Cook, Robert L. MD, MPH*†; Comer, Diane M.†; Wiesenfeld, Harold C. MD, CM‡; Chang, Chung-Chou H. PhD*†; Tarter, Ralph PhD§; Lave, Judith R. PhD∥; Clark, Duncan B. MD, PhD§¶
IN THE UNITED STATES, SEXUALLY transmitted diseases (STDs) and substance abuse are 2 of the most serious health problems facing adolescents and young adults. Of the 12 million new cases of STDs diagnosed each year, most occur in individuals aged 15 to 24 years.1 This is the same age group in which problems related to the use of alcohol, marijuana, and other drugs are most prevalent.2 Alcohol and drug use have been consistently associated with risky sexual behaviors and with STDs.3–8 Therefore, the prevalence of substance use problems would be expected to be higher among persons seeking evaluation at STD clinics than in the general population.
Each year in the United States, STD clinics receive visits from over 2 million individuals, the majority of whom are young and from low-income and minority groups.9,10 These individuals seek evaluation at STD clinics for reasons such as the presence of genitourinary symptoms, a referral from other healthcare providers, or the desire for a general STD checkup or HIV test that can be obtained for little or no cost.10 Although counseling to prevent HIV infections and other STDs is an important role of STD clinics, the clinic personnel tend to have limited time and receive limited training in the skills needed to educate and counsel their patients about other health issues.11,12 Topics such as alcohol or drug use are often not addressed in this setting.
Only a few studies have reported on the prevalence of substance use disorders (substance abuse or dependence) among persons attending STD clinics. In a study of 201 persons attending an STD clinic in Baltimore, Maryland, the current prevalence of alcohol use disorder was 9.0% and of marijuana use disorder was 10.9%.13 The mean age of the study population was 32 years old, and 96% were black. In a study of 1740 persons attending STD clinics in Michigan, 16.7% had a lifetime diagnosis of alcohol abuse and were still drinking, and 5.3% had a lifetime diagnosis of marijuana abuse and were still using marijuana.14 The mean age of participants in that study was 26.5 years, and 77% were black. Although these 2 studies suggest that that substance use disorders are common among persons attending STD clinics, their sample populations were largely older than those who are typically at highest risk for STDs and for alcohol and drug use disorders.
The primary objectives of our study were to describe the patterns of alcohol and drug use and associated disorders in a population of young persons attending an STD clinic and to determine the associations of alcohol and drug use disorders to sexual risk behaviors and newly diagnosed STDs in this setting.
Materials and Methods
Participants were recruited from an urban STD clinic that is located within the Pittsburgh metropolitan area and provides STD screening, diagnosis, and treatment at no cost to approximately 150 persons a week. Men and women were eligible for the study if they were attending the clinic for a new problem, were 15 to 24 years old, and received a full assessment at the clinic. Pregnant women were excluded, because pregnancy can affect substance use behavior. All participants signed a consent form approved by the University of Pittsburgh Institutional Review Board.
From 1999 to 2002, part-time research team members attended the clinic one or more days each week and approached consecutive eligible patients attending the clinic. Of the 829 within the eligible age range who were approached, 358 (43%) agreed to participate. We did not systematically ask reasons for not participating, but most patients who did not join the study informally indicated a lack of interest or time. Using chart abstraction, we compared participants with the 471 eligible persons who did not participate in terms of sex, race/ethnicity, reported alcohol consumption (as noted by the clinician), and clinical diagnosis of STDs. The only significant difference was participation rate (51% for women and 37% for men, P <0.001). We enrolled an additional 90 participants who contacted study research staff in response to study brochures that were occasionally distributed at the clinic when research assistants were not present. These participants met the same eligibility criteria described here and did not differ from the directly approached participants on demographic or clinical characteristics.
Participants received a clinical assessment for STDs and completed an interviewer-administered questionnaire about demographics, substance use, sexual behavior, and sexual partners.
Clinical and Laboratory Assessment.
For each participant, a trained clinician completed a standardized clinical assessment that included a visual inspection of the genital area and the collection of test specimens. During the visit, clinicians reviewed Gram-stained slides of urethral secretions and reviewed wet mount preparations of vaginal secretions. In males, urethral samples were sent to a clinical laboratory and tested for chlamydia and gonorrhea. In females, cervical specimens were tested for chlamydia and gonorrhea, and vaginal samples were sent for culture for trichomonas. All participants provided a blood sample to be screened for syphilis, and clinical lesions suspicious for genital herpes were swabbed and sent for viral culture. Genital warts were diagnosed by their characteristic clinical appearance.
For purposes of the study, a confirmed STD was defined as a laboratory-confirmed diagnosis of chlamydia, gonorrhea, trichomonas, syphilis, or genital herpes or as a clinical diagnosis of genital warts. Persons diagnosed with genital herpes or warts were classified as a new STD only if they indicated no history of these infections by self-report. In men, the presence of nongonococcal urethritis (NGU) in the absence of other infections was not defined as a confirmed STD.
Completion of the Interviewer-Administered Questionnaire.
A female interviewer with extensive training in substance use assessment administered a structured questionnaire either in person (n = 177 [49%]) or by telephone (n = 186 [51%]) within 2 weeks of the visit. The choice of interview method was made by the study participant.
Participants were asked about the frequency of use of 12 different categories of drugs. Frequency options included 9 categories assessing use in the past year: none in the past year, less than once a month, once a month, 2 to 3 times a month, once a week, 2 to 3 times a week, 4 to 5 times a week, everyday, and several times a day. These responses were then grouped into 3 categories: no use in past year, <once a month, and at least once a month. Alcohol drinkers were asked to name the type of beverage they consumed most often. Binge drinking was defined as consuming multiple drinks (5 for men or 4 for women) at one sitting at least once a month.15
Participants who reported any alcohol or marijuana use during the past 12 months then completed a version of the Structured Clinical Interview for Diagnostic and Statistical Manual-IV (SCID) that was especially designed to determine whether young people meet the criteria for a current (past year) DSM-IV diagnosis of alcohol abuse, alcohol dependence, marijuana abuse, or marijuana dependence.16 This version, which includes youth-directed questions (e.g., questions about missing school because of substance use) has moderate to high interrater reliability and good concurrent validity in adolescents.17
All participants were asked during the past 12 months how many sexual partners they had, how often they used condoms, and whether they had experienced any of several types of condom-related problems. For these analyses, we categorized persons as having multiple sexual partners if they reported more than the median number of sexual partners for men (>4 partners) and for women (>2 partners). Participants were also asked about characteristics of their most recent main sexual partner and about their perceptions of the role of alcohol use in their own sexual situations. After completing the questionnaire, participants each received a small monetary compensation of $20 to $40, depending on the length of the interview, together with information about alcohol and drug treatment options available in the community.
We used chi-squared statistics and t tests to compare categorical variables and continuous variables. We then used multivariate logistic regression to examine the relationship of different categories of substance use disorders to sexual behavior and STD outcomes. Multivariate analyses all adjusted for age, race, gender, and insurance. All analyses were conducted using SPSS, version 11.5.
Characteristics of the Study Sample
The mean age of the 448 study participants was 20.4 years (standard deviation: 2.2 years), and the range was 15 to 24 years. Approximately 50% were women; 41% were white, 54% were black, and 3% were of other racial/ethnic groups. Two thirds were working at least part-time, 14% were full-time students, and 19% were neither working nor currently a student. Forty percent had no health insurance. Participants presented to the STD clinic because they had symptoms (42%), were referred by clinicians or friends (25%), felt fine but wanted an STD checkup (15%), believed their partner had an STD (9%), or other reasons (9%).
Alcohol and Drug Use Frequency and Patterns
A large proportion of the 448 study participants used alcohol, tobacco, or marijuana at least once a month (Table 1). Fewer than 5% of participants reported use of any other types of drugs in the past month, although at least 10% of participants reported using ecstasy, hallucinogens, or sedative/hypnotic drugs at least once in the past year. Males were significantly more likely than females to report consumption of alcohol and marijuana at least monthly (Table 1), whereas there was no significant gender differences in the use of other types of drugs.
Although 46.8% of participants consumed alcohol at least once a week, only 2% consumed it once or more a day. Many (48.0% of men and 39.6% of women) reported binge drinking at least once a month. Beer and malt liquor were the most common beverages (consumed by 48.1% of drinkers) followed by hard liquor (43.4%) and wine or wine coolers (8.4%). A greater proportion of participants consumed marijuana daily. Although 37.3% smoked marijuana at least once a week, 14.7% smoked it once a day and 6.5% smoked it several times a day.
Diagnostic Criteria for Alcohol and Marijuana Use Disorders
Of the study participants, 28.3% of the study participants met diagnostic criteria for alcohol abuse or dependence, 29.0% met criteria for marijuana abuse or dependence, and 42.9% met criteria for either alcohol or marijuana abuse or dependence (Table 2). The most common diagnostic symptom of a substance use disorder was repeated (i.e., 3 or more times in the past year) use of alcohol or marijuana in dangerous situations such as driving a vehicle (29.9%). Other common symptoms included spending a significant amount of time intoxicated (25.4%), using more or longer than intended (23.2%), and acquiring tolerance (22.1%).
Men were significantly more likely than women to meet criteria for a substance use disorder (51.6% vs. 34.2%, P <0.001) and to meet several specific diagnostic criteria of alcohol or marijuana use disorders, including use in dangerous situations, use despite problems, spending a significant amount of time intoxicated, and avoiding others resulting from substance use (Table 2). Substance use disorders were more common in whites than in blacks (49.2% vs. 38%, P = 0.024), with nearly all of the difference coming from a greater prevalence of alcohol use disorders in whites. When compared by age, the prevalence of alcohol use disorders was nearly identical in younger (age 15–19) versus older (age 20–24) participants (27.3% vs. 29.5%, P = 0.60), whereas marijuana use disorders were somewhat more common in the younger age group than in the older age group (32.8% vs. 24.8%, P = 0.062).
Risky Sexual Behaviors and Sexually Transmitted Diseases
The mean number of sexual partners was 5.2 for men and 2.9 for women (P <0.001) (Table 3). One in 10 participants used condoms every time. Among those who used condoms at all (n = 389), 71.2% reported condom use problems in the past year. Specific problems included a condom that broke (44%), fell off (25%), was removed halfway through sex (27%), or was put on halfway through sex (26%). Over one in 3 participants reported having unplanned sex in the past year as a result of drinking alcohol, and an even greater proportion felt that someone else was trying to get them drunk in order to have sex (Table 3).
Over one fifth (21.7%) of participants reported being diagnosed with an STD in the 12 months before the current visit. A new STD was detected in 30.6% of participants. The most common STDs were chlamydial infection and gonorrhea in both men and women (Table 3). None of the participants were diagnosed with syphilis.
Alcohol and Marijuana Use Disorders, Risky Sexual Behavior, and Sexually Transmitted Diseases
Men with a substance use disorder (alcohol or marijuana abuse or dependence) reported significantly more past year sexual partners than men without a substance use disorder (Table 3). Men with a substance use disorder were also significantly more likely than men without a substance use disorder to have had a main partner who had ever been in jail, to have inconsistent condom use, to have had unplanned sex resulting from drinking alcohol, to have tried to get someone drunk to have sex, and to have any diagnosed STD (Table 3).
Women with a substance use disorder reported significantly more past year sexual partners compared with women without a substance use disorder (Table 3). Women with a substance use disorder were also significantly more likely to report multiple sexual partners, anal sex, receiving drugs or money for sex, to have removed condoms halfway through sex, to have unplanned sex due to drinking alcohol, and to have thought that someone was trying to get them drunk to have sex (Table 3).
In multivariate analyses that adjusted for age, race, gender, and insurance status, participants with an alcohol or marijuana use disorder were significantly more likely than those without a substance use disorder to have multiple sexual partners (OR = 2.29; 95% CI = 1.52–3.44), to be inconsistent condom users (OR = 3.06; 95% CI = 1.49–6.30), and to have an STD (OR = 1.69; 95% CI = 1.09–2.62). The increased risk of these sexual behaviors and STDs was similar regardless of whether persons had only an alcohol or marijuana use disorder or whether they had both alcohol and marijuana use disorders (data not shown).
In our sample of 448 persons who were aged 15 to 24 years and visited an STD clinic, we found that 52% of men and 35% of women had a clinically diagnosed substance use disorder. Indeed, the overall proportion of young persons who had a substance use disorder (42.9%) exceeded the proportion who had a confirmed STD (30.6%). Among the participants, one in 4 reported regular use of alcohol and/or marijuana in dangerous situations (such as driving a car), and one in 5 reported spending a substantial amount of time intoxicated or using alcohol or drugs more or longer than intended.
In this sample, the prevalence of alcohol use disorders (28.3%) and marijuana use disorders (29.0%) was apparently much higher than that found in young persons in the general population. According to the 2003 National Survey on Drug Use, 17.2% of persons aged 18 to 25 had alcohol abuse or dependence, and 5.9% had marijuana (cannabis) abuse or dependence.2 The prevalence of other drug use in persons attending this STD clinic was relatively rare and apparently similar to that reported for the general population. In the 2003 National Survey on Drug Use, the prevalence of any substance use in the past month among persons age 18 to 25 was as follows: alcohol 61.4%, tobacco 44.8%, marijuana 17%, cocaine/crack 2.0%, hallucinogens 1.7%, stimulants 1.3%, and ecstasy 0.7%.2
Overall, participants with a substance use disorder were 70% more likely than those without a substance use disorder to have a current STD and were 2 to 3 times more likely to have multiple sexual partners or be inconsistent condom users. These findings are consistent with other studies of young persons that demonstrate an association between alcohol and marijuana use and risky sexual behaviors and STDs.3–8 These associations could be the result of a direct effect of substance abuse on risky sexual behavior or because both substance abuse and risky sexual behavior are often associated with a third factor such as a personality trait that is associated with risky behaviors in general.13,18,19 Regardless of the true mechanism, over one third of subjects in our sample perceived that in the past year, alcohol consumption resulted in their engaging in sexual behavior that would not have happened in the absence of alcohol consumption.
Several potential limitations of our study warrant mention. First, it is unlikely that our findings can be generalized to all young persons, because individuals who attend an STD clinic typically engage in riskier sexual behaviors than do those who do not attend an STD clinic.20,21 However, the findings should be applicable to the large numbers of young persons who attend an STD clinic in the United States each year. Second, our measures of substance use and risky behavior were based on self-report, although we used a formal clinical assessment for substance use disorders and obtained biologic evidence of STDs. Third, because of the cross-sectional study design, it is not possible to determine whether there is a direct causal relationship between alcohol and drug use and risky sexual behavior in this sample.
Alcohol and marijuana use disorders in young persons are harmful to individuals and to society at large.22–24 The prevalence of substance abuse appears to be higher in youth attending STD clinics than in the general population, Thus, these findings raise the question of whether STD clinics should institute formal protocols to screen for alcohol and drug problems and to address these problems if detected.
STD clinics may ultimately prove to be an ideal setting in which to integrate screening and intervention strategies related to substance use problems among young persons. Screening and referring persons with substance abuse problems to other settings is one option but may not be successful. In one study in London, STD clinic attendees were screened for alcohol consumption.25 The 98 persons found to have excessive alcohol use were offered brief written advice (accepted by 93%) and a follow-up appointment with an alcohol health worker. Of the 30 persons who accepted a follow-up appointment, only one actually attended it.25 Several studies have shown that a single brief intervention focused on alcohol or drug consumption can result in a reduction in substance use over time.26,27 However, there are currently no data on whether such brief interventions can reduce substance use or be cost-effective in an STD clinic setting. More research is needed to determine which interventions will be most effective at reducing substance use and their associated outcomes in youth attending STD clinics.
1. American College of Obstetrics and Gynecologists Committee on Adolescent Health. ACOG Committee Opinion #301: Sexually transmitted diseases in adolescents. Obstet Gynecol 2004; 104:891–898.
2. Substance Abuse and Mental Health Services Administration. Results From the 2003 National Survey on Drug Use and Health: National Findings. Office of Applied Studies, NSDUH Series H–25, DHHS Publication No. SMA 04–3964). Rockville, MD; 2004. Available at: http://www.oas.samhsa.gov/nhsda/2k3nsduh/2k3Results.htm
3. Cook RL, Clark DB. Is there an association between alcohol consumption and sexually transmitted diseases? A systematic review. Sex Transm Dis 2005; 32:156–164.
4. Kingree JB, Betz H. Risky sexual behavior in relation to marijuana and alcohol use among African-American, male adolescent detainees and their female partners. Drug Alcohol Depend 2003; 72:197–203.
5. Liau A, Diclemente RJ, Wingood GM, et al. Associations between biologically confirmed marijuana use and laboratory-confirmed sexually transmitted diseases among African American adolescent females. Sex Transm Dis 2002; 29:387–390.
6. Mertz KJ, Finelli L, Levine WC, et al. Gonorrhea in male adolescents and young adults in Newark, New Jersey: Implications of risk factors and patient preferences for prevention strategies. Sex Transm Dis 2000; 27:201–207.
7. Cook RL, Pollock NK, Rao AK, Clark DB. Increased prevalence of herpes simplex virus type 2 among adolescent women with alcohol use disorders. J Adolesc Health 2002; 30:169–174.
8. Boyer CB, Shafer MA, Teitle E, Wibbelsman CJ, Seeberg D, Schachter J. Sexually transmitted diseases in a health maintenance organization teen clinic: Associations of race, partner's age, and marijuana use. Arch Pediatr Adolesc Med 1999; 153:838–844.
9. Landry DJ, Forrest JD. Public health departments providing sexually transmitted disease services. Fam Plann Perspect 1996; 28:261–266.
10. Celum CL, Bolan G, Krone M, et al. Patients attending STD clinics in an evolving health care environment. Demographics, insurance coverage, preferences for STD services, and STD morbidity. Sex Transm Dis 1997; 24:599–605.
11. Eng T, Butler W. The Hidden Epidemic: Confronting Sexually Transmitted Diseases. Washington, DC: National Academy Press, 1997.
12. Stein Z. Family planning, sexually transmitted diseases, and the prevention of AIDS—Divided we fail? Am J Public Health 1996; 86:783–784.
13. Erbelding EJ, Hutton HE, Zenilman JM, Hunt WP, Lyketsos CG. The prevalence of psychiatric disorders in sexually transmitted disease clinic patients and their association with sexually transmitted disease risk. Sex Transm Dis 2004; 31:8–12.
14. Aktan GB, Calkins RF, Johnson DR. Substance use, need, and demand for substance user treatment services in patients treated for sexually transmitted diseases in Michigan. Subst Use Misuse 2001; 36:1651–1676.
15. Wechsler H, Dowdall GW, Davenport A, Rimm EB. A gender-specific measure of binge drinking among college students. Am J Public Health 1995; 85:982–985.
16. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed rev. Washington, DC: American Psychiatric Association, 2000.
17. Martin C, Pollock N, Bukstein O, Lynch K. Inter-rater reliability of the SCID alcohol and substance use disorders section among adolescents. Drug Alcohol Depend 2000; 59:173–176.
18. Leigh B, Stall R. Substance use and risky sexual behavior for exposure to HIV. Am Psychol 1993; 48:1035–1045.
19. Bailey S, Gao W, Clark D. Diary study of substance use and unsafe sex among adolescents with substance use disorders. J Adolesc Health. In press.
20. Howards PP, Thomas JC, Earp JA. Do clinic-based STD data reflect community patterns? Int J STD AIDS 2002; 13:775–780.
21. Manhart LE, Aral SO, Holmes KK, et al. Influence of study population on the identification of risk factors for sexually transmitted diseases using a case–control design: The example of gonorrhea. Am J Epidemiol 2004; 160:393–402.
22. Committee on Developing a Strategy to Reduce and Prevent Underage Drinking. Reducing Underage Drinking: A Collective Responsibility. Washington, DC: National Academies Press, 2003.
23. Macleod J, Oakes R, Copello A, et al. Psychological and social sequelae of cannabis and other illicit drug use by young people: A systematic review of longitudinal, general population studies. Lancet 2004; 363:1579–1588.
24. Compton WM, Grant BF, Colliver JD, Glantz MD, Stinson FS. Prevalence of marijuana use disorders in the United States: 1991–1992 and 2001–2002. JAMA 2004; 291:2114–2121.
25. Crawford MJ, Lowe PC, Greene L, Brookings C. The prevalence of excessive alcohol consumption and the acceptability of brief advice in a sexual health clinic: Cross sectional survey. Sex Transm Infect 2004; 80:416–417.
26. McCambridge J, Strang J. The efficacy of single-session motivational interviewing in reducing drug consumption and perceptions of drug-related risk and harm among young people: Results from a multi-site cluster randomized trial. Addiction 2004; 99:39–52.
27. Tait RJ, Hulse GK. A systematic review of the effectiveness of brief interventions with substance using adolescents by type of drug. Drug Alcohol Rev 2003; 22:337–346.