. Although the mechanisms by which alcohol may reduce the likelihood of condom use or safer sex practices have not been delineated empirically, several studies have found that even after the advent of the AIDS epidemic, gay men were less likely to use condoms or engage in safer sex practices after drinking and/or drug use than when sober (Coates et al., 1988; Doll, 1989; Leigh, 1990; McKirnon and Peterson, 1989; Ostrow, 1987; Stall et al., 1986; Siegal et al., 1989; Valdeserri et al., 1988). One recent study among a cohort of gay men found that one-fifth of the men studied adopted safer practices but then relapsed into unsafe practices. Drinking and drug use was one of the most frequently cited reasons for relapse, particularly among men with no regular partner (Stall et al., 1990). It should be noted that some studies have not reported a relation, and one study (Martin, 1989) found a relation in a cohort of gay men that dissipated over time as both drinking and unsafe sex declined. A few studies have also found that unprotected sex is more likely to occur among adolescents after drinking than when not drinking (Flanigan and Hitch, 1980; Hingson et al., 1990b, 1990c; Robertson and Plant, 1988; Strunin et al., 1990b). Some studies have also found increased risk of unprotected sex after drug use. Among heterosexual adults, relationships have been less consistently observed (Beckman, 1979; Leigh, 1990; Temple and Leigh, 1990; Bagnall et al., 1990). However, this population has been less extensively studied and some of the



133

inconsistency may be due to the method of data collection; whether data were collected through survey interviews or personal diary. Relationships were most likely to be found among "heavy" drinkers, and authors of these studies caution that personality, situational characteristics, and behavioral factors may confound observed relations between drinking and unprotected sex. Also, adults are more likely than adolescents to be married or have steady sexual partners, and these factors could influence their sexual practices after drinking or drug use. Two important implications can be drawn from this small but growing literature. First, alcohol and the use of other psychoactive drugs can undermine the benefits of campaigns that have increased knowledge about the modes of HIV and STD transmission and attempted to foster attitudes and beliefs that promote condom use and safer sex practices. Second, the persistence of these relationships is not inevitable. The relationship among gay men seems to have been stronger earlier in the AIDS epidemic and in at least one cohort dissipated over time with reductions in both drinking and unsafe sex. These conclusions suggest that while alcohol and drug use currently contribute to unsafe sex practices, the problem may be subject to modification. However, many questions still remain. In order to plan the most effective interventions to reduce the likelihood of HIV transmission, transmission of other STDs, and unwanted pregnancy among adolescents, it is important to assess further: (1) how many adolescents have sexual intercourse after drinking and drug use; (2) whether adolescents are more likely to have unprotected sexual intercourse after drinking or drug use because (a) they are more likely to have sex or (b) they are less likely to use condoms or both; and (3) whether those who are more likely to have sex and/or unprotected sex after drinking and drug use hold different beliefs about AIDS, STDs, and pregnancy.

METHODS This paper reports on an exploration of these three questions in Massachusetts by the use of a statewide sample of 16-19 year olds surveyed in 1990. In the winter of 1989 and 1990 a statewide, random digit-dial survey of 16- 19 year olds was conducted in Massachusetts by using methods developed by Wakesberg (1978). Within each household, one adolescent was randomly selected by using methods designed by Kish (1965). 1,152 participated in the survey, representing a response rate of 87 %. The survey was conducted in English and Spanish and explored knowledge about HIV transmission; number of sexual partners; whether they had sexual intercourse with males, females, or both; frequency of condom use after drinking and when sober; and frequency of condom use after drug use and when not using drugs. Questions were asked about specific beliefs identified in the Health Belief Model concerning HIV, other STDs, and pregnancy (Becker and Joseph, 1988; Janz and Becker, 1984). Measures of social acceptability of condom use were also assessed. Respondents were also asked their age and level of educa-


134

STRUNIN AND HINGSON

tion. Surveys of teenage respondent knowledge and exposure to education about AIDS were previously conducted in 1986 ( N = 829) (Strunin and Hingson, 1987) and 1988 (Hingson et al., 1990b) using identical sampling methods. Chi-square analysis tested significance of changes in knowledge, beliefs, and behaviors over time and whether alcohol and drug use were associated with condom use. Condom use was dichotomized as always use condoms versus sometimes or never use condoms, The chi-square test of symmetry assessed whether individuals: (i) were more likely to have sex if they and someone they were interested in sexually had been drinking or taking drugs; (ii) were more likely to have sex after drinking; and (iii) were less likely to use condoms after drinking and drug use. Chi-square analysis tested for differences in characteristics and beliefs of adolescents who were likely to have sex if they and someone they are interested in sexually had been drinking or taking drugs, and who used condoms less often after drinking or taking drugs.

RESULTS Sample Characteristics Males comprised 45 % of the sample and females 55%. Eighty-nine percent of the sample was White, 4% Black, 3% Hispanic, 1% Asian, and 3% other. Thirtyone percent were 16 years old, 24% 17 years old, 25% 18 years old, and 20% 19 years old. Concerning their sexual activity and drug use, 66% of the sample reported having had sexual intercourse in the past year compared to 55 % in 1986 and 61 % in 1988. In 1990,82% reported drinking alcoholic beverages with 7 % drinking five or more drinks daily. Nineteen percent reported smoking marijuana in the past month, and 7% reported other drug use. Use of drugs other than alcohol or marijuana declined from 13% in 1986 to 7% in 1990. Among sexually active adolescents, 83% drank alcohol, 22% reported using marijuana, and 8% reported using drugs other than alcohol and marijuana. Sexual Intercourse after Drinking and Drug Use Among sexually active adolescents, 64% reported having sex after drinking and 15% had sex after drug use. Among sexually active adolescents who drank, 72% had sex after drinking and among those who used marijuana and other drugs, a smaller proportion, 56%, had sex after drug use.


135


Likelihood of Having Sexual Intercourse after Drinking Even though 61 % of sexually active adolescents believed sex is less pleasurable after drinking alcohol, 49% responded that they were more likely to have sex if either they or someone they were interested in sexually had been drinking, 30% were as likely to do so, and only 21% were less likely to have sex after drinking. Not surprisingly, respondents who believed sex is more pleasurable after drinking were more likely to report they would have sex if they and their partner had been drinking. Whites, males, adolescents more involved with alcohol and drug use, and those more likely to engage in risky sexual behaviors were more likely to have intercourse if they and someone they were interested in sexually had been drinking. Adolescents who drank more “heavily,” smoked marijuana, used other drugs, and sold drugs to others were more likely to have sex if they and their partner had been drinking. Further, as indicated by Table 1, adolescents who had multiple sexual partners in the past year, who were less likely to have asked about a partner’s risky sexual behavior for AIDS or if they had injected drugs, and who were less likely to have used a condom in the past 6 months were also more likely to have sex after drinking. Although respondents who believed that condoms are effective in preventing STDs and pregnancy were more likely to have sexual intercourse after drinking, numerous other beliefs about AIDS, STDs, and pregnancy were not associated with whether adolescents were more likely to have sexual intercourse after drinking. Beliefs about HIV, other STDs, or pregnancy did not systematically differentiate those more likely to have sex if they had been drinking. Likelihood of Having Sexual Intercourse after Drug Use Drug use was much less likely than alcohol to increase the likelihood of sex. Thirty-two percent said they were more likely to have sexual intercourse if either they or someone they were interested in sexually had been using drugs, 44% were as likely to do so, and one-quarter were less likely to have sex after using drugs. Adolescents who believed that sex is more pleasurable after drug use and after drinking were more likely to have sex if they had been using drugs. Significantly more males than females were more likely to have sexual intercourse after drug use as were those who reported having five or more sexual partners in the past year, those more likely to have sex after drinking, and those who did not ask partners to use condoms. This is elaborated in Table 2. As with drinking, numerous other beliefs about AIDS, STDs, and pregnancy did not predict whether adolescents were more likely to have sexual intercourse after drug use.

STRUNIN AND HINGSON

136 Table 1

-


Selected Characteristics of Sexually Active Adolescents More Likely to Have Sexual Intercourse if Drinking Alcohol (N 676) More likely to have sex (N= 299) (96) Male (50)o Female (50) White (78) Black (15) Other (6) Average daily drinks: 0 c 1 (64) I < 2 (12) 2 < 3 (8) 3 < 4 (6) 4 < 5 (5) 5+ (6) Used marijuana past month: No (24) 1-3 (12) 4+ (13) Use other drugs: No (91) Yes (9) Sold drugs: Yes (14) No (86) Number of sexual partners past year: 1(51) 2-4 (38) 5+ (11)

Likelihood asked partners about behaviors that might pose risk of HIV infection: Very likely (30) Fairly likely (21) Not likely (49) Asked partner-if used IV drugs: Yes (31) No (69) Asked partner to use condom past 6 months: Yes (44) No (56) OPercent distribution.

As likely to have sex (N 185) (%)

-

Less likely to have sex

(N = 126) ( W ) Significance

.oooo

67 31 52 37 44

24 37 29 33 41

9 32 20 30 15

41 56 62 65 78 68

32 27 29 27 19 20

27 16 9 9 4 13

45 61 62

32 26 21

24 13 11

47 66

30 31

23 3

70 45

25 31

23

38 58 68

33 27 26

29 15 6

.ooo1

35 47 57

33 37 21

32 16 16

.oooo

41 52

34 28

24 19

.03

43 54

33 28

24 19

.03

5

.03

.ooo5

.o003

.002

.o001

ALCOHOL, DRUGS,AND ADOLESCENTSEXUAL BEHAVIOR

137

Table 2


Selected Characteristicsof Sexually Active Adolescents Who Used Drugs and Who Were More Likely to Have Had Sex after Drug Use More likely to have sex (N= 51) (%)

As likely to have sex (N= 70) (%)

Less likely to have sex (N= 41) (I) Significance

-

Male (55)n Female (45) Number of sexual partners past year: 1(35) 2-4 (47) 5+ (18) Likelihood ask partners about behavior that pose a risk for HIV infection: Very (23) Fairly (20) Not likely (58) Asked partner to use a condom: Yes (36) No (64) Sex more pleasurable after drug use: More (24) Some (8) Less (68) Likelihood of sex after drinking: More (64) Some (26) Less (10) Sold drugs to others: Yes (34) No (66)

44

41 21

42

15 38

29 28 48

32 54 38

29 18 10

.02

19 54 28

42 23 52

39 23 19

.003

26

35

38 47

36 18

57 23 24

37 69 41

5

8 34

45 10 6

35 70 18

19 20 75

39 27

48 42

13 31

.001

.04

.ooO1

.ooO1

.04

aPercent distribution.

Condoin Use a f e r Drinking

Significantlymore sexually active adolescents said they were less likely to use condoms after drinking than said they were more likely to use them. Seventeen percent reported using condoms less often after drinking, 74% reported condom use as often whether drinking or sober, and 10%reported more frequent use after drinking. This is documented in Table 3. Adolescents who experienced first inter-

138

STRUNIN AND HINGSON

Table 3 Condom Use When Drinking and Not Drinking among Sexually Active MassachuseiTs Teenage Drinkersr


Condom use when not drinking Always Condom use when drinking Always Sometimcs Never

Sometimes

N

z

N

112 38

28 10

1

-

27

Never

%

N

16

4

116

29 7

1 5 82

%

1 21

OUse condoms less after drinking, 66/398 (17%);p < .05.

course at an earlier age and those who asked partners if they injected drugs were more likely to be in the group that used condoms less often after drinking (Table 4). There were no significant differences between those who used or did not use condoms less often after drinking with regard to numerous other characteristics or beliefs about AIDS, STDs, or pregnancy. In other words, as documented in Table 4, regardless of the respondent’s perceived susceptibility to and concerns about AIDS, other STDs, and pregnancy, 17% of sexually active respondents were less likely to use condoms when they had been drinking than when they were sober.

Condom Use after Drug Use

In contrast to having sex after drinking, having sex after using drugs had little influence on whether adolescents used condoms. Seven percent reported using condoms more often after using drugs, 83 Ireported condom use as often, and 9% reported less frequent use after using drugs. This is elaborated in Table 5. However, the small subgroup who were less likely to use condoms after drug use disproportionately included people who engaged in risky sexual behavior. Adolescents who more frequently had sex after drinking and after drug use, had been offered injectable drugs, had sexual intercourse with an injecting drug user, or did not have a regular sexual partner were less likely to use condoms after drug use. However, as shown in Table 6, adolescents less likely to use condoms after drug use did not differ from other drug-using sexually active adolescents on numerous other beliefs about AIDS, other STDs, or pregnancy.


139

Table 4


Selected Characteristics of Sexually Active Adolescents Who Had Sex after Drinking Who Use Condoms Less during Sex after Drinking Use condoms Do not use less after condoms less drinking after drinking (N = 66) (I)(N = 332) ( I ) Significance Discussed AIDS with friends: Yes (89)a No (11) Likelihood a man could get AIDS from sex with an infected man: Very (83) Somewhat (16) Little/not at all (1) Age at 1st intercourse: C

13 (11) 14 (12) 15 (22) 16 (25) 17 (23) 18+ (16)

Asked sexual partner if injected drugs: Yes (30) No (70) Sex more pleasurable after drinking: More (33) Some (15) Less (51) How often had sex after drug use: Most of time (7) Sometimes (18) Rarely (46) Never (29) OPercent distribution,

14 31

85 69

15 18 80

85 82 20

32 10 14 12 21 16

68 89 86

.004

.001

.02

88 78 84

25 13

I5

11 22 10

89 78

55 4 13 18

45 96 86 82

.004

87

.009

90

.OOO8

140

STRUNIN AND HINGSON Table 5

Condom Use after Drug Use and Not Using Drugs6 ~~

~


Condom use when not taking drugs Always

Sometimes

Condom use after drug use

N

%

Always Sometimes Never

22

21

5

5

-

-

N

Never

%

N

%

I

I

-

-

35 5

33

1 30

29

5

1

~~

oUse condoms less after drug use, 10/105 (10%);N.S.

Table 6

Selected Characteristics of Sexually Active Adolescents Who Had Sex after Drugs Who Use Condoms Less Often during Sex after Drinking Use condoms less after drinking (N = 10) (%I Likelihood a man would get AIDS duMg sex with an infected man: Very (84)a Somewhat (13) A little (3) Refused to have sex with someone who used IV drugs: Yes (24) No (76) Had partners who used IV drugs: Yes (3) No (97) Asked partner if used IV drugs: Yes (32) No (68) OPercent distribution.

Other sexually active adolescents who had sex after drugs (N = 95) (%)

Significance

I 14 61

93 86 33

24

76 95

.o I

5

67 8

33 92

.003

21 4

79 96

.02

.002


141


CONCLUSIONS AND DISCUSSION In Massachusetts, telephones are owned by 95%of households. Low income households and non-White households are least likely to own them. Because members of low income non-White racial/ethnic groups are overrepresented among all AIDS cases in the USA and are at the highest risk for HIV infection, this survey may underestimate behaviors that are risky for HIV transmission. The data from this survey indicate that education and counseling to dissuade adolescents from having unprotected sex should target not only condom use but increased sexual activity among adolescents. Considering that in our studies the proportion of adolescents who had sexual intercourse increased from 61 % in 1988 to 66% in 1990 despite increases in the proportions who consistently use condoms, 31% in 1988 and 37% in 1990, in both years similar proportions reported having unprotected sexual intercourse, 41% in 1988 and 39% in 1990. The data further indicate that alcohol and drug use may contribute to some adolescents being more likely to have sexual intercourse and a smaller fraction to being less likely to use condoms when having sex. As contributors to these problems, alcohol use affects many more teenagers than drug use. Sixty-four percent of the sexually active adolescents had sexual intercourse after drinking compared to only 15%after drug use. Even among adolescents who drank or used drugs, a higher proportion had sexual intercourse after drinking than after using drugs: 72% of the sexually active who drank had sexual intercourse after drinking, and 56% of the sexually active who used drugs had sexual intercourse after drug use. Alcohol use was also more likely than other drug use to both increase the likelihood of adolescents having sexual intercourse and not using condoms. While only 32% of sexually active adolescents said they were more likely to have sexual intercourse if they and someone they were interested in sexually had been using drugs, 44% said they were more likely to have sexual intercourse if they had been drinking. While 10%said they were less likely to use condoms after drugs, 17% were less likely to use condoms after drinking. Since only about one-third of adolescents consistently use condoms, the most important risk for HIV, other STDs, and pregnancy posed by alcohol and drug use appears to be the increased likelihood of sexual intercourse, not the decreased likelihood of condom use. It should be noted that adolescents more likely to have sex after drinking and drug use engaged in behaviors that put them disproportionately at risk for HIV infection, other STDs,and pregnancy. Those more likely to have sexual intercourse if they had been drinking, reported more sexual partners and less condom use. Those more likely to have sexual intercourse after using drugs had more sexual partners and less often asked partners to use condoms. Those who used condoms less often after drug use were more likely to report having sexual intercourse with injecting drug users.


142

STRUNlN AND HINGSON

Finally, the adolescents in our study indicated that beliefs about AIDS, STDs, and pregnancy were not associated in any pronounced pattern with likelihood of sexual intercourse or use of condoms after drinking and drug use. In other words, regardless of their concerns about AIDS, STDs, or pregnancy, many adolescents were more likely to have sex or unprotected sex if they had been drinking, and to a lesser extent, if they had been using drugs. What steps can be taken to address these problems? During the summer of 1990 the U.S.Secretary of Health and Human Services announced that the National Advertising Council would disseminate public service announcements warning teenagers that after drinking and drug use many people are more likely to have unprotected sex that could result in HIV infection. While this is an important first step, obviously a more comprehensive approach to the problem is needed. First, school educational programs about HIV infection and AIDS, other STDs, and pregnancy should all stress the disinhibiting features of alcohol. Further, alcohol misuse prevention and treatment programs should discuss the risk(s) of unprotected sex and HIV infection after drinking, and STD and family planning clinics should query patients about their alcohol use and stress the risk of unprotected sex, HIV infection, and unplanned pregnancy after drinking. Adolescents should be made aware that if they drink they are likely to do things they may not do when sober, including having sexual intercourse or not using condoms when having sexual intercourse. Among the sexually active adolescents in this survey (of whom only three were married), 23% responded that they would be happy if they or their partner became pregnant, and over double the proportion of males than females said they would be happy (32 vs 15%,p = .0001). For these sexually active males and females, not using a condom would result in an ostensibly desirable outcome. Desire for pregnancy may mitigate against birth control, including using condoms. This subgroup needs to be identified and dissuaded about their desires for pregnancy, otherwise education about drinking or drug use contributing to unprotected sex might actually increase unprotected sex after drinking or drug use. Some studies have found parental norms to be influential on adolescent drinking (Jessor and Jessor, 1977), while others report that peer modeling has more influence (Kandel et al., 1976; Margulies et al., 1977; Smart et al., 1978). Adolescents’ drinking practices may reflect the sentiments or examples of their peers or may reflect their own norms or preferences (Biddle et al., 1980; Maddox and McCall, 1964; Schlegel et al., 1977). Educational programs designed to reduce substance use/misuse and delay onset of use have demonstrated some success, particularly those that (1) involve adolescents as peer leaders (Perry, 1989), (2) teach resistance skills through role modeling (Botvin and Wills, 1986), (3) emphasize short-term adverse consequences of substance uselmisuse (Perry, 1980), and (4) involve parents in assignments adolescents are given in school (Pentz et al., 1989).



143

Whether such strategies can also be used to reduce sexual risk taking after drinking and drug use warrants systematic investigation. Second, steps can be taken to make alcohol and drugs less accessible to adolescents. Although all states in the USA currently have a legal minimum purchase age of 2 1, many adolescents continue to drink. For example, in Massachusetts approximately one in ten adolescents under the legal drinking age has false identification, and few adolescents encounter difficulty locating stores that do not ask for age identification. Approximately half of the adolescents surveyed in 1990 had someone else, a sibling or friend, who was about the legal purchase age purchase alcohol for them. Steps to heighten enforcement of age 21 as a purchase age could prove helpful. Enactment and enforcement of social host liability legislation might also reduce distribution of alcohol to minors. Increased taxes on alcoholic beverages might further make purchase of alcohol more difficult for adolescents. Third, educational and marketing programs to stimulate condom use can have an effect. Between 1986 and 1988, condom sales in the USA rose from 240 million to 299 million, partly in response to increased concerns about AIDS. Since then, however, condom use had leveled off (Moran et al., 1990). The “consumer” orientation of commercial marketing suggests several strategies to promote greater condom use (DeJong and Winston, 1990): (1) The image of the condom user has to be changed and associated with personal qualities that are considered desirable such as status, popularity, and intelligence. (2) If promotion efforts can demonstrate a new normative consensus among men and women in favor of condom use, then condom use may increase. (3) The condom should be marketed as a product used by couples rather than by individuals. Accordingly, promotions should model how a sexual partner might be persuaded to use condoms (Solomon and DeJong, 1989a). (4) Promotion efforts should also suggest that condoms need not interfere with sexual pleasure and might even enhance it if their use is approached in a sexually appealing way (Solomon and DeJong, 1989b). This does not require graphic depictions of sexual acts, but does necessitate a frank presentation of how condom use can be mutually satisfying to both partners. Finally,just as perceived reduction in sexual pleasure has been associated with adolescents less likely to use condoms, education programs might want to emphasize that alcohol and drug use can reduce sexual pleasure and that most adolescents hold this view. Further, educational programs may be able to convey messages portraying intoxicated persons as less sexually attractive and desirable than those who are sober. This type of advertising has conveyed similar negative images to adolescents about smokers and has contributed to some observed reduction in smoking. Studies that have observed a relation between alcohol use and unprotected sexual intercourse are relatively recent and, therefore, little research has systematically explored interventions to reduce this relationship. This appears to be a potentially important area for future research; it could also produce obvious benefits in reducing HIV infection, transmission of other STDs, and unwanted pregnancy.

STRUNIN AND HINGSON

144


ACKNOWLEDGMENTS This research was supported by a grant from the National Institute and Alcohol Abuse and Alcoholism (R01-AA08056-01A1S1). The SUNey was conducted by the Center for Survey Research at the University of Massachusetts, Boston. The authors thank Beth Berlin for assistance with data analysis.

REFERENCES ANONYMOUS (1991).Mortality attributed to HIV infection/AIDS-United States, 1981-1990.Morbid Mortal. Wkly. Rep. 40: 41-55. ARAL, S.O.,and HOLMES, K. K. (1984).Epidemiology of sexually transmitted diseases. In K. K. Holmes, P. A. Mardh, P. F. Sparling, and P. J. Wiesner (eds.), Sexually Traminitfed Disemes. Ncw York McGraw-Hill. BAGNALL, G., PLANT, M. A., and WARWICK, W. (1990).Alcohol, drugs and AIDS-related risks: Results from a prospective study. AIDS 2: 309-318. BANDURA, A. (1984).Self-efficacy: Toward a unifying theory of behavioral change. Psychol. Rev. 84: 191-215. BECKER, M., and JOSEPH, J. (1988).AIDS and behavioral change to avoid risk A review. Am. J. Public Health 11:685-689. BECKMAN, L.J. (1979).Reported cffects of alcohol on sexual feelings and behaviors of women alcoholics and non-alcoholics. J. Stud. Alcohol 4 0 212-282. BIDDLE, B.J., BANK, B. J., and MARLIN, M. M. (1980).Social determinants of adolesccnt drinking: What they think, what they do and what I think and do. J. Stud Alcohol 41: 3. BOTVIN, G., and WILLS, T. L. (1986).Personal and social skills training. Cognitivc behavioral approaches to substance abusc prevention. In C. Bell and R. Bettjes (eds.), Prevention Research: Deterring Drug Abuse urnong Children and Adolescents, NIDA Rcscarch Monograph 63, pp. 8-49. CENTERS FOR DISEASE CONTROL (1991).AIDS Monthly Surveillance Report for December. Atlanta, Georgia, August 1991. COATES, T. J., STALL, R. D., CATANIA, J. D., and KEGELES, S. (1988).Behavioral factors in the spread of HIV infection. AIDS 1: 239-246. CROWE, L., and GEORGE, W. (1989).Alcohol and human sexuality. Psychol. Bull. 105: 374-386. DEJONG, W., and WINSTON, J. A. (1990).Responding to AIDS: Limits on the strategic use of the broadcast mcdia to effect behavior change. In J. Sepulveda, H. Fineberg, and J. Mann (cds.), Coinriiunicatiunund Education to Prevent AIDS. New York: Oxford University Press. DOLL, L. (1989).Alcohol Use as a Co-factorfor Disease and High Risk Behavior. Paper presented at the NIAAA Alcohol and AIDS Network Conference, Tucson, Arizona, May. FISHBEIN, M., and AZJEN, I. (1975).Belief Attitude. Intention, and Behavior: An Introduction to Theory and Research. Reading, Massachusetts: Addison-Wesley. FLANIGAN, B., and HITCH, M. (1980).Alcohol use and sexual intercourse and contraception: An cxplnratory study. J. Adolesc. Health Drug Educ. 31: 6-40. GOODMAN, E., and COHALL, A. T. (1989).Acquired immunodeficiency syndrome and adolescents: Knowledge, attitudes, bclicfs, and behaviors in a New York City adolescent minority population. Pediatrics 84:36-42. HABERBERGER, R.,JR., DUNCAN, D., FRISCH, L. E., and NARVE, M. D. (1985). Epidemiological and clinical correlates of cndoccrvical chlamydia1 infections in female university students presenting for routine pap examination. J. Am. Coll. Health 33: 262-263.



145

HAYES, C. D. (ed.) (1987). Risking the Future: Adolescent Sexuality, Pregnancy, and Childbearing. Vol. 1. Washington, D.C.: National Academy Press. HILLARD, J., KITCHELL, C., TURNER, U. G., 3rd., KEALING, R. P., and SHANK, R. F. (1984). Knowledge and attitudes of university health service clients about genital herpes: Implications for patient education and counseling. J. Am. Coll. Health 33: 112-1 17. HINGSON, R., STRUNIN, L., and BERLIN, B. (1990a). Changes in knowledge and behaviors among adolescents, Massachusetts statewide surveys, 1986-1988. Pediatrics 85: 24-29. HINGSON, R., STRUNIN, L., BERLIN, B., and HEEREN, T. (1990b). Beliefs about AIDS, use of alcohol, drugs, and unprotected sex among Massachusetts adolescents. Am. J. Public Health 80: 295-299. HINGSON, R., STRUNIN, L., HEEREN, T., and BERLIN, B. (1990~). Changes in Adolescent AIDS Knowledge and Condom Use. Paper presented at the 18th Annual American Public Health Association Meeting, New York. JANZ, N. K., and BECKER, M. H. (1984). The health belief model: A decade later. Health Educ. Q.1 1: 1-47. JESSOR, R., and JESSOR, S. L. (1977) Problem BehaviorandPsychosocial Development: A Longitudinal Study of Youth. New York: Academic Press. KANDEL, D. B., TREIMAN, D., FAUSE, T., and SINGLE, E. (1976). Adolescent involvement in legal and illegal drug use: A multiple classification analysis. Sac. Forces 55: 438-458. KEGELES, S., ADLER, GREENBLATT, R., CATANIA, J., CARDENAS, C., GOTTLIEB, J., MILLER, J., DOLCINO, M. M., and COATES, T. J. (1989). AIDS riskbehavior among sexually active Hispanic and Caucasian adolescent females. In Abstracts: V International Conference on AIDS, The Scientific and Social Challenge. Ottawa, Canada: International Development Research Centre, p. 711. KISH, L. (1965). Survey Sampling. New York Wiley. LEIGH, B. (1990). Alcohol Use and Sexual Behavior in Discrete Events. Paper presented at the 16th Annual Alcohol Epidemiology Symposium, Kettil Bmun Society, Budapest, Hungary, June. MADDOX, G. L., and McCALL, B. (1964). Drinking among Teenagers:A Sociologicallnterpretation ofAlcohol Use by High School Students. New Brunswick, New Jersey: Rutgers Center of Alcohol Studies, Monograph No. 4. MARGULIES, R. Z., KESSLER, R. C., and KANDEL, D. B. (1977). Longitudinal study of onset of drinking among high school students. J. Stud Alcohol 38: 897-912. MARTIN, J. (1989). Drinking and Sexual Activity in a Cohort of New York Gay Men. Paper presented at the NIAAA Alcohol and AIDS Network Conference, Tucson, Arizona, May. MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH (1990). AIDS Newsl. 9: 1-2. McKIRNON, D. J., and PETERSON, P. J. (1989). Psychosocial and cultural factors in alcohol and drug abuse: An analysis of a homosexual community. Addict. Eehav. 14: 545-553. M O W N , J. S., JANES, H. R., PERMAN, T. A,, and STONE, K. M. (1990). Increase in condom sales following AIDS education and publicity, United States. Am. J. Public Healfh 80: 607-608. OSTROW, P. (1987). Barriers to the Recognition of Links between DrugandAlcoholAbuse andAIDS in Acquired Immunodeficiency Syndrome and Chemical Dependency [NIAAA DHHA Publication (ADM) 87 15131. Washington, D.C.: U S . Government Prhting Office, pp. 15-20. PENTZ, M. A., DWYER, J. H., MAcKINNON, D. P., FLAY, B. R., HANSEN, W. B., WANG, E. Y., and JOHNSTON, C. A. (1989). A multicommunity trial for primary prevention of adolescent drug abuse. Effects on drug use prevalence. J. Am. Med. Assoc. 261: 3259-3266. PERRY, C. (1980). Modifying smoking behavior of teenagers: A school based intervention. Am. J. Public Health 70: 722-125. PERRY, C. L. (1989). Prevention of Alcohol Use and Substance Abuse in Adolescence: Teacher vs. Peer-led Intervention, Special Issue: Preventive Interventions in Adolescence. University of Minnesota, US Crisis, April, 10-52-61.


146

STRUNIN AND HINGSON

PLANT, M. A. (1990). Alcohol, sex and AIDS. Alcohol Alcoholism 25: 293-301. RICE, R.. ARAL, S., BLOUNT, J. H.,and ZAIDI, A. A. (1987). Gonorrhea in the United States 1975-1984: Is the giant only sleeping? Sex. Trans. Dis. 14: 83-87. IUCKERT, V. K., JAY, M. S., GOlTLIEB, A,, and BRIDGES, C. (1989). Adolescents and AIDS: Female’s attitudes and behaviors toward condom purchase and use. 1.Adolesc. Health Care 10: 3 13-3 16. ROBERTSON, J. A,, and PLANT, M. A. (1988). Alcohol, sex and risk of HIV infection. Drug Alcohol Depend. 22: 75-78. SCHLEGEL, R. P., CRAWFORD, C. A., and SANBORN, M. D. (1977). Cotrespondence and mediational properties of the Fishbein model: An application to adolescent alcohol use. J. Exp. Soc. Psychol. 13: 421-430. SIEGAL, K., MESOGNO, F., CHEN, J., and CHRIST, G. (1989). Factors distinguishing homosexual males practicing risky and safe sex. Soc. Sci. Med. 28: 561-569. SMART, R. B., GRAY, G., and BENNETT, C., (1978). Predictors of drinking and signs of heavy drinking among high school students. Int. J. Addict. 13: 1079-1094. SOLOMON, M. Z., and DHONG, W., (1989a). Promoting condoms: Recommendations for efforts in clinic and community settings. In Condorns in the Prevenfiotr of Sexually Transmitted Diseases: The Proceedings of a Conference. Research Trianglc Park, North Carolina: American Social Health Association. SOLOMON, M. Z., and DEJONG,W. (1989b). Recent sexually transmitted prevention efforts and their implications for AIDS health education. Healfh Educ. Q. 79: 453-458. STALL, R., EKSTRAND, M., POLLACK, L., and COATES, R. (1990). Relapse from Safer Sex: The A I D S Behavioral Research Project. Paper presented at the Sixth International Conference on AIDS, June. STALL, R., McKUSICK, L., WILEY, J., COATES, T., and OSTROW, D. (1986). Alcohol use and drug use during sexual activity and compliance with safe sex. Health Educ. Q.13: 359-371. STRUNIN, L., and HINGSON, R. (1987). Acquired immunodeficiency syndrome and adolescents: Knowledge, beliefs, attitudes and behaviors. Pediatrics 79: 825-828. STRUNIN, L., HINGSON, R., BERLIN, B., and HEEREN,T. (1990a). Do Beliefsabout H W ,Condom Use, Pregnancy and STDs Predict Adolescent Condom Use? Paper presented at the Sixth International conference on AIDS, San Francisco, California. STRUNIN, L., HINGSON, R., BERLIN, B., and HEERIN, T. (1990b). Alcohol and Condom Use among Adolescents. Paper presented at the 18th Annual American Public Health Association Meeting, New York. TEMPLE, M., and LEIGH, B. (1990). Alcohol Use and Sexual Behavior in Discrete Events. Characteristics of Sexual Encounters Involving and Not Involving Alcohol. Paper presented at the 16th Annual Alcohol Epidemiology Symposium, Kcttil Bruun Society, Budapest, Hungary, June. VALDESERRI, R., LYTER, D.,KEVILOR,L., CALLAHAN, C., KINGLEY, L., andRANALD0. C. (1988). Variables influencing condom use in a cohort of gay and bisexual men. Am. J. Public Hectlth 78: 801-805. WAKESBERG, J. (1978). Sampling methods for random digit dialing. J. Am. Stat. A d . 73: 40-46. WASHINGTON, A. E., JOHNSON, R. E., and SANDERS, L. L. (1987). Chlamydia1 trdchoniatis infections in the United States: What are they costing us? J. Am. Med Assoc. 257: 2070.

Correlates of adolescent sexual behavior.

Drugs and sexual behavior in man.

a Adolescent Sexual Behavior.

Objective and Perceived Weight: Associations with Risky Adolescent Sexual Behavior.

ethnic disparities in adolescent sexual risk behavior.

Adolescent Alcohol Exposure Persistently Impacts Adult Neurobiology and Behavior.

Behavioral economic decision making and alcohol-related sexual risk behavior.

Sisters' and Girlfriends' Sexual and Childbearing Behavior: Effects on Early Adolescent Girls' Sexual Outcomes.

The impact of future expectations on adolescent sexual risk behavior.

Quality of Parent-Adolescent Conversations About Sex and Adolescent Sexual Behavior: An Observational Study.

HIV-related sexual risk behavior among African American adolescent girls.

Evaluation of the effects of drugs on sexual behavior.

Alcohol Consumption and Risky Sexual Behavior Among Persons Attending Alcohol Consumption Venues in Gaborone, Botswana.

Factors influencing adolescent girls' sexual behavior: a secondary analysis of the 2011 youth risk behavior survey.

[Pediatric and adolescent gynecology. Psychosocial background--sexual behavior and pregnancy termination].

Differences in sexual risk behaviors between lower and higher frequency alcohol-using African-American adolescent females.

Adult Binge Drinking: Childhood Sexual Abuse, Gender and the Role of Adolescent Alcohol-Related Experiences.

Transitions in body and behavior: a meta-analytic study on the relationship between pubertal development and adolescent sexual behavior.

Prepubertal initiation of sexual experiences and older first partner predict promiscuous sexual behavior of delinquent adolescent males--unrecognized child abuse?

Drugs, alcohol and malabsorption.

Alcohol and drugs.

The role of beliefs in sexual behavior of adolescents: Development and validation of an Adolescent Sexual Expectancies Scale (ASEXS).

Drugs and alcohol.

Drugs and alcohol.