Sexually Transmitted Diseases:
Alcohol and Condom Use: A Meta-Analysis of Event-Level Studies
LEIGH, BARBARA C. PhD
From the Alcohol and Drug Abuse Institute, University of Washington, Seattle, Washington
A meta-analysis of sexual encounters revealed that alcohol use was related to nonuse of condoms at first intercourse but not in other sexual encounters.
Supported by grant K02 AA0183 from the National Institute on Alcohol Abuse and Alcoholism (NIAAA).
Reprint requests: Barbara C. Leigh, PhD, Alcohol and Drug Abuse Institute, University of Washington, 1107 NE 45th Street, Suite 120, Seattle, WA 98105. E-mail: firstname.lastname@example.org
Received for publication August 14, 2001,
revised November 21, 2001, and accepted November 26, 2001.
Background: Although it is often assumed that drinking alcohol interferes with condom use, studies on this topic have used several different methods and have yielded inconsistent findings. By examining drinking and condom use in specific sexual encounters, the role of alcohol in influencing unprotected intercourse is targeted.
Goal: The goal of the study was to assess the relationship of alcohol use and condom use in discrete sexual encounters using meta-analysis.
Study Design: Studies in the literature were identified by computerized searches of MEDLINE and PsycINFO and hand searches of reference lists. Summary odds ratios were calculated for all analyses and for subgroups formed according to type of sexual encounter (first, most recent, most recent with a new sexual partner).
Results: The association of alcohol use and condom use varied by type of sexual encounter: drinking at first intercourse was associated with decreased condom use (odds ratio [OR], 0.54; 95% CI, 0.44–0.66), but drinking was unrelated to condom use in recent sexual encounters (OR, 1.04; 95% CI, 0.89–1.21) and in recent encounters with new partners (OR, 1.1; 95% CI, 0.92–1.32).
Conclusion: Drinking is not necessarily linked to unprotected intercourse; the relationship between alcohol use and unprotected sex depends on context and sexual experience of the partners.
IN THE MIDST OF epidemics of HIV and STDs, research on potentially modifiable factors that may influence sexual risk behavior remains vital. One such factor may be drinking alcohol with sex. 1,2 Because alcohol is thought to interfere with judgment and decision-making, some suggest that its use in conjunction with sexual activity might increase the probability that risky behaviors will occur. 3,4
Recent years have seen an explosion of research on this topic, but several literature reviews have noted the inconsistency of study findings. 2,5–9 Individual studies vary considerably in the method used to assess the alcohol/risky sex association. In many studies, general drinking habits (for example, quantity or frequency of use) are simply correlated with general measures of risky sexual behavior (for example, frequency of unprotected intercourse). A more targeted approach is an event-level method, in which respondents are asked about drinking and unprotected sex in a specific sexual encounter. The chief advantage of such a method, compared with simply correlating general measures of drinking habits and sexual risk, is that it ensures that drinking and unprotected sex occurred on the same occasion, thus strengthening (but not guaranteeing) causal inferences.
Results of these event-level studies are also inconsistent. 2 Meta-analysis provides a way to review and integrate these studies using quantitative methods rather than judgment alone 10 and to identify factors that contribute to variation among the studies, thereby enhancing understanding of the dynamics of the relationship of alcohol use to unprotected sex. This article describes a meta-analysis of studies that examined the relationship between alcohol use and condom use in discrete sexual encounters. For nonexperimental studies such as these, the primary value of meta-analysis lies in identifying and exploring reasons for heterogeneity in results, rather than calculating a single estimate of effect size. 11,12 To that end, several factors that may contribute to heterogeneity are examined, including age, gender, and type of sexual encounter.
To identify studies for inclusion in the analysis, first, personal files were searched and colleagues in the field were contacted. Second, MEDLINE and PsycINFO were searched for publications from the period 1966 to 2000, using combinations of keywords and phrases, including alcohol, condom, intercourse, and sexual encounter. Finally, bibliographies of reviews and empirical articles were examined.
Studies were included if (1) respondents were interviewed about a specific sexual encounter, were asked whether a condom was used in that encounter, and were asked whether alcohol was used before or during the encounter; (2) enough information was given to calculate odds ratios and standard errors; and (3) they were published in English.
The outcome of interest was whether a condom was used in the sexual encounter. Odds ratios (representing the association of drinking and condom use in the sexual encounter) and standard errors were either extracted from the published results or calculated from raw data given in the published paper. If a study reported results separately for men and women, separate odds ratios were calculated. Odds ratios were summarized across studies using inverse-variance weighting, as implemented in the Meta routine in Stata. 13,14 Q-tests for heterogeneity of individual estimates were also performed. 15 Results of fixed-effects analyses are reported here 12; results of random-effects models were not substantially different.
Thirteen studies met the inclusion criteria (Table 1 shows the study characteristics). Nine were conducted in the United States, 16–24 two in Norway, 25,26 one in Canada, 27 and one in France. 28 Investigators in 4 of the 13 studies interviewed adolescents, 18,19,25,26 those in 8 studies interviewed adults (aged 18 years and older), 16,17,20,21,23,24,27,28 and those in 1 study interviewed both adolescents and adults. 22 In 2 studies, respondents reported on their first sexual en-counter 22,25; in 6, on their most recent sexual en-counter 16–18,23,27,28; and in 2, on their most recent sexual encounter with a new sexual partner. 20,21 In each of three studies, respondents reported on two different events: first sexual encounter and first encounter with the most recent partner, 19 most recent sexual encounter and most recent casual sexual encounter, 26 and most recent sexual encounter and most recent sexual encounter with a new sexual partner. 24
An additional five studies assessed participants’ use of any substances with sex, including alcohol or other drugs. 23,29–32 All of these studies assessed substance use and condom use at the most recent sexual encounter, two among adolescents 31,32 and three among adults. 23,29,30 Because of the different pharmacological effects of different kinds of drugs, these studies are analyzed separately from the alcohol-only studies.
Fifteen studies did not meet the inclusion criteria. Ten studies did not provide sufficient information to calculate odds ratios and/or standard errors 33–42; two did not use a binary outcome variable, making calculation of odds ratios impossible 43,44; and three reported the percentage of respondents who used alcohol and the percentage who used condoms but did not report how these factors were related. 45–47 Only one of these studies 44 reported that drinking was related to decreased condom use.
Thirteen studies that analyzed more than one instance of an event were also excluded from the analysis, including studies that analyzed a drinking-sexual encounter and a nondrinking-sexual encounter by the same person, 48–50 a protected and an unprotected sexual encounter by the same person, 51–54 more than one event per person using an analysis of pooled events, 55–57 or data from retrospective or prospective diaries of drinking and sexual behavior. 58–60 Because these studies used several different analytical methods—paired t tests, McNemar tests for matched pairs, logistic regression or chi-square analyses of pooled events, and generalized estimating equations—summarizing them is difficult, given the limitations of using standardized effect sizes. 61 Five of these studies assessed participants’ use of any substances, including alcohol or drugs, 52–54,57,59 and the remainder assessed alcohol only. Only two of these studies 51,55 reported any significant association of alcohol and condom use, and that was only in certain subgroups.
Studies of Alcohol and Condom Use
Results of the 26 analyses extracted from the individual studies of alcohol use and condom use showed that people who used alcohol in conjunction with sex were slightly less likely to use condoms; however, the Q test indicated significant heterogeneity among the odds ratios (Table 2). To explore this variability, different subgroups of studies were tested (Table 2 and Figure 1). On the basis of suggestions that the relationship of alcohol use to sexual risk-taking may differ for adolescents and adults, 62 for first sexual encounters versus recent encounters, 8 and for encounters with new partners versus established partners, 59 separate analyses were undertaken for subgroups, characterized by event type (first intercourse, most recent sexual encounter, and most recent sexual encounter with new partner) and age (adolescent and adult). People who drank in conjunction with their first sexual encounter were less likely to use condoms than those who did not drink (odds ratio [OR], 0.54), but drinking was unrelated to condom use in recent sexual encounters (OR, 1.04) and in recent encounters with new partners (OR, 1.1). Although drinking was related to nonuse of condoms among adolescents in general (OR, 0.71; 95% CI, 0.61–0.83), this finding was due almost entirely to the overrepresentation of adolescents in studies of first intercourse; for recent encounters among adolescents, drinking was unrelated to condom use (OR, 0.92; 95% CI, 0.75–1.14).
Meta-regression 63 was used to investigate associations between the alcohol effect and study characteristics. Study characteristics included in the analysis were age of the sample (adolescent or adult), type of event (first, recent, recent with new partner), and gender composition of the sample (male, female, or both). Type of event was related to the alcohol effect, with lower odds ratios for the first sexual encounter than for recent encounters (Z = 3.27;P = 0.001), and to recent encounters with new partners (Z = 3.82;P < 0.001). Odds ratios were also lower in samples of adolescents than in samples of adults (Z = 1.86;P = 0.06). Gender composition of the sample was not associated with the alcohol effect.
Studies of Alcohol or Drugs and Condom Use
Results from the eight analyses of alcohol or drug use and condom use showed that people who used any substances in conjunction with sex were less likely to use condoms (summary OR, 0.77; 95% CI, 0.64–0.91), with some heterogeneity in odds ratios (Q [7 df] = 11.1;P = 0.13;Figure 2). The summary odds ratio was highly influenced by a single large study 31; without this study the summary odds ratio for the remaining seven analyses was 0.90 (95% CI, 0.69–1.18).
Tests for publication bias were performed with the Metabias routine in Stata, 64 which performs tests for funnel-plot asymmetry 65,66; no evidence of publication bias was found.
The results of this meta-analysis showed that alcohol use was related to nonuse of condoms at first intercourse, with a trend among adolescents in general toward nonuse of condoms when drinking. Among adults, drinking was unrelated to use of condoms in sexual encounters. The first sexual experience represents a significant and novel milestone, and the factors that affect contraceptive use may not apply to subsequent events. 8 First-timers are novices at sex and probably at drinking as well, and their decisions may reflect the limited knowledge and experience one might expect of beginners. In their first sexual experiences, often with ambivalent feelings, the partners may find that the perceived power of alcohol as a sexual disinhibitor influences their decisions regarding sex and protection. Moreover, drinking, especially for those having sex for the first time, may interfere with planning, which affects the likelihood of using contraception. 26,67
The analysis suggested that using other substances, either alone or in addition to alcohol, may be associated with nonuse of condoms, but none of the reports of the individual studies reviewed gave information about what drugs were used. Alcohol has long been associated with sexual behavior in many contexts 68; therefore, it is not surprising that there have been many studies examining the relationship of alcohol use to sexual behavior in general 68,69 and unprotected sex in particular. 2 Other drugs receiving special attention in relation to sexual risk-taking are methamphetamine, 70 inhalants, 71 and crack/cocaine. 72 Not only do these drugs have different pharmacological effects but they also may be used in very different situations. For example, alcohol can be an instrument of courtship, 68 and as such is more common in encounters with new sexual partners. 24 Cocaine, according to conventional wisdom, has desirable effects on sexual performance, 73 and crack is often associated with trading sex for drugs. 74 Among homosexual men, some research has identified strong relationships between risky sex and the use of nitrites 71 or methamphetamine. 70 Differences in pharmacological effects, situations of use, and reasons for use may lead to different relations of these drugs to unprotected sex.
In the studies reviewed here, drinking with sex was analyzed as a binary measure, without reference to the amount of alcohol consumed. The effect of alcohol on behavior, from a mild energetic state to depression and coma, varies with quantity. 75 A sufficient amount of alcohol leads to depressed reflexes and decreased coordination, potentially interfering with condom use. The amount of alcohol consumed may contribute to the strong relationship of alcohol use and unprotected sex at first intercourse if the amount drunk is particularly large in these encounters. For example, in one study of adults, 36% of women and 55% of men who drank before their most recent sexual encounter with a new partner had 5 or more drinks, 76 whereas studies of first sexual encounters have shown that 54% of young women who drank before their first sexual encounter had 7 or more drinks 77 and that 75% of young men had 5 or more drinks. 67
By ensuring that alcohol use and unprotected sex are temporally paired, an event-level method strengthens causal inferences, but it does not eliminate confounding variables. For example, lifestyle factors such as a propensity for risk-taking, sensation-seeking, or unconventionality might lead to both alcohol use and unprotected sex in these events. Therefore, a link between drinking and unprotected sex in first sexual encounters might represent these lifestyle factors rather than a causal effect of alcohol. 2,78
A cause–effect model and a lifestyle model have different implications for prevention and education. Prevention programs that assume a causal effect of alcohol on risky sex might be ineffective if drinking and risky sex are linked through lifestyle factors. 78 Health education messages that are based on a causal model may even have paradoxical harmful effects, if highlighting a link between drinking and risky sex gives people a convenient excuse for engaging in risky behaviors. 2,79 Moreover, a general message that alcohol leads to sexual risk behavior is misleading, given that this link is found only at first intercourse, where drinking seems entangled with ambivalent feelings and lack of planning. Incorporating these complex relations into education programs for adolescents is a challenging task. 79
The interplay between alcohol use and sexual behavior is part of a context that incorporates elements of personality, situation, and relationships. 26,78 Alcohol use is more common in sexual encounters between casual partners than in encounters involving primary partners, 19,20,23,24 and most people who report drinking in a sexual encounter report that their sexual partner was drinking as well. 24,77 Some findings suggest that drinking is related to unprotected sex for casual sexual partners and not primary partners 49,59 or that alcohol affects sexual activity only at certain points in a relationship. 8 The major finding of this meta-analysis—that drinking is related to unprotected sex only in first sexual encounters—highlights the importance of the context of the sexual encounter in influencing both drinking and sexual behavior.
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