http://informahealthcare.com/gye ISSN: 0951-3590 (print), 1473-0766 (electronic) Gynecological Endocrinology, 2014; 30(8): 581–586 ! 2014 Informa UK Ltd. DOI: 10.3109/09513590.2014.910190
ALCOHOL AND DRUG ABUSE
Alcohol and drug abuse and risky sexual behaviours in young adult women Camil Castelo-Branco1,2,3, Nuria Parera4, Nicola´s Mendoza5, Ezequiel Pe´rez-Campos6, In˜aki Lete7, and the CEA group* 1
Clinic Institute of Gynecology, Obstetrics and Neonatology, Hospital Clinic, 2Faculty of Medicine, University of Barcelona, Barcelona, Spain, 3Institut d’Investigacions Biome´diques August Pi i Sunyer (IDIBAPS), Barcelona, Spain, 4Servicio de Medicina de la Reproduccio´n, Departamento de Obstertricia i Ginecologı´a, Institut Universitari Dexeus, Barcelona, Spain, 5Margen Clinic, Granada, Spain, 6Department of Obstetrics and Gynecology, Hospital General de Requena, E-46340 Requena, Valencia, Spain, and 7Department of Obstetrics and Gynecology, Hospital Santiago Apo´stol, Vitoria-Gasteiz, Spain Abstract
Keywords
Objective: To assess alcohol abuse as a predictor of risky sexual behavior among adolescents and young adult women, a high-risk population for unintended pregnancies. Subjects: Totally 3163 adolescent and young adult women, 18–29 years, were assessed on sociodemographics, alcohol and drug use and risky sexual behaviors. Interventions: Participants answered a structured questionnaire on their leisure habits, drug and alcohol consumption, contraception and sexual behaviors. Results: Most of the young adult women perceive that sexuality is an important part of their life but not a main concern (77.6%) and that alcohol removes the barriers to have sex (62.3%). Additionally, 77.0% claimed that contraception had ‘‘a lot’’ (53.4%) and ‘‘quite’’ (23.6%) influence on the quality of their sexuality. However, up to a 38.4% of the interviewed women had had sex without using any contraception and 29.6% of them acknowledged that had taken alcohol and of these, 40.7% said that alcohol was responsible for not using contraception. Alcohol abuse predicted an increase in risky sexual behaviours (4.45 CI: 2.01–9.75, p50.0001). The effect of alcohol was independent of age. Conclusions: These findings suggest that contraception-related behavioural interventions for young adult women should discuss the link between alcohol and sexual risk behavior.
Alcohol abuse, contraception, drug consumption, perceived risk, sexuality
Introduction Over the last few years, research dedicated to understanding relationships between drug and alcohol use and unsafe sex has grown. The World Health Organization’s Gender, Alcohol and Culture: An International Study project [1] has increased attention on the need to study gender differences in drinking and differential responses that might be useful in addressing problems related to alcohol use. In many countries, research has shown that females drink less alcohol (by volume) and less frequently than their male counterparts [2,3]. Nonetheless, estimates of alcohol
*CEA Study Group (in alphabetical order): C. Castelo-Branco, Institut Clı´nic de Ginecologia, Obstetrı´cia i Neonatologia, Hospital Clı´nic, Facultat de Medicina, Universitat de Barcelona, IDIBAPS, Barcelona; M. Correa, Hospital Universitario de Canarias, Santa Cruz de Tenerife; M.A. Go´mez, Family Planning Center Alicante; J.V. Gonza´lez, Hospital Clı´nico Universitario Lozano Blesa, Zaragoza; I. Lete, Hospital Santiago Apo´stol, Vitoria-Gasteiz; P. Lobo, Hospital Infanta Sofı´a, San Sebastia´n de los Reyes, Madrid; N. Mendoza, Margen Clinic, Granada; N. Parera, Institut Dexeus, Barcelona; E. Pe´rez-Campos, Hospital General de Requena, Valencia; E. de la Viuda, Hospital Universitario de Guadalajara. Address for correspondence: Camil Castelo-Branco, Clinic Institute of Gynecology, Obstetrics and Neonatology, Hospital Clinic, Villarroel 170, 08036 Barcelona, Spain. Tel: +34 93 227 54 36. Fax: +34 93 227 93 25. E-mail: [email protected]
History Received 5 January 2014 Revised 1 March 2014 Accepted 19 March 2014 Published online 20 May 2014
use among European females indicate that approximately 30% are alcohol drinkers [4] and roughly a third of male drinkers drink at risky levels over weekends [5]. One in 10 women surveyed for the Demographic Health Survey (1998)] had experienced symptoms of alcohol problems during her lifetime [6]. In addition, data from this survey suggested that women who are poor and with low educational level were significantly more likely to report lifetime alcohol problems [6]. On the other hand, a recent study using path models showed that contextual variables (family socio-economic status and negative family interaction) were relatively weak predictors of young adulthood alcohol use and abuse, whereas the effects of childhood individual variables (e.g. aggression, popularity, behavioral inhibition) on adulthood alcohol use and abuse generally were the key variables to predict the alcohol abuse being mediated by the same behavioral variables in adolescence [7]. Furthermore, among young women who have had sexual relations, many have reported that the use of alcohol and other drugs helps them to overcome their wariness [8]. Some risk-taking behaviors such as negligence in contraceptive use and intercourse under the influence of alcohol have been suggested as main reasons behind the increasing numbers of abortions among young women [9]. While the explanations that have been put forward identify a variety of underlying linkages, newer research has begun to highlight the idea that human desire factors into this equation.
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At present, however, very little scientific evidence explains how desire, drug use and unsafe sex intersect. In response to this, a qualitative study with a very large number of subjects was undertaken to understand the relationship between these factors among young adult women. As in Spain circuit parties (i.e. thematic, techno-music, dance parties, drink parties) are attended by many young women who use drugs, including dangerous amounts of alcohol, and engage in unsafe sex, this population was selected as an ideal focal point for data collection and further intervention.
Materials and methods Subjects The sample was taken from women between 18 and 29 years old from all Spanish Autonomous Communities, covering an estimated population of 3 584 923 women in 2009 according to the data provided by the Statistical Unit of the census of the Statistics National Institute. Sample size was established based on the fact that the studied conditions, drug and alcohol use, sexual intercourse and contraception use and knowledge may affect most of the women. Using statistical software to calculate sample size, for a population size of 3 584 923 women and an expected sample distribution p/q ¼ 50/50, with a maximum acceptable error of 2% we obtained a sample size of 2997 women with a 95% confidence interval. Therefore, a total of 3976 were asked to take part in this survey. Of them, 3163 women were finally interviewed by 57 professional interviewers between March and April of 2010 (refusal rate of 20%, not in attendance at phone call 25%) (Table 1). Design of the study This cross-sectional, open, observational and descriptive study was integrated in two different phases. The inclusion of the 3163 women in the study was bimodal, combining the personal interview (first phase, n ¼ 2250) with the phone call interview Table 1. The geographical distribution of the study population was stratified in a non-proportional model.
Andalusia Aragon Asturias Balearic Islands Canary Islands Cantabria Castile & Leon Castile-La Mancha Catalonia Valencian community Extremadura Galicia Madrid Murcia Navarra Basque country La Rioja Total
Women screened Total sample
Women included Studied sample
Sample error (%)
364 187 188 184 229 192 230 225 321 281 190 235 302 200 207 236 190 3976
278 150 150 150 183 149 190 189 264 233 151 193 250 149 149 185 150 3163
6.0 8.2 8.2 8.2 7.4 8.2 7.2 7.2 6.1 6.5 8.2 7.2 6.3 8.2 8.2 7.3 8.2 1.78
At least 150 interviews in each of the 17 autonomous communities were done and the rest of interviews (n ¼ 600) were distributed proportionally according to the population of the most inhabited autonomous communities (Andalusia, Canary Islands, Castile y Leo´n, Castile-La Mancha, Catalonia, Valencia, Galicia, Madrid and Basque Country). For the treatment of national data set, a weighing was made in order to match the weight of the interviews conducted in each Autonomous Community with the weight of the real population.
(2nd phase, n ¼ 913) in order to better meet the quota of age and geographical distribution. Inclusion of subjects by telephone interviews was by two-stage random selection (random telephone numbers and random individual in the home). Personal interviews were carried out stratified by Autonomous community and size of the cities, with selection of the addresses by random routes and individuals within the families using tables of random numbers. Inclusion and exclusion criteria Twenty-one subjects were excluded for the following conditions: (1) did not complete the questionnaire (n ¼ 15), (2) neurophysiological diseases determined from the interview (n ¼ 3) and (3) difficulty in the understanding and interpretation of the questions (n ¼ 16) (some subjects presented more than one reason). Each subject signed a written informed consent form and a research privacy form prior to testing. The procedures in this study were approved by the Institutional Review Board at the Hospital Clinic (Barcelona, Spain). Questionnaire The survey included items of open and multiple-choice questions, visual analogic scales and numeric assessments with a total of 37 questions. An initial version was tested on 20 women and no comprehension problems were observed. The information was gathered from young adult women using a semistructured questionnaire specifically designed to collect information on their beliefs on health, quality of life, sexuality and use of contraception. The questionnaire included 6 items to filter the subjects according to their beliefs and preferences, 8 items related to socio-demographic variables and 23 items related to sexuality. Of the last ones devoted to sexuality, 10 items explored the relationship with alcohol and drugs use and 13 items were related to contraception. The questions were based on instruments used in previous studies (Sigma Dos, Madrid, unpublished data) and aimed to be clear and concise so as to increase reliability. Alcohol consumption was classified as ‘‘nothing at all’’ (no alcohol), ‘‘some’’ (up to 2 glasses of wine, beer or champagne or 1 of whiskey, rum, gin, etc.) ‘‘average’’ (3–4 glasses of wine, beer or champagne or 2 of whiskey, rum, gin, etc) and ‘‘a lot ’’ (more than 4 glasses of wine, beer or champagne, or more than 2 whiskey, rum, gin, etc) in every session. Each interview took around 20 min and, if the woman was not at home, up to three calls were made at different times of the day in order to reach her. Finally, the preference with the different political spectrum and satisfaction with life was assessed by a visual analogue scale (VAS), with values from 0 (left side: left extreme) to 10 cm (right side: right extreme). Statistical analysis All statistical procedures were performed using SPSS 12.0 for Windows (Chicago, IL). Results were expressed as mean ± SD and total number and percentages. Patients were allocated in age groups (18–20; 21–23; 24–26; 27–29 years old) for comparisons. A multivariate analysis was performed to exclude differences in age, smoking, physical activity, chronic treatment or diseases and to consider a potential confounding factors. Multiple linear regressions were used to model bivariate relationships, to test for additive effects and to control for possible confounding variables such as age, smoking and physical activity among others. ANOVA was used to determine differences on the different items according to the age-groups. Adjustments were made for covariates where applicable. Comparison of categorical data was performed with the chi-square test and likelihood ratio.
Alcohol, drugs and risky sex
DOI: 10.3109/09513590.2014.910190
All values are expressed as means ± standard deviation (SD) and percentages, unless stated otherwise. The overall significance was set at p 0.05.
Results Beliefs and preferences Body care and health (68.7%) have greater importance than other issues such as having free leisure time (15%), satisfying sex life
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(6.2%) or earn money (9.5%) (p50.001). No differences between age-groups were observed. Sexuality was an important issue but not a ‘‘priority’’ for near eight of each 10 interviewed women (77.6%) whereas for an 11.6% was a main concern in their lives. In a multiple option answer, the most common leisure activity during weekends was to visit family or friends (55.0%) followed by ‘‘going out for beer, wine or drinks’’ (42.0%) and resting do nothing (33.4%). Only a 9.8% of interviewed women referred go to thematic drink parties on a regular basis and a 31.7% from time to time (Table 2).
Table 2. Beliefs and preferences. Age-range Total
18–20
21–23
24–26
27–29
3163
790
793
784
796
The most Important thing in your life is? (%) Body care & health 68.7** Free leisure time 15 Earn money 9.5 Satisfying sex life 6.2 50.001
71.5 14.6 7.5 6.2 50.001
72.7 13.2 7.8 5.3 50.001
64.4 16.9 11 7 50.001
68 14.7 10.9 6 50.001
How important is Sexuality? (%)# Main concern 11.6 Important 77.6 Minor 7.7 Nothing 2 50.001 Prefer do not answer 1.2
9.4 74.3 11.1* 4* 50.001 1.2
8.9 81.5* 6.8 1.7 50.001 1.8
15.1* 76.1 7.1 0.5 50.001 1.3
11.9 78.8 6.3 2 50.001 1.1
How do you imagine the world in the future? (%) Will be better 33.2 Equal 20.1 Will be worst 42.6 50.05 Do not know 4.2
29.3 18.2 48* 50.01 4.5
32.5 20.7 41.7 50.05 5.1
31.2 21.6 43.7 50.05 3.4
38.5 19.4 38.1 50.05 4
11.4 69.3 19.2
13.7 75.9 10.2
14.8 74 10.8
14.4 65.5 20.1
48*/** 42.3* 9.6
29.3 58.6 12
26.7 56.9 16.4
14.3** 56.9 28.3**
0.01/0.001 50.05 50.001
Go out for beer/wine with friends Frequently 42 Sometimes 46.2 Never 11.6
46.1 40.1 13
45.5 44.3 10.2
43.6 46.9 9.4
34.9* 51.4* 13.8
50.05 50.05
Go to thematic drink parties Frequently Sometimes Never
9.8 31.7 57.7
21.8* 44.3 33.8
10.4 40.2 47.9
7.1 29.7 62.7
3* 17.7* 78.2*
50.01 50.01 50.005
Practice sport Frequently Sometimes Never
21.3 47.6 30.4
19.4 49 30.9
22 46.1 31
23.9 48.4 27.1
19.8 46.9 32.9
Resting, no activities Frequently Sometimes Never
33.4 54.6 11.7
37 52.4 10.6
30.5 54.4 14.8
32 57.4 10.1
34.3 53.7 11.8
Visit family & friends Frequently Sometimes Never
55 42.1 2.8
56.4 41.7 1.9
55.2 42.3 2.3
55.3 42 2.5
53.6 42.3 4.1
Total number
Leisure in weekends (%) Go to Cinema, Theatre, Museums Frequently 13.7 Sometimes 71 Never 15.2 Go to the Disco Frequently Sometimes Never
28.3 54.1 17.4
p
50.05 50.05 50.01 50.05
50.01
Results are expressed as total numbers and percentages and distributed according age ranges. *Displays differences between age groups. **is related to the total column significance (50.001). #no intra-group differences were assessed.
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Alcohol consumption (weekends) Only a 23.1% of the subjects stated that they drunk ‘‘nothing at all’’ whereas one-third (33.3%) said that they drunk ‘‘some’’ alcohol and the other third (33.2%) recognised to drink ‘‘average’’. On the other hand, a 10% acknowledged that they drunk ‘‘a lot’’ in all sessions. Interestingly, when they were asked about their friends’ consumption, the percentages of high intake increased. Only 5.4% said that their friends or colleagues drunk ‘‘nothing at all’’ and 23.1% ‘‘some’’ whereas up to 43.3% said ‘‘average’’ and 27.3% stated that friends drunk ‘‘a lot.’’ After adjusting by age, the 18–20 years age-group was the one that recognise to consume more alcohol, both themselves and accompanying people (p50.01 and p50.01 respectively). In addition, a 31.5% of interviewed subjects recognised to have been occasionally drunk to the point of not remembering the next day what had happened. This figure surpassed the 55.8% when they referred on their friends. In line with data on alcohol consumption, the 18–20 years age-group presented the higher proportion of subjects that reported this condition (39.2%). These percentages go down with increasing age (33.7%, 27.4% and 28.1% in 21–23, 24–26 and 27–29 age-group respectively) (p50.01). In addition, when the question was referred to their friends, this group also showed the highest percentages (64.9% versus 59.5%, 50.8% and 51.3% in 21–23, 24–26 and 27–29 age-group, respectively) (p50.01). Drugs and sex Most of the Spanish young adult women (62.3%) believed that alcohol consumption removes barriers to practice sex (21.8% ‘‘a lot’’, 40.5% ‘‘quite’’ 19.0% ‘‘little’’ and 14.9% ‘‘nothing’’). However, when the questions were referred to themselves, only 21.7% of girls said that alcohol effectively removes barriers to practice sex (6.6% ‘‘a lot’’, 15.1% ‘‘quite’’, 26.7% ‘‘little’’ and 46.5% ‘‘nothing’’) (Figure 1). By age-groups, this belief (A)
presented a trend to be lower in the 18–20 group (59.8%) compared with the other groups (65%, 62.5% and 62% in 21–23, 24–26, 27–29 age-group respectively) Drugs and risky sex: A total of 1215 women (38.4%) acknowledged that they had sex without using contraception occasionally, being at the risk of unintended pregnancy. This condition occurred more frequently in the 24–26 and 27–29 agegroups (42.5% and 41.9%, respectively, versus 31% and 35% in the 18–20 and 21–23 age-groups p50.01). Of these 1215 women, up to 360 reported having consumed alcohol at this time. The influence of alcohol in risky conducts was recognised mainly by the younger subjects (46.4% in the18–20 age–group versus 31%, 41% and 38.7% in the 21–23, 24–26 and 27–29 age-groups respectively (no significant). Alcohol, hashish and design drugs were positive predictors for engaging in risky sex whereas practice sport and be religious were negative predictors (Table 3). In addition, the higher alcohol intake the higher increase in the risk for to be involved in risky sex. Women who recognised to drink a lot increased by 4 this risk. Multiple linear regression demonstrated that the effect of alcohol and drugs in risky sex was independent of age (Table 4). Contraception and sex A greater use of condoms was observed among women who consume alcohol on weekends compared with no consumers (47.4% versus 35.2%, p50.01). No significant differences were observed among users of other methods in relation to alcohol consumption. Double-method: those women who have claimed to be IUD or hormonal contraception users (39.8% in total) were questioned whether in addition they use condoms to prevent sexually transmitted infections. The greater percentage of double method users was found in the younger age-group declining its use with age (42%, 36.5%, 36.3% and 29.2%, respectively, p ¼ 0.019). (B)
Alcohol
Alcohol
46.5% 46,5%
40.5% 40,5%
26.7% 26,7%
21.8% 21,8%
19.0% 19,0% 14.9% 14,9%
15.1% 15,1% 3.8% 3,8%
Mucho A lot
Bastante Quite
Poco Little
Nada Nothing
N.S./N.C. No response
(A)
6.6% 6,6%
5.1% 5,1%
Mucho A lot
Bastante
Poco
Quite
(B)
Little
Nada Nothing
NoN.S./N.C. response
50.1% 50,1%
51.2% 51,2%
40.4% 40,4% 35.5% 35,5% 27.2% 27,2%
27.3% 27,3% 17% 17,0%
14.5% 14,5%
27.1% 27,1%
21.6% 21,6%
21,5% 19.9% 19,9% 21.5%
16.0% 16,0% 8.0% 8,0%
Other illicit drugs Pastillas/Drogas de diseño
Cannabis/Marihuana
A lot Mucho
Quite Bastante
Little Poco
NadaNothingNS/NCNo response
6.1% 4.7% 4,7% 6,1% 2.5% 2,5%
2.8% 3,4% 3.4% 3,4% 2,8% 3.4%
Cannabis/Marihuana
A lot Mucho
Bastante Quite
Pastillas/Drogas diseño Other illicitde drugs Poco Little
Nada Nothing NS/NC No response
Figure 1. I have the control. Relationship between alcohol and drugs consumption and the belief that these actions remove barriers to practice sex. (A) Do you believe that alcohol and drugs removes barriers to have sex? (B) And particularly in your case?.
Alcohol, drugs and risky sex
DOI: 10.3109/09513590.2014.910190
Table 3. Multivariable model of prediction of engaging in risky sex. Variable Age 18–20 21–23 24–26 27–29 Alcohol consumption A lot Average Some Nothing at all Drugs consumption No Tobacco Hashish/Cannabis Design drugs Fidelity to partner Fear to pregnancy Fear to STI Religious Shame Contraception Condom Hormonal IUDs Coitus interruptus Sport
Odds ratio
95% CI
1.35 Reference 1.42 1.41
0.98–2.45
4.54 2.12 Reference 0.34
2.01–9.75 1.25–5.36
p Value
0.91–2.01 0.87–1.98 50.0001 50.005
0.15–1.28
Reference 1.49 1.88 2.15 0.45 0.43 0.25 0.11 0.37
0.92–2.89 1.40–2.48 1.00–3.17 0.25–1.09 0.21–1.11 0.11–1.01 0.09–0.98 0.19–1.18
Reference 1.15 1.08 1.25 0.75
0.89–2.19 0.99–1.99 1.00–2.22 0.25–0.97
50.05 50.05
50.05
50.05
Table 4. Multiple linear regression for risky sex (dependent variable). Variable
B
Alcohol consumption 0.9944 Hashish/Cannabis 2.3333 Design drugs 2.7821 Religious 3.5772 Sport 4.3724 Age 2.150
SE for B 0.0839 1.0663 1.1026 1.6672 1.0999 1.0455
Beta
T
0.5142 11.843 0.0946 4.188 0.1104 5.787 0.0978 2.177 0.1644 3.979 0.0985 1.978
p Value 0.0000 0.0290 0.01 0.05 0.001 0.05
The effect of alcohol and drugs on risky sex was independent of age.
Emergency contraception: A third of the sample (33.3%) claimed to have used emergency contraception (EC) on occasion. The use of EC was significantly lower in the 27-29 age-group (29.1%; versus 33.5%, 35.7% and 35.5% in the 18–20, 21–23 and 24–26 age-groups p ¼ 0.017) and higher among young people who say drinking alcohol on weekends (35.8% versus 25.2% p50.01).
Discussion There is growing awareness of changes in the levels and patterns of women’s use of alcohol and drugs. International data suggest that patterns of consumption among younger women are beginning to echo that of their male counterparts. Similarly, alcohol consumption among older women is also increasing in some developed countries. While the focus of this research was a general exploration of the relationship between drug use and unsafe sex in young adult women, it was situated particularly in drink circuit parties (DCP) where previous research indicates drug use and unsafe sex occur commonly [10–13]. This study aimed to provide a more in-depth analysis of the situation in Spain, trying to understand what type of young people attend to night recreational settings and how they have fun, their use of alcohol and illicit drugs, their sexual behaviours and how these issues are correlated.
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The sample included only young adult women with a social status ranging from medium-low to medium-high and the majority had at least 12 years of scholarship. The recreational habits of Spanish young people from the 17 autonomous communities under analysis follow a pattern which is not that different from the typical European pattern of entertainment and can be considered ‘‘normalised’’ since it follows the dominant and expansive paradigm of recreational life, consumption and entertainment [14,15]. For the majority of the Spanish young adult women included in the study as for other European young adults [16], the enjoyment comes from interacting with friends, drinking, enjoying the music and dancing. In general, women included in this study recognised the consumption of alcohol by themselves and by their friends and almost four in ten acknowledged that they have had sex without using contraception at risk of becoming pregnant unintentionally. Nearly one-third of these young adult women who had claimed to have had sexual intercourse without contraception reported having consumed alcohol at this time. Drug and alcohol use inevitably relax sexual habits and consequently increase carefree and careless sex [17]. There is a commonsense understanding among the respondents about this relationship since 62.3% recognised that alcohol influence to have unsafe sex. However, 360 of the 3163 interviewed women (11.3%) had sexual intercourse that they regretted afterwards due to the use of this drug, which demonstrates a perception of the risk of adopting these sexual behaviours. These data are similar to those observed by Lomba in Portugal [13]. Lessening, euphoria and disinhibition, the decrease in selfcontrol and in the perception of the risk caused by alcohol and psychoactive substances makes users less alert and end up overlooking the messages of safe sex which they would take into account if abstemious. Recent data from a cross-sectional study of young people in nine European cities [17] suggested an epidemic of recreational drug use and gorge drinking that exposes a great amount of young Europeans to routine consumption of substances, which modify their sexual decisions and increase their probability of unsafe and regretted sex. For most of them, substance use/abuse has become an integral part of their strategic approach to sex, locking them into continued use. Engaging in substances with both physiological and psychological links to sex requires approaching substance use and sexual behaviour in the same way that individuals experience them, as part of the same social process [17]. On the other hand, it is not clear whether drug use is a marker for high-risk sexual behaviour, drug use leads to high-risk sex, high-risk sex leads to drug use or some other combination [18]. Finally, we should recognise that this study presents several limitations to consider generalisable the data reported. Firstly, the potential bias due to the response rate, and also a possible recall bias. Second, the fact that was designed as a cross-sectional study may imply that presumed direction of causation may be reversed with time. However, the study included an important number of subjects and this may minimise the bias effect on the final results. In summary, given the fact that there are an increasingly high number of nightlife recreational settings including DCPs and that they are increasingly popular with young people, efforts aimed at preventing outcomes associated with casual sex (e.g. pregnancy, sexually transmitted infections, or mental health) should target specific drinking settings where young adults might be at high risk for risky alcohol use and unsafe sex behaviors [19]. Future research should be targeted to design and implement programs of harm reduction intervention. Therefore, a primary summit of such research must be the acceptance of the high possibility that social, cultural and situational factors, in combination with illegal drugs and alcohol taking practices, may determine the nature of
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relationships between drug use and sexual risk behaviour. This fact emphasise the need to assess the influence of recreational settings as an environmental factor for alcohol and drug use and sexual risk behaviours, and to create a better understanding of the interaction between these three variables among young adult women.
Gynecological Endocrinology, 2014; 30(8): 581–586
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9.
Ethics approval The study was performed in a sample of general population and all the participants demonstrated comprehension after the explanation of the interview. The procedures in this study were approved by the Institutional Review Board at the Hospital Clinic (Barcelona, Spain).
Declaration of interest Authors report no conflict of interest. MSD Spain provided an unrestricted grant
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ALCOHOL AND DRUG ABUSE
Alcohol and drug abuse and risky sexual behaviours in young adult women Camil Castelo-Branco1,2,3, Nuria Parera4, Nicola´s Mendoza5, Ezequiel Pe´rez-Campos6, In˜aki Lete7, and the CEA group* 1
Clinic Institute of Gynecology, Obstetrics and Neonatology, Hospital Clinic, 2Faculty of Medicine, University of Barcelona, Barcelona, Spain, 3Institut d’Investigacions Biome´diques August Pi i Sunyer (IDIBAPS), Barcelona, Spain, 4Servicio de Medicina de la Reproduccio´n, Departamento de Obstertricia i Ginecologı´a, Institut Universitari Dexeus, Barcelona, Spain, 5Margen Clinic, Granada, Spain, 6Department of Obstetrics and Gynecology, Hospital General de Requena, E-46340 Requena, Valencia, Spain, and 7Department of Obstetrics and Gynecology, Hospital Santiago Apo´stol, Vitoria-Gasteiz, Spain Abstract
Keywords
Objective: To assess alcohol abuse as a predictor of risky sexual behavior among adolescents and young adult women, a high-risk population for unintended pregnancies. Subjects: Totally 3163 adolescent and young adult women, 18–29 years, were assessed on sociodemographics, alcohol and drug use and risky sexual behaviors. Interventions: Participants answered a structured questionnaire on their leisure habits, drug and alcohol consumption, contraception and sexual behaviors. Results: Most of the young adult women perceive that sexuality is an important part of their life but not a main concern (77.6%) and that alcohol removes the barriers to have sex (62.3%). Additionally, 77.0% claimed that contraception had ‘‘a lot’’ (53.4%) and ‘‘quite’’ (23.6%) influence on the quality of their sexuality. However, up to a 38.4% of the interviewed women had had sex without using any contraception and 29.6% of them acknowledged that had taken alcohol and of these, 40.7% said that alcohol was responsible for not using contraception. Alcohol abuse predicted an increase in risky sexual behaviours (4.45 CI: 2.01–9.75, p50.0001). The effect of alcohol was independent of age. Conclusions: These findings suggest that contraception-related behavioural interventions for young adult women should discuss the link between alcohol and sexual risk behavior.
Alcohol abuse, contraception, drug consumption, perceived risk, sexuality
Introduction Over the last few years, research dedicated to understanding relationships between drug and alcohol use and unsafe sex has grown. The World Health Organization’s Gender, Alcohol and Culture: An International Study project [1] has increased attention on the need to study gender differences in drinking and differential responses that might be useful in addressing problems related to alcohol use. In many countries, research has shown that females drink less alcohol (by volume) and less frequently than their male counterparts [2,3]. Nonetheless, estimates of alcohol
*CEA Study Group (in alphabetical order): C. Castelo-Branco, Institut Clı´nic de Ginecologia, Obstetrı´cia i Neonatologia, Hospital Clı´nic, Facultat de Medicina, Universitat de Barcelona, IDIBAPS, Barcelona; M. Correa, Hospital Universitario de Canarias, Santa Cruz de Tenerife; M.A. Go´mez, Family Planning Center Alicante; J.V. Gonza´lez, Hospital Clı´nico Universitario Lozano Blesa, Zaragoza; I. Lete, Hospital Santiago Apo´stol, Vitoria-Gasteiz; P. Lobo, Hospital Infanta Sofı´a, San Sebastia´n de los Reyes, Madrid; N. Mendoza, Margen Clinic, Granada; N. Parera, Institut Dexeus, Barcelona; E. Pe´rez-Campos, Hospital General de Requena, Valencia; E. de la Viuda, Hospital Universitario de Guadalajara. Address for correspondence: Camil Castelo-Branco, Clinic Institute of Gynecology, Obstetrics and Neonatology, Hospital Clinic, Villarroel 170, 08036 Barcelona, Spain. Tel: +34 93 227 54 36. Fax: +34 93 227 93 25. E-mail: [email protected]
History Received 5 January 2014 Revised 1 March 2014 Accepted 19 March 2014 Published online 20 May 2014
use among European females indicate that approximately 30% are alcohol drinkers [4] and roughly a third of male drinkers drink at risky levels over weekends [5]. One in 10 women surveyed for the Demographic Health Survey (1998)] had experienced symptoms of alcohol problems during her lifetime [6]. In addition, data from this survey suggested that women who are poor and with low educational level were significantly more likely to report lifetime alcohol problems [6]. On the other hand, a recent study using path models showed that contextual variables (family socio-economic status and negative family interaction) were relatively weak predictors of young adulthood alcohol use and abuse, whereas the effects of childhood individual variables (e.g. aggression, popularity, behavioral inhibition) on adulthood alcohol use and abuse generally were the key variables to predict the alcohol abuse being mediated by the same behavioral variables in adolescence [7]. Furthermore, among young women who have had sexual relations, many have reported that the use of alcohol and other drugs helps them to overcome their wariness [8]. Some risk-taking behaviors such as negligence in contraceptive use and intercourse under the influence of alcohol have been suggested as main reasons behind the increasing numbers of abortions among young women [9]. While the explanations that have been put forward identify a variety of underlying linkages, newer research has begun to highlight the idea that human desire factors into this equation.
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At present, however, very little scientific evidence explains how desire, drug use and unsafe sex intersect. In response to this, a qualitative study with a very large number of subjects was undertaken to understand the relationship between these factors among young adult women. As in Spain circuit parties (i.e. thematic, techno-music, dance parties, drink parties) are attended by many young women who use drugs, including dangerous amounts of alcohol, and engage in unsafe sex, this population was selected as an ideal focal point for data collection and further intervention.
Materials and methods Subjects The sample was taken from women between 18 and 29 years old from all Spanish Autonomous Communities, covering an estimated population of 3 584 923 women in 2009 according to the data provided by the Statistical Unit of the census of the Statistics National Institute. Sample size was established based on the fact that the studied conditions, drug and alcohol use, sexual intercourse and contraception use and knowledge may affect most of the women. Using statistical software to calculate sample size, for a population size of 3 584 923 women and an expected sample distribution p/q ¼ 50/50, with a maximum acceptable error of 2% we obtained a sample size of 2997 women with a 95% confidence interval. Therefore, a total of 3976 were asked to take part in this survey. Of them, 3163 women were finally interviewed by 57 professional interviewers between March and April of 2010 (refusal rate of 20%, not in attendance at phone call 25%) (Table 1). Design of the study This cross-sectional, open, observational and descriptive study was integrated in two different phases. The inclusion of the 3163 women in the study was bimodal, combining the personal interview (first phase, n ¼ 2250) with the phone call interview Table 1. The geographical distribution of the study population was stratified in a non-proportional model.
Andalusia Aragon Asturias Balearic Islands Canary Islands Cantabria Castile & Leon Castile-La Mancha Catalonia Valencian community Extremadura Galicia Madrid Murcia Navarra Basque country La Rioja Total
Women screened Total sample
Women included Studied sample
Sample error (%)
364 187 188 184 229 192 230 225 321 281 190 235 302 200 207 236 190 3976
278 150 150 150 183 149 190 189 264 233 151 193 250 149 149 185 150 3163
6.0 8.2 8.2 8.2 7.4 8.2 7.2 7.2 6.1 6.5 8.2 7.2 6.3 8.2 8.2 7.3 8.2 1.78
At least 150 interviews in each of the 17 autonomous communities were done and the rest of interviews (n ¼ 600) were distributed proportionally according to the population of the most inhabited autonomous communities (Andalusia, Canary Islands, Castile y Leo´n, Castile-La Mancha, Catalonia, Valencia, Galicia, Madrid and Basque Country). For the treatment of national data set, a weighing was made in order to match the weight of the interviews conducted in each Autonomous Community with the weight of the real population.
(2nd phase, n ¼ 913) in order to better meet the quota of age and geographical distribution. Inclusion of subjects by telephone interviews was by two-stage random selection (random telephone numbers and random individual in the home). Personal interviews were carried out stratified by Autonomous community and size of the cities, with selection of the addresses by random routes and individuals within the families using tables of random numbers. Inclusion and exclusion criteria Twenty-one subjects were excluded for the following conditions: (1) did not complete the questionnaire (n ¼ 15), (2) neurophysiological diseases determined from the interview (n ¼ 3) and (3) difficulty in the understanding and interpretation of the questions (n ¼ 16) (some subjects presented more than one reason). Each subject signed a written informed consent form and a research privacy form prior to testing. The procedures in this study were approved by the Institutional Review Board at the Hospital Clinic (Barcelona, Spain). Questionnaire The survey included items of open and multiple-choice questions, visual analogic scales and numeric assessments with a total of 37 questions. An initial version was tested on 20 women and no comprehension problems were observed. The information was gathered from young adult women using a semistructured questionnaire specifically designed to collect information on their beliefs on health, quality of life, sexuality and use of contraception. The questionnaire included 6 items to filter the subjects according to their beliefs and preferences, 8 items related to socio-demographic variables and 23 items related to sexuality. Of the last ones devoted to sexuality, 10 items explored the relationship with alcohol and drugs use and 13 items were related to contraception. The questions were based on instruments used in previous studies (Sigma Dos, Madrid, unpublished data) and aimed to be clear and concise so as to increase reliability. Alcohol consumption was classified as ‘‘nothing at all’’ (no alcohol), ‘‘some’’ (up to 2 glasses of wine, beer or champagne or 1 of whiskey, rum, gin, etc.) ‘‘average’’ (3–4 glasses of wine, beer or champagne or 2 of whiskey, rum, gin, etc) and ‘‘a lot ’’ (more than 4 glasses of wine, beer or champagne, or more than 2 whiskey, rum, gin, etc) in every session. Each interview took around 20 min and, if the woman was not at home, up to three calls were made at different times of the day in order to reach her. Finally, the preference with the different political spectrum and satisfaction with life was assessed by a visual analogue scale (VAS), with values from 0 (left side: left extreme) to 10 cm (right side: right extreme). Statistical analysis All statistical procedures were performed using SPSS 12.0 for Windows (Chicago, IL). Results were expressed as mean ± SD and total number and percentages. Patients were allocated in age groups (18–20; 21–23; 24–26; 27–29 years old) for comparisons. A multivariate analysis was performed to exclude differences in age, smoking, physical activity, chronic treatment or diseases and to consider a potential confounding factors. Multiple linear regressions were used to model bivariate relationships, to test for additive effects and to control for possible confounding variables such as age, smoking and physical activity among others. ANOVA was used to determine differences on the different items according to the age-groups. Adjustments were made for covariates where applicable. Comparison of categorical data was performed with the chi-square test and likelihood ratio.
Alcohol, drugs and risky sex
DOI: 10.3109/09513590.2014.910190
All values are expressed as means ± standard deviation (SD) and percentages, unless stated otherwise. The overall significance was set at p 0.05.
Results Beliefs and preferences Body care and health (68.7%) have greater importance than other issues such as having free leisure time (15%), satisfying sex life
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(6.2%) or earn money (9.5%) (p50.001). No differences between age-groups were observed. Sexuality was an important issue but not a ‘‘priority’’ for near eight of each 10 interviewed women (77.6%) whereas for an 11.6% was a main concern in their lives. In a multiple option answer, the most common leisure activity during weekends was to visit family or friends (55.0%) followed by ‘‘going out for beer, wine or drinks’’ (42.0%) and resting do nothing (33.4%). Only a 9.8% of interviewed women referred go to thematic drink parties on a regular basis and a 31.7% from time to time (Table 2).
Table 2. Beliefs and preferences. Age-range Total
18–20
21–23
24–26
27–29
3163
790
793
784
796
The most Important thing in your life is? (%) Body care & health 68.7** Free leisure time 15 Earn money 9.5 Satisfying sex life 6.2 50.001
71.5 14.6 7.5 6.2 50.001
72.7 13.2 7.8 5.3 50.001
64.4 16.9 11 7 50.001
68 14.7 10.9 6 50.001
How important is Sexuality? (%)# Main concern 11.6 Important 77.6 Minor 7.7 Nothing 2 50.001 Prefer do not answer 1.2
9.4 74.3 11.1* 4* 50.001 1.2
8.9 81.5* 6.8 1.7 50.001 1.8
15.1* 76.1 7.1 0.5 50.001 1.3
11.9 78.8 6.3 2 50.001 1.1
How do you imagine the world in the future? (%) Will be better 33.2 Equal 20.1 Will be worst 42.6 50.05 Do not know 4.2
29.3 18.2 48* 50.01 4.5
32.5 20.7 41.7 50.05 5.1
31.2 21.6 43.7 50.05 3.4
38.5 19.4 38.1 50.05 4
11.4 69.3 19.2
13.7 75.9 10.2
14.8 74 10.8
14.4 65.5 20.1
48*/** 42.3* 9.6
29.3 58.6 12
26.7 56.9 16.4
14.3** 56.9 28.3**
0.01/0.001 50.05 50.001
Go out for beer/wine with friends Frequently 42 Sometimes 46.2 Never 11.6
46.1 40.1 13
45.5 44.3 10.2
43.6 46.9 9.4
34.9* 51.4* 13.8
50.05 50.05
Go to thematic drink parties Frequently Sometimes Never
9.8 31.7 57.7
21.8* 44.3 33.8
10.4 40.2 47.9
7.1 29.7 62.7
3* 17.7* 78.2*
50.01 50.01 50.005
Practice sport Frequently Sometimes Never
21.3 47.6 30.4
19.4 49 30.9
22 46.1 31
23.9 48.4 27.1
19.8 46.9 32.9
Resting, no activities Frequently Sometimes Never
33.4 54.6 11.7
37 52.4 10.6
30.5 54.4 14.8
32 57.4 10.1
34.3 53.7 11.8
Visit family & friends Frequently Sometimes Never
55 42.1 2.8
56.4 41.7 1.9
55.2 42.3 2.3
55.3 42 2.5
53.6 42.3 4.1
Total number
Leisure in weekends (%) Go to Cinema, Theatre, Museums Frequently 13.7 Sometimes 71 Never 15.2 Go to the Disco Frequently Sometimes Never
28.3 54.1 17.4
p
50.05 50.05 50.01 50.05
50.01
Results are expressed as total numbers and percentages and distributed according age ranges. *Displays differences between age groups. **is related to the total column significance (50.001). #no intra-group differences were assessed.
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Alcohol consumption (weekends) Only a 23.1% of the subjects stated that they drunk ‘‘nothing at all’’ whereas one-third (33.3%) said that they drunk ‘‘some’’ alcohol and the other third (33.2%) recognised to drink ‘‘average’’. On the other hand, a 10% acknowledged that they drunk ‘‘a lot’’ in all sessions. Interestingly, when they were asked about their friends’ consumption, the percentages of high intake increased. Only 5.4% said that their friends or colleagues drunk ‘‘nothing at all’’ and 23.1% ‘‘some’’ whereas up to 43.3% said ‘‘average’’ and 27.3% stated that friends drunk ‘‘a lot.’’ After adjusting by age, the 18–20 years age-group was the one that recognise to consume more alcohol, both themselves and accompanying people (p50.01 and p50.01 respectively). In addition, a 31.5% of interviewed subjects recognised to have been occasionally drunk to the point of not remembering the next day what had happened. This figure surpassed the 55.8% when they referred on their friends. In line with data on alcohol consumption, the 18–20 years age-group presented the higher proportion of subjects that reported this condition (39.2%). These percentages go down with increasing age (33.7%, 27.4% and 28.1% in 21–23, 24–26 and 27–29 age-group respectively) (p50.01). In addition, when the question was referred to their friends, this group also showed the highest percentages (64.9% versus 59.5%, 50.8% and 51.3% in 21–23, 24–26 and 27–29 age-group, respectively) (p50.01). Drugs and sex Most of the Spanish young adult women (62.3%) believed that alcohol consumption removes barriers to practice sex (21.8% ‘‘a lot’’, 40.5% ‘‘quite’’ 19.0% ‘‘little’’ and 14.9% ‘‘nothing’’). However, when the questions were referred to themselves, only 21.7% of girls said that alcohol effectively removes barriers to practice sex (6.6% ‘‘a lot’’, 15.1% ‘‘quite’’, 26.7% ‘‘little’’ and 46.5% ‘‘nothing’’) (Figure 1). By age-groups, this belief (A)
presented a trend to be lower in the 18–20 group (59.8%) compared with the other groups (65%, 62.5% and 62% in 21–23, 24–26, 27–29 age-group respectively) Drugs and risky sex: A total of 1215 women (38.4%) acknowledged that they had sex without using contraception occasionally, being at the risk of unintended pregnancy. This condition occurred more frequently in the 24–26 and 27–29 agegroups (42.5% and 41.9%, respectively, versus 31% and 35% in the 18–20 and 21–23 age-groups p50.01). Of these 1215 women, up to 360 reported having consumed alcohol at this time. The influence of alcohol in risky conducts was recognised mainly by the younger subjects (46.4% in the18–20 age–group versus 31%, 41% and 38.7% in the 21–23, 24–26 and 27–29 age-groups respectively (no significant). Alcohol, hashish and design drugs were positive predictors for engaging in risky sex whereas practice sport and be religious were negative predictors (Table 3). In addition, the higher alcohol intake the higher increase in the risk for to be involved in risky sex. Women who recognised to drink a lot increased by 4 this risk. Multiple linear regression demonstrated that the effect of alcohol and drugs in risky sex was independent of age (Table 4). Contraception and sex A greater use of condoms was observed among women who consume alcohol on weekends compared with no consumers (47.4% versus 35.2%, p50.01). No significant differences were observed among users of other methods in relation to alcohol consumption. Double-method: those women who have claimed to be IUD or hormonal contraception users (39.8% in total) were questioned whether in addition they use condoms to prevent sexually transmitted infections. The greater percentage of double method users was found in the younger age-group declining its use with age (42%, 36.5%, 36.3% and 29.2%, respectively, p ¼ 0.019). (B)
Alcohol
Alcohol
46.5% 46,5%
40.5% 40,5%
26.7% 26,7%
21.8% 21,8%
19.0% 19,0% 14.9% 14,9%
15.1% 15,1% 3.8% 3,8%
Mucho A lot
Bastante Quite
Poco Little
Nada Nothing
N.S./N.C. No response
(A)
6.6% 6,6%
5.1% 5,1%
Mucho A lot
Bastante
Poco
Quite
(B)
Little
Nada Nothing
NoN.S./N.C. response
50.1% 50,1%
51.2% 51,2%
40.4% 40,4% 35.5% 35,5% 27.2% 27,2%
27.3% 27,3% 17% 17,0%
14.5% 14,5%
27.1% 27,1%
21.6% 21,6%
21,5% 19.9% 19,9% 21.5%
16.0% 16,0% 8.0% 8,0%
Other illicit drugs Pastillas/Drogas de diseño
Cannabis/Marihuana
A lot Mucho
Quite Bastante
Little Poco
NadaNothingNS/NCNo response
6.1% 4.7% 4,7% 6,1% 2.5% 2,5%
2.8% 3,4% 3.4% 3,4% 2,8% 3.4%
Cannabis/Marihuana
A lot Mucho
Bastante Quite
Pastillas/Drogas diseño Other illicitde drugs Poco Little
Nada Nothing NS/NC No response
Figure 1. I have the control. Relationship between alcohol and drugs consumption and the belief that these actions remove barriers to practice sex. (A) Do you believe that alcohol and drugs removes barriers to have sex? (B) And particularly in your case?.
Alcohol, drugs and risky sex
DOI: 10.3109/09513590.2014.910190
Table 3. Multivariable model of prediction of engaging in risky sex. Variable Age 18–20 21–23 24–26 27–29 Alcohol consumption A lot Average Some Nothing at all Drugs consumption No Tobacco Hashish/Cannabis Design drugs Fidelity to partner Fear to pregnancy Fear to STI Religious Shame Contraception Condom Hormonal IUDs Coitus interruptus Sport
Odds ratio
95% CI
1.35 Reference 1.42 1.41
0.98–2.45
4.54 2.12 Reference 0.34
2.01–9.75 1.25–5.36
p Value
0.91–2.01 0.87–1.98 50.0001 50.005
0.15–1.28
Reference 1.49 1.88 2.15 0.45 0.43 0.25 0.11 0.37
0.92–2.89 1.40–2.48 1.00–3.17 0.25–1.09 0.21–1.11 0.11–1.01 0.09–0.98 0.19–1.18
Reference 1.15 1.08 1.25 0.75
0.89–2.19 0.99–1.99 1.00–2.22 0.25–0.97
50.05 50.05
50.05
50.05
Table 4. Multiple linear regression for risky sex (dependent variable). Variable
B
Alcohol consumption 0.9944 Hashish/Cannabis 2.3333 Design drugs 2.7821 Religious 3.5772 Sport 4.3724 Age 2.150
SE for B 0.0839 1.0663 1.1026 1.6672 1.0999 1.0455
Beta
T
0.5142 11.843 0.0946 4.188 0.1104 5.787 0.0978 2.177 0.1644 3.979 0.0985 1.978
p Value 0.0000 0.0290 0.01 0.05 0.001 0.05
The effect of alcohol and drugs on risky sex was independent of age.
Emergency contraception: A third of the sample (33.3%) claimed to have used emergency contraception (EC) on occasion. The use of EC was significantly lower in the 27-29 age-group (29.1%; versus 33.5%, 35.7% and 35.5% in the 18–20, 21–23 and 24–26 age-groups p ¼ 0.017) and higher among young people who say drinking alcohol on weekends (35.8% versus 25.2% p50.01).
Discussion There is growing awareness of changes in the levels and patterns of women’s use of alcohol and drugs. International data suggest that patterns of consumption among younger women are beginning to echo that of their male counterparts. Similarly, alcohol consumption among older women is also increasing in some developed countries. While the focus of this research was a general exploration of the relationship between drug use and unsafe sex in young adult women, it was situated particularly in drink circuit parties (DCP) where previous research indicates drug use and unsafe sex occur commonly [10–13]. This study aimed to provide a more in-depth analysis of the situation in Spain, trying to understand what type of young people attend to night recreational settings and how they have fun, their use of alcohol and illicit drugs, their sexual behaviours and how these issues are correlated.
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The sample included only young adult women with a social status ranging from medium-low to medium-high and the majority had at least 12 years of scholarship. The recreational habits of Spanish young people from the 17 autonomous communities under analysis follow a pattern which is not that different from the typical European pattern of entertainment and can be considered ‘‘normalised’’ since it follows the dominant and expansive paradigm of recreational life, consumption and entertainment [14,15]. For the majority of the Spanish young adult women included in the study as for other European young adults [16], the enjoyment comes from interacting with friends, drinking, enjoying the music and dancing. In general, women included in this study recognised the consumption of alcohol by themselves and by their friends and almost four in ten acknowledged that they have had sex without using contraception at risk of becoming pregnant unintentionally. Nearly one-third of these young adult women who had claimed to have had sexual intercourse without contraception reported having consumed alcohol at this time. Drug and alcohol use inevitably relax sexual habits and consequently increase carefree and careless sex [17]. There is a commonsense understanding among the respondents about this relationship since 62.3% recognised that alcohol influence to have unsafe sex. However, 360 of the 3163 interviewed women (11.3%) had sexual intercourse that they regretted afterwards due to the use of this drug, which demonstrates a perception of the risk of adopting these sexual behaviours. These data are similar to those observed by Lomba in Portugal [13]. Lessening, euphoria and disinhibition, the decrease in selfcontrol and in the perception of the risk caused by alcohol and psychoactive substances makes users less alert and end up overlooking the messages of safe sex which they would take into account if abstemious. Recent data from a cross-sectional study of young people in nine European cities [17] suggested an epidemic of recreational drug use and gorge drinking that exposes a great amount of young Europeans to routine consumption of substances, which modify their sexual decisions and increase their probability of unsafe and regretted sex. For most of them, substance use/abuse has become an integral part of their strategic approach to sex, locking them into continued use. Engaging in substances with both physiological and psychological links to sex requires approaching substance use and sexual behaviour in the same way that individuals experience them, as part of the same social process [17]. On the other hand, it is not clear whether drug use is a marker for high-risk sexual behaviour, drug use leads to high-risk sex, high-risk sex leads to drug use or some other combination [18]. Finally, we should recognise that this study presents several limitations to consider generalisable the data reported. Firstly, the potential bias due to the response rate, and also a possible recall bias. Second, the fact that was designed as a cross-sectional study may imply that presumed direction of causation may be reversed with time. However, the study included an important number of subjects and this may minimise the bias effect on the final results. In summary, given the fact that there are an increasingly high number of nightlife recreational settings including DCPs and that they are increasingly popular with young people, efforts aimed at preventing outcomes associated with casual sex (e.g. pregnancy, sexually transmitted infections, or mental health) should target specific drinking settings where young adults might be at high risk for risky alcohol use and unsafe sex behaviors [19]. Future research should be targeted to design and implement programs of harm reduction intervention. Therefore, a primary summit of such research must be the acceptance of the high possibility that social, cultural and situational factors, in combination with illegal drugs and alcohol taking practices, may determine the nature of
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relationships between drug use and sexual risk behaviour. This fact emphasise the need to assess the influence of recreational settings as an environmental factor for alcohol and drug use and sexual risk behaviours, and to create a better understanding of the interaction between these three variables among young adult women.
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8.
9.
Ethics approval The study was performed in a sample of general population and all the participants demonstrated comprehension after the explanation of the interview. The procedures in this study were approved by the Institutional Review Board at the Hospital Clinic (Barcelona, Spain).
Declaration of interest Authors report no conflict of interest. MSD Spain provided an unrestricted grant
10.
11.
12.
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