Alcohol Use and Risky Sexual Behavior among College Students and Youth: Evaluating
the Evidence*
M. LYNNE COOPER, Ph.D. Department of Psychology, 210 McAlester Hall, University of Missouri-Columbia,
Columbia, Missouri 65211
ABSTRACT.Objective: To evaluate the empirical associations between
alcohol use and risky sex at two levels of analysis. Global associations test
whether individuals who engage in one behavior are more likely to engage in
the other, whereas event-specific associations test whether the likelihood of
engaging in one behavior on a given occasion varies as a function of engaging
in the other on that same occasion. Method: Studies examining the association
between drinking and risky sex in samples of college students and youth were
reviewed. Those published in the past 10 years and using event-level methodology
or random sampling were emphasized. Results: Findings were generally
consistent across levels of analysis, but differed across types of risky behaviors.
Drinking was strongly related to the decision to have sex and to indiscriminate
forms of risky sex (e.g., having multiple or casual sex partners), but was inconsistently
related to protective behaviors (e.g., condom use). Moreover, the links among
alcohol use, the decision to have sex and indiscriminate behaviors were found
in both between-persons and within-persons analyses, suggesting that these relationships
cannot be adequately explained by stable individual differences between people
who do and do not drink. Analysis of event characteristics showed that drinking
was more strongly associated with decreased protective behaviors among younger
individuals, on first intercourse experiences and for events that occurred on
average longer ago. Conclusions: Future efforts aimed at reducing alcohol use
in potentially sexual situations may decrease some forms of risky sex, but are
less likely to affect protective behaviors directly. (J. Stud. Alcohol,
Supplement No. 14: 101-117, 2002)
THE MAJORITY of young people (75% of boys and 60% of girls; Alan Guttmacher
Institute, 1994) have had sex by the time they graduate from high school, and
the majority of those who have not will have their first sexual experience while
in college. Sexual experience during this developmental period, however, tends
to be sporadic, furtive and poorly managed (for reviews, see Brooks-Gunn and
Paikoff, 1997; Miller et al., 1993). Thus even sexually experienced students
enter college with much to learn in the sexual arena. College life, with its
greatly expanded opportunities for self-governance and independence, provides
an important new context in which young people learn to manage their sexual
relationships and their sexuality.
Like most learning processes, learning to manage one's
sexuality provides opportunities for mastery and growth,
but also poses risk of emotional trauma and pain and of
costly physical health consequences such as unplanned pregnancy,
sexually transmitted diseases and, in rare cases, even
death. To evaluate the extent to which drinking among collegiate
youth is associated with increased participation in
sexual behaviors that lead to negative outcomes such as
these, this article reviews and evaluates empirical research
on the link between alcohol use and high-risk sexual behavior
to determine whether and, if so, to what extent the
two behaviors reliably covary among youth in general and
college youth in particular.
This review is organized in three parts. The first part
provides relevant background and contextual information,
including a brief overview of theoretical explanations for
the link between drinking and risky sexual behavior. The
second part summarizes the data on prevalence of drinking
and sexual behavior among college students and then reviews
and evaluates the evidence on the co-occurrence or
overlap of the two behaviors. The issue of overlap is addressed
at two levels of analysis in this review. The first
level examines the extent to which an individual who engages
in one behavior is more likely to engage in the other
(called global overlap by Leigh and Stall, 1993). The second
level examines whether a person who engages in one
behavior on a specific occasion is more likely to engage in
the other behavior on that same occasion (situational overlap).
To enhance the generalizability of findings from this
review, data from studies using randomly selected samples
are emphasized where possible. To ensure the relevance of
the data to contemporary drinking and sexual practices, findings
from more recent studies (primarily those conducted
in the past 10 years) also are emphasized. Finally, the third
part concludes with a summary of findings and offers recommendations
for intervention and research.
For the purposes of the present review, high-risk sexual
behavior is defined as any behavior that increases the probability
of negative consequences associated with sexual contact,
including AIDS or other sexually transmitted diseases
(STDs) and unplanned pregnancy. These behaviors are considered
in two broad categories: (1) indiscriminate behaviors,
including having multiple partners; having risky, casual
or unknown partners; and failure to discuss risk topics prior
to intercourse and (2) failure to take protective actions, such
as use of condoms and birth control. Alcohol effects on the
decision to have intercourse is also examined in that the
occurrence of intercourse per se can be viewed as the ultimate
root cause of sexual risk taking. Frequency of intercourse
is not, however, treated as a risk behavior. Although
more frequent intercourse, all other things being equal, increases
risk of exposure (de Vincenzi, 1994), intercourse
frequency is significantly associated with having an exclusive
sexual partner (Cooper et al., 1998). Thus intercourse
frequency, analyzed without reference to relationship status
(as is typically the case), is an ambiguous risk indicator at
best.
Background and Overview
Adverse consequences of sexual risk taking on college
campuses
Extant data suggest that negative consequences associated
with sexual risk taking are common on college campuses.
According to results of a recent nationwide survey,
for example, 15% of college students have been pregnant
or gotten a partner pregnant (Douglas et al., 1997). Statewide
studies conducted in California (Patrick et al., 1997)
and Texas (Wiley et al., 1996) found similar overall rates
(14% and 22%, respectively). Moreover, across all studies,
women reported higher rates than men (from 20% to 40%)
(Table 1).
A nationwide study of Canadian college freshmen found
that nearly 6% of sexually experienced students had been
diagnosed by a doctor with an STD at least once
(MacDonald et al., 1990). Rates among U.S. college students
range from 12% of sexually experienced students in
California (Patrick et al., 1997) to nearly 25% on a
midwestern campus (Reinisch et al., 1995). The higher rates
found in U.S. studies may reflect cultural, geographic or
methodological differences, but at least partly reflect the
younger age of students in the Canadian sample. Across all
studies, rates of STDs were higher (in some cases, nearly
twice as high) among women than men. Finally, estimates
of HIV infection rates (from seroprevalence studies) range
from 0.0% to 1.0% on individual campuses, with an average
rate across 19 U.S. campuses of 0.2% (Gayle et al.,
1990; see also Kotloff et al., 1991).
In sum, these data suggest that although aggregate rates
of HIV infection are low among college students, the rates
on some campuses are alarmingly high: as high as 1 in 100
students. Moreover, the experience of pregnancies and other
STDs appears relatively common on college campuses, particularly
among women. Considered together, these data
indicate that a substantial minority of college students suffer
one or more adverse consequences associated with sexual
risk taking and support the need to identify factors, particularly
modifiable ones like alcohol use, that might contribute
to sexual risk taking in this population.
Alternative explanations for the link between alcohol use
and risky sexual behavior
Targeting drinking proximal to intercourse as part of a
strategy to reduce sexual risk taking will prove effective,
however, only to the extent that drinking causally promotes
risky behaviors. Although alcohol is widely assumed to
cause such behaviors, a number of plausible alternative models
exist that might account for their relationship (Cooper,
1992; Halpern-Felsher et al., 1996), only some of which
posit a causal effect for alcohol. The two most widely endorsed
models are briefly described below.
Acute causal effects of alcohol. The first model assumes
that the acute effects of alcohol intoxication cause one to
take sexual risks that otherwise would not be taken. At
least two plausible mechanisms have been theorized to underlie
this effect. According to alcohol myopia theory (Steele
and Josephs, 1990), alcohol disinhibits behavior primarily
as a result of its pharmacologic effects on information processing.
By reducing the scope and efficiency of information
processing, simple, highly salient cues that instigate
behavior (e.g., sexual arousal) continue to be processed,
whereas more distal and complex cues that would ordinarily
inhibit behavior (e.g., the possibility of getting AIDS)
are no longer adequately processed. Accordingly, alcohol
is hypothesized to have its strongest effects when a behavior
is controlled by instigatory and inhibitory cues that are
strong and nearly equal in force. When instigatory cues are
strong and inhibitory cues are weak, the behavior is likely
to occur regardless of the individual's sobriety. Under the
reverse circumstance, the behavior is unlikely to occur, again
regardless of the individual's sobriety. Thus only in situations
where both sets of cues would otherwise be strong
should the reduced processing of inhibitory cues lead to
more extreme (or different) social behavior.
In contrast, expectancy models posit that an individual's
behavior after drinking is driven by preexisting beliefs about
alcohol's effects on behavior, in the manner of a self-fulfilling
prophecy (Lang, 1985). Thus individuals who believe
that alcohol promotes risky sexual behavior should be
more likely to engage in risky behaviors when they drink
than those who do not hold these beliefs. Expectancy formulations
thus indicate that the strength and nature of individually
held beliefs about alcohol's effects should moderate
the acute effects of alcohol on sexual risk taking. In short,
although these two theories differ in the factors hypothesized
to moderate the effects of alcohol on risky behaviors
viz., the nature and strength of competing cues versus
individually held beliefs about alcohol effects), both nevertheless
attribute causality to the acute effects of alcohol
intoxication and assume that these effects unfold over a
brief time course.
Results of two recent studies lend strong support to the
importance of instigating and inhibiting cues in the immediate
situation. In one study (MacDonald et al., 2000b),
male undergraduates were randomly assigned to one of three
conditions (no alcohol control, placebo, intoxicated) and
then divided into low and high arousal groups on the basis
of their self-reported response to a film depicting a potential
sexual encounter between an attractive couple. Results
showed that only those subjects who were both intoxicated
and aroused reported stronger intentions to have unprotected
sex. Presumably, intoxicated subjects had sufficient cognitive
capacity to process arousal cues, but unlike their sober
counterparts, lacked sufficient capacity to process simultaneously
more remote inhibiting cues. In a second study,
MacDonald et al. (2000a) showed that stamping the hands
of college students as they entered a bar with a message
highlighting the threat of AIDS reduced the negative effects
of alcohol on intentions to use condoms. By increasing
the salience of AIDS, the hand stamp presumably
facilitated retrieval of condom-related cues among intoxicated
patrons who otherwise lacked the cognitive capacity
to retrieve these cues. Together these studies suggest that
intoxicated individuals respond to the more salient of the
two sets of cues in a given situation, be they instigatory or
inhibitory.
At the same time, compelling evidence also supports
expectancy formulations. In a recent laboratory study
(George et al., 2000), participants who believed that they
had consumed alcohol (although in fact none had been consumed)
reported greater sexual arousal, perceived their interaction
partners as more sexually disinhibited and showed
erotic slides to their partner significantly longer if and only
if they also held strong beliefs about alcohol's capacity
both to disinhibit and to enhance sexual experience. In other
words, the mere belief that alcohol had been consumed
activated preexisting beliefs about alcohol's effects, which
in turn generated feelings, cognitions and behaviors in line
with these beliefs.
Finally, results of a recent correlational study suggest
that both expectancy and cue effects operate in real-world
situations. Dermen and Cooper (2000) examined alcohol
effects on condom use for three different occasions of intercourse
(first ever, most recent first and last). Drinking
was associated with lower rates of condom use at first intercourse,
but only among those who both believed that
alcohol increases sexual risk taking and were highly conflicted
about using a condom on that occasion. Expectancies
alone were found to moderate alcohol effects on the
second occasion, whereas conflict alone moderated alcohol
effects on the final occasion. Thus the best available evidence
suggests that alcohol effects on sexual risk taking
are likely to be conditional on individually held beliefs about
alcohol's effects on sexual behavior, situation-specific contingencies
controlling the behavior or a combination of the
two.
Spurious model. A second alternative model invokes a
third-variable explanation in which stable aspects of the
individual or of his or her life situation are thought to cause
both drinking and risky sex. For example, a person may
engage in both behaviors to satisfy thrill or sensationseeking
needs, because of poor impulse control or coping
skills or in an effort to cope with negative emotions (Cooper,
1992; Leigh and Stall, 1993). Alternatively, an individual
may drink and have risky sex as part of a larger
lifestyle, such as being single or living in a fraternity house
(Baer, 1994), where both behaviors are tacitly or, in some
cases, explicitly encouraged. Extant research lends support
to this perspective by showing that the same personality
factors (impulsivity and negative emotionality) prospectively
predict involvement in both behaviors (Caspi et al., 1997),
and that parallel motivational processes underlie both behaviors
(Cooper et al., 2000). A more direct test of this
hypothesis was provided by two recent studies in which
the relationship between measures of alcohol use and risky
sexual behavior was estimated both before and after controlling
for plausible third variables. In both studies, sensation
seeking was found to account completely for the
relationship between drinking and risky sex (Justus et al.,
2000; Kalichman et al., 1996). Thus it seems plausible that,
under at least some circumstances or for some individuals,
the link between drinking and risky sex can be adequately
explained by third variable causes.
In sum, two widely held models have been advanced to
account for the relationship between drinking and risky sex.
Moreover, even though these models appear to offer opposing
accounts of the relationship between drinking and
risky sex, empirical evidence supports both. Thus, despite
commonly endorsed beliefs that alcohol causally promotes
risky sexual behavior, theory and empirical data paint a
more complex picture of their relationship. In the following
section, studies examining the link between drinking
and risky sexual behavior among college students are reviewed
and evaluated in light of these models.
Drinking and Risky Sex: Overlapping Behaviors
among College Students?
Prevalence of both behaviors on college campuses
As described elsewhere (O'Malley and Johnston, this
supplement), the vast majority of college students drink,
and a substantial minority (about 40%) can be classified as
heavy episodic (HE) drinkers (often defined as having five
or more drinks on a single occasion during a specified time
period, such as the past 2 weeks). Similarly, most college
students are sexually experienced, and many engage in multiple
forms of risky sexual behavior (Table 1). According
to findings from the National College Health Risk Behavior
Survey (Douglas et al., 1997), 8 of 10 college students
between the ages of 18 and 24 years have ever had intercourse.
Of these, 62% had recent (past 3 months) intercourse.
More important, about 25% of students have had
six or more lifetime sex partners, and only a minority take
adequate precautions to prevent pregnancy or sexual infection.
For example, 4 in 10 had used the "pill," and about as
many had used a condom, at last sex. Fewer than 4 in 10
reported that either they or their partner had always used a
condom in the past 30 days. Finally, in a national study of
Canadian college students (MacDonald et al., 1990), 17%
reported having ever had anal sex, but fewer than 25%
reported always using a condom.
Although none of the above national studies included
detailed measures of indiscriminate partner choice, several
studies conducted on individual college campuses suggest
that many students exercise poor judgment in partner choice.
For example, a random sample survey of students at a
midwestern university found that women reported an average
of three and men an average of five "one-night stands"
(i.e., having sex with someone once and only once) in their
lifetime (Reinisch et al., 1995). Moreover, 1 in 20 University
of Maryland students reported having had sex with at
least one high-risk partner (i.e., someone who had HIV or
was an IV drug user, a hemophiliac, a male bisexual or a
female prostitute [Kotloff et al., 1991]).
Although the above data indicate that alcohol use, sexual
behavior and failures to use protection are commonplace
among college students, they do not establish whether the
same person engages in all of these behaviors or, more
importantly, whether the likelihood of engaging in one behavior
depends on involvement in another. Indeed, because
of the high base rates of these behaviors, we would expect
a nontrivial proportion of students both to drink and to
engage in some form of risky sexual behavior by chance
alone. For example, given that 9 of 10 students drink and 8
of 10 have had sex, 7 of 10 students should both drink and
have had sex by chance alone. Similarly, given that 4 of 10
students are HE drinkers and 3 of 10 have had six or more
sex partners, more than 1 in 10 should have engaged in
both behaviors by chance alone. Thus simply demonstrating
that some percentage of college students engages in
both behaviors does not mean that the two behaviors are
reliably linked. Existing data (reviewed next) do, however,
document a reliable global association between these
behaviors.
Alcohol use and risky sexual behavior at the global level
Studies examining the link between alcohol and risky
sex at the global level typically ask participants about their
overall involvement in some high-risk behavior and their
overall frequency and quantity of alcohol use. Studies using
this approach have generally found strong relationships
between alcohol use and indiscriminate behaviors, but inconsistent
ones between alcohol use and protective behaviors.
A national survey of more than 17,000 collegiate youth,
for example, found that HE drinkers were nearly three times
as likely to have had multiple sex partners in the past month
than were non-HE drinkers (Wechsler et al., 1995). Similarly,
a national study of more than 4,000 sexually experienced
youth ages 14 to 21 years (Santelli et al., 1998) found
that adjusted proportions of young men who had multiple
partners in the past month rose from 23% to 61% as the
number of alcohol-related behaviors increased, whereas the
proportions among young women rose from 8% to 48%.
Based on another national study of young adults (18- to
30-year olds), Graves (1995) reported that rates of multiple
partnerships were two to three times greater among HE
than non-HE drinkers and were similar for men and women.
In contrast to the consistent positive link between general
drinking patterns and having multiple partners, HE and non-
HE drinkers were not found to differ in rates of condom
use in the previously cited study of collegiate youth
(Wechsler et al., 1994). The Youth Risk Behavior Survey
(a national sample of noncollege youth) also found that
alcohol experience failed to discriminate condom users from
nonusers at last intercourse (Lowry et al., 1994). However,
in her national sample of young adults, Graves (1995) found
that more frequent HE drinking was associated with lower
rates of condom use.
Although several studies using convenience samples of
college youth point to links between alcohol use and protective
behaviors (e.g., McEwan et al., 1992), many of these
studies were flawed. For example, McEwan et al. reported
that the proportion of British university students who had
had unprotected sex with a stranger rose from 4% among
nondrinkers to 27% among heavy drinkers. Their measure,
however, confounded indiscriminate partner choice with failure
to use a condom, thus making it unclear whether the
observed covariation with drinking pattern reflects variance
due to the indiscriminate behavior or to nonuse of condoms.
Other studies have reported that the frequency of drinking
proximal to intercourse is positively associated with the
frequency of having unprotected sex or with the number of
unprotected sex episodes in a given time period (O'Leary
et al., 1992). Such data are confounded, however, because
both the alcohol and risky sex measures depend on frequency
of intercourse. Finally, numerous studies have interpreted
the fact that college students say they did not use
protection because they were drinking as evidence for a
causal link between drinking and protective behaviors
(Meilman, 1993; Wechsler et al., 1994). However, because
people are notoriously poor at correctly identifying the
causes of their behavior (Nisbett and Ross, 1980), such
reports are better interpreted as expectancies or beliefs about
alcohol's effects on risky sexual behavior, rather than as
veridical accounts of alcohol effects on behavior. In short,
the extant data reveal an inconsistent link between alcohol
use and precautionary measures, a pattern that appears similar
for men and women.
Co-occurrence of alcohol use and risky sexual behavior at
the situational level
Although the above data indicate that people who drink
are more likely to engage in indiscriminate sexual behaviors
such as having multiple partners, they do not help us
to adjudicate between competing explanations for the link
between alcohol and risky sex. In fact, such data are equally
compatible with both causal models. Determining whether
alcohol use and risky sexual behaviors are reliably linked
on a specific occasion, however, allows us to begin to
adjudicate between the two models because covariation on a
given occasion is a necessary but not sufficient condition
for attributing risky sexual behaviors to acute alcohol
intoxication.
Evidence from multiple studies shows that college students
regularly combine drinking with sex on specific occasions
(see Table 1). As previously argued, however, some
overlap would be expected by chance alone. Thus two strategies
have been used to test whether drinking and risky sex
reliably covary at the situation level: (1) between-persons
tests in which the behavior of people who drink on a given
occasion are compared with those who do not drink to determine
if drinkers exhibited riskier behaviors on that occasion
and (2) within-persons tests in which the behaviors of
individuals are compared on drinking and nondrinking occasions
to determine whether riskier behaviors were exhibited
on drinking occasions. Although most studies have used
between-persons comparisons, such comparisons cannot rule
out the possibility that stable individual differences cause
people both to drink and take risks on a given occasion
(Cooper et al., 1990). In contrast, because an individual's
personality or lifestyle is unlikely to change from event to
event, within-persons comparisons are less vulnerable to
this alternative explanation and thus enable stronger attributions
to alcohol use as the causal agent.
Using both analytic strategies, three key questions have
been addressed at the situational level of analysis: (1) Does
drinking in potentially sexual situations alter the probability
that intercourse will occur? Once intercourse occurs,
does drinking beforehand (2) increase indiscriminate risky
sexual behaviors, or (3) decrease protective behaviors? Studies
addressing each of these questions are summarized in
Table 2 and are reviewed next.
Alcohol use and intercourse probability. Using data from
three independent samples, a total of seven betweenpersons
and three within-persons tests of the link between
alcohol and intercourse probability have been conducted.
Across these studies, five of the seven between-persons tests
were significant and positive, and two were nonsignificant.
The within-persons tests yielded one positive, one negative
and one null finding. Despite the pattern of inconsistent
results, a closer examination of these studies suggests a
potentially heuristic integration.
In the first study to provide a within-persons test (Harvey
and Beckman, 1986), 69 university women kept daily logs
of their alcohol use and sexual behavior. Contrary to the
women's self-professed beliefs about alcohol's capacity to
increase sexual desire, they were actually less likely to initiate
intercourse after a drinking than after an alcohol-free
period. In the second study to provide a within-persons test
(Cooper and Orcutt, 1997), alcohol use and sexual behavior
were measured on two different first-date occasions,
separated by 4.5 years. Results showed that intercourse probability
across the two dating occasions covaried with male,
but not with female, partner use. (Supplemental analyses
indicated that the male partner effect was not due to
coercion.)
Together, these studies raise the possibility that alcohol
can either inhibit or promote sexual contact, depending on
characteristics of the individual and the relationship. Given
that reliable effects were found only among men in the
Cooper and Orcutt (1997) study, the use of an all-female
sample in Harvey and Beckman's (1986) study could account
for the discrepant result. Perhaps more important,
only individuals in stable relationships were included in
Harvey and Beckman's study, whereas Cooper and Orcutt
examined first-date situations, which are likely to involve
new or casual partners. According to alcohol myopia theory,
alcohol effects on intercourse probability should be greatest
in situations where both strong instigating (e.g., sexual
arousal) and strong inhibiting (e.g., fear of disease, anticipation
of guilt or regret) cues control the behavior. Although
instigating cues might be similar when having sex
with a new versus established sex partner, inhibiting cues
are unlikely to be. Consistent with this analysis, Cooper
and Orcutt (1997) found that intercourse probability increased
only among men who both drank and were highly
conflicted (i.e., perceived both strong benefits and strong
costs) about having sex on the date.
This finding may also help explain why the effect was
restricted to men. For women, the perceived costs of having
sex (e.g., loss of reputation) substantially outweighed
perceived benefits, thus creating little conflict. In contrast,
costs and benefits were nearly equal in strength among men,
leading to greater conflict about whether to have sex. In
short, these data suggest that alcohol has the potential to
disinhibit sexual behavior among both men and women,
but that whether it will depends on what the behavior means
to the individual in the situation.
Alcohol use and indiscriminate sexual behaviors. Two
different indicators of indiscriminate sexual behavior have
been examined: having sex with a casual or hardly known
partner and failure to discuss risk topics prior to intercourse.
Using data from four independent samples, a total of nine
between-persons and two within-persons tests of the link
between drinking and partner intimacy have been conducted.
Eight of the nine between-persons tests and both of the
within-persons tests were significant, with all effects indicating
a positive link between drinking and having a more
casual partner. Using data from four independent samples,
a total of six between-persons and two within-persons tests
of the link between alcohol and risk discussion were also
conducted. Five of the six between-persons and both of the
within-persons tests were significant, with all effects showing
decreased risk discussion among individuals who drank
prior to intercourse. In the studies that reported results separately
for men and women (Graves, 1995) or tested gender
interactions (Cooper et al., 1994), no evidence for gender
differences in either outcome was found.
It is interesting to note that the two null results (for
partner intimacy and discussion) were obtained in the same
study for the same event—last intercourse (Cooper et al.,
1989, 1990). Because this event included only sexual experiences
with an established sexual partner, few respondents
considered their partner casual (see Study 4, Table 2); thus
simple restriction of range may account for the null finding.
In addition, it seems likely that individuals who intended
ever to discuss risk topics would have done so by
their last intercourse experience, which occurred in the Cooper
et al. (1989, 1990) study about 1 year after first intercourse
with that partner. Although an individual might feel
conflicted about bringing up risk-related topics with a new
sex partner, it is unlikely that he or she would continue to
feel conflicted a year later with the same partner. A related
possibility is that these behaviors index qualitatively different
phenomena in the early versus later stages of a relationship.
In an established relationship, for example,
perceiving your partner as less intimate may indicate a stagnant
or troubled relationship, whereas failure to discuss risk
topics may indicate intimacy avoidance or social skill deficits
on the part of one or both partners. Thus, although
these behaviors may validly index risk in the early stages
of a relationship, their meaning—and hence their relationship
to alcohol use—may shift over time.
Alcohol use and protective behaviors. A total of 25
between-persons and 4 within-persons tests of the link between
alcohol and condom use have been conducted using
data from 15 independent samples. Of these, only five between-
persons tests (two at p < .10) and one within-persons
test showed a significant inverse relationship between
drinking and condom use. Of the remaining 23 betweenpersons
tests, one revealed significantly more condom use
among those who drank (Dermen and Cooper, 2000),
whereas 22 were nonsignificant. Ten between-persons and
one within-persons tests of the link between alcohol and
birth control use were conducted using data from five independent
samples. Of these, five between-persons tests
showed a significant or marginally significant relationship
between drinking and decreased birth control use, whereas
the remaining six tests were nonsignificant.
Comparison of sexual events for which significant decreases in condom or birth
control use were found with events that yielded null results pointed to several
factors that might explain the variability in results. First, sample size was
significantly positively associated with obtaining an alcohol effect (mean [SD]
size = 504 [303.6] versus 318 [302.3], t = 1.7, p < .10, for studies
finding significant versus nonsignificant effects). Second, a preponderance
of significant effects were found for lifetime first intercourse: 5 of 8 such
tests were significant, compared with 2 of 13 tests for first time with most
recent or current partner and 3 of 15 tests for last intercourse (X2
= 6.3, 2 df, p < .05). Third, participants were significantly younger
at the time of sexual events for which an inverse effect of alcohol use on protective
behaviors was found (mean = 17.4 [1.6] years) compared with events finding no
such effect (mean = 19.6 [2.5] years; t = 3.4, p < .01). Fourth,
significant alcohol effects were more likely for events that occurred longer
ago; r = -.37 (p < .05) between year of data collection and finding
a significant inverse effect. Indeed, all significant effects were found for
events that occurred during or prior to 1990. Because event (first intercourse
versus other events), age at time of intercourse and year in which the event
occurred were interrelated (r's ranged from .38 to .54, p's <
.05), a logistic regression analysis was conducted to determine whether the
three event characteristics independently predicted the likelihood of obtaining
a significant alcohol effect. Results showed that although the set of event
characteristics was significant (X2 = 12.2, 3 df, p
< .01), none of the characteristics individually predicted outcome. This suggests
that effects among these factors cannot be adequately parsed. Finally, other
event characteristics (including gender and racial composition of the samples,
whether the sample was a college or noncollege sample, whether a random or convenience
sample was used, whether condom or birth control use served as the dependent
measure and whether a between-persons or within-persons test was conducted)
were not related to obtaining a significant effect. In short, these data suggest
that the link between drinking and failure to take protective actions is likely
circumscribed by historical context, as well as by developmental stage and chronological
age.
Conclusions and Recommendations for Research
and Prevention
Summary and conclusions
The above research supports a number of conclusions
about the link between alcohol use and risky sexual behavior
among college students and more generally among adolescents
and young adults. First, existing research indicates
that alcohol use and certain types of sexual behavior covary.
Not only does the likelihood that an individual has ever
drunk alcohol predict the likelihood he or she has ever had
sex, but level of alcohol involvement also predicts level of
sexual involvement. Equally strong evidence suggests that
drinking in a potentially sexual situation (e.g., on a date) is
associated with an increased probability of intercourse on
that occasion and that drinking prior to intercourse is associated
with risky partner choice as well as with decreased
risk discussion on that occasion. Each of these relationships
has been observed using within-persons designs, thus
ruling out the possibility that strictly between-person differences
can account for the data. These effects, however,
may be qualified by relationship status and, in the case of
intercourse probability, perhaps by gender as well.
In contrast to the relatively clear-cut results linking alcohol
use to increased participation in indiscriminate sexual
behaviors (especially having casual sex), studies examining
the link between drinking proximal to intercourse and decreased
protective behaviors (i.e., condom and birth control
use) reveal a weaker link. Indeed, the overwhelming majority
of studies, whether examining global or situationspecific
associations, found no effect whatsoever. The primary
exceptions to this pattern were found for younger,
sexually inexperienced adolescents and for sexual events
occurring during or prior to 1990. Thus these data suggest
that the link between alcohol use and protective behaviors
is both developmentally and historically limited.
Gender and race differences in the relationship between
drinking and risky sexual behaviors are equivocal. Although
gender differences have been reported (e.g., Cooper and
Orcutt, 1997), they have not been consistently observed
across different behaviors or across different studies investigating
the same behavior (e.g., Dermen and Cooper, 2000).
Evidence on race differences is inconclusive because of the
small number of studies that have included black youth
and because few black adolescents and young adults drink
in sexual situations (Cooper et al., 1994; Leigh et al., 1995).
Despite the complexity of these findings, the overall pattern
of data can be parsimoniously interpreted within the
framework of Steele and Josephs' (1990) alcohol myopia
theory. As previously described, alcohol is hypothesized to
affect behavior only when that behavior is controlled by
competing cues (one set favoring action and one inhibiting
action) of nearly equal strength. Theoretically, then whether
alcohol affects behavior in a given situation should be determined
by the relative strength and content of the dominant
versus peripheral cues governing behavior in that
situation. For example, when dominant cues favor inaction
and peripheral cues favor action, alcohol may lead to behavioral
inhibition as opposed to disinhibition. Thus, to the
extent that the nature and strength of competing cues (or
costs and benefits) related to having sex with a particular
partner or to engaging in any specific sexual behavior vary
across the life span of the relationship, alcohol's effects on
those behaviors should also vary across time (or stage)
within that relationship. Likewise, because the nature and
strength of these cues are thought to follow a distinctive
course for men and women at different stages of relationship
development (McCabe and Collins, 1984), the nature
of alcohol effects on behavior may differ for men and
women at some, although not necessarily all, stages of a
relationship (cf., Cooper and Orcutt, 1997). Indeed, it is
likely that any classificatory variable (e.g., age, historical
period, race) that can be shown to moderate alcohol effects
on sexual behavior is in fact a proxy for mean or grouplevel
differences in the type and relative strength of competing
cues that control the behavior in question. This line
of reasoning therefore suggests that direct assessment of
the competing cues and associated levels of conflict about
engaging in the behavior should yield more precise specification
of the conditions under which alcohol leads to increased
or perhaps even decreased sexual risk taking.
At the same time, beliefs about the effects of alcohol on
risky sexual behavior also appear to play an important role.
Indeed, overwhelming evidence indicates that people believe
that alcohol causally promotes risky sexual behaviors.
These beliefs, in turn, have been shown to promote drinking
in sexual or potentially sexual situations (Dermen and
Cooper, 1994; Leigh, 1990) and (in the absence of actual
alcohol) to elicit disinhibited sexual behavior consistent with
individually held expectancies in laboratory studies (George
et al., 2000). Evidence that individually held expectancies
moderate alcohol's effects on risky sexual behavior, however,
is less consistent (see Dermen and Cooper, 2000;
Dermen et al., 1998; Leigh, 1990). Although such inconsistencies
could reflect well-known statistical difficulties associated
with detecting interactions in correlational data
(McClelland and Judd, 1993) or difficulties inherent in predicting
complex behaviors in specific situations (Epstein,
1983), they might also reflect a need for greater refinement
in our theories and methods for testing these theories. One
possibility is that the strength and relevance of an
individual's beliefs about how alcohol affects sexual behavior
vary across situations and that these variations are
partly determined by the specific meaning that engaging in
the behavior has for the individual on that occasion. Consider,
for example, an individual who experiences conflict
about having sex on two different occasions. On the first
occasion, conflict arises because he is aroused, but fears
that having sex will lead to undesired expectations on the
part of his partner with whom he has no intention of pursuing
a relationship. On the second occasion, the individual
is again aroused by the prospect of having intercourse, but
this time experiences conflict because he fears that having
sex might damage a relationship that he hopes will develop
into a more serious one. Thus the belief that alcohol leads
to excesses in behavior might provide a plausible post hoc
excuse for having sex in the first situation, but would be
irrelevant in the latter situation to concerns about damaging
an incipient relationship. In short, a complex match
may be required between the content of one's beliefs about
alcohol effects on behavior and the perceived costs and
benefits of engaging in that behavior on a given occasion.
Such possibilities underscore the potentially crucial role that
an individual's idiosyncratic construction of his or her behavioral
options in a given situation play, as well as the
need to integrate expectancy and conflict inhibition models
of alcohol effects on behavior.
One question that remains unanswered, however, is why
drinking should be more reliably linked to indiscriminate
behaviors than to protective behaviors. At least two interrelated
explanations may account for this pattern of findings.
First, alcohol effects on protective behaviors may be entirely
indirectly mediated by its effects on indiscriminate
behaviors (Cooper et al., 1999). According to this possibility,
drinking directly affects the likelihood of having a casual
partner and of discussing risk-relevant topics, and these
behaviors in turn affect the probability of taking protective
actions. Differences in the magnitude of the relationships,
and hence the ease with which they can be detected, would
follow as a consequence of one being a direct effect and
the other being an indirect one. The second possibility is a
subset of the first one in that it invokes a specific type of
intervening variable model in which the direct and indirect
(or spurious) effects are opposite in sign. Specifically, Cooper
and Orcutt (2000) have shown that this circumstance
(known as suppression) may arise because people are more
likely both to drink and to use a condom if they have sex
with a casual than a serious partner. It therefore follows
that the overall association between drinking and condom
use includes this pathway of positive influence, which would
attenuate, or possibly mask altogether, any adverse direct
effects of drinking on condom use. To the extent that this
analysis is accurate, the total effect of alcohol use on condom
use would necessarily be smaller than its direct effect,
after controlling for partner intimacy. Consistent with this
interpretation, we found that the total effect of alcohol use
on condom use was -.04 and not significant, but that its
direct effect after controlling for partner intimacy ratings
was -.17 and significant. Findings reported by Gold et al.
(1992), who reported the only significant within-persons
effect for condom use among the previously reviewed studies,
lend further credence to this interpretation. The key
difference between their study and the remaining studies
was that they controlled for partner intimacy by limiting
their analyses to the subset of individuals who had equally
intimate partners across the two occasions. To summarize,
these data suggest that the overall magnitude of the relationship
between alcohol use and protective behaviors is
small because these behaviors are part of a larger multivariate
network of relationships in which the two variables
are only indirectly linked, or in which any direct relationship
they have is obscured by a countervailing process.
Finally, because of pragmatic concerns with the potentially
devastating consequences of acute alcohol intoxication,
the present review has focused to a substantial degree
on this particular explanation for the link between drinking
and risky sex. This focus should not be interpreted, however,
as a statement about the greater plausibility or importance
of this causal model relative to other possible models.
In fact, given the highly conditional nature of the link between
alcohol and risky sex at the level of the situation, it
seems unlikely that acute alcohol effects alone could adequately
account for the robust associations observed between
these behaviors at the global level. Moreover, even
though within-persons procedures show that the same person
is more likely to engage in risky sex on drinking than
on nondrinking occasions, these data do not unambiguously
point toward a causal effect of alcohol on risky sexual behavior.
Indeed, they are equally compatible with both reverse
causal and third-variable situational explanations as
well (Cooper, 1992; Cooper et al., 1994). In short, the extant
data indicate that no single causal model can adequately
account for the relationship between alcohol use and risky
sexual behavior and rather that a range of plausible models
must be embraced. The present review focused on two such
models that are both consistent with the evidence on
covariation and plausible in terms of what is known about
alcohol use, risky sex and their interrelationship. Together
these considerations suggest that it is time to move beyond
the question of which model better accounts for the observed
covariation of these two behaviors and to begin instead
to address the question of under what circumstances,
or for which individuals or subgroups, different causal processes
operate.
Recommendations for future research and intervention
efforts
Based on the above review, a number of recommendations
can be offered for future research and intervention
efforts.
Study design. The vast majority of research on this topic
has been cross-sectional and included only global assessments
of behavior. Although such studies (assuming known
sampling parameters) can provide useful data on the prevalence
and magnitude of the contemporaneous association
of these behaviors, they are not optimal for illuminating
processes by which these behaviors are linked. The strongest
tests of hypotheses concerning acute alcohol effects,
for example, require short-term, repeated measures in which
multiple sexual or potentially sexual events are examined.
Diary studies, although they present formidable methodological
challenges (Reis and Gable, 2000), nevertheless
represent the most rigorous, ecologically valid approach currently
available for testing key premises of acute effect models.
Compared with the more widely used critical event
approach in which alcohol and sexual behaviors are described
for some past occasion such as first intercourse,
diary studies can collect data virtually online. The resulting
proximity in time of the self-report to the actual experience
greatly reduces, if not eliminates, retrospective recall bias,
thus leading to substantially more accurate reporting.
Critical event methodology will remain an important adjunct
to diary studies, however, in part because of its greater
flexibility and ease of use. For this reason, it will be important
to develop a better understanding of the limits of
the critical event approach, as well as to identify ways to
enhance its validity. Regardless of whether a critical event
or diary method is used, data should be collected for at
least two events (that vary on alcohol consumption) and
analyzed using within-persons procedures. Such procedures
offer one of the only feasible ways to rule out stable individual
differences as an alternative interpretation of any
observed linked between drinking and risky sexual behavior.
Although issues of external validity are paramount, controlled
experimentation can also play an important role.
Small-scale laboratory analog studies designed to test highly
focused hypotheses about underlying mechanisms (cf.,
Fromme et al., 1999) can explore subtle aspects of causal
process that would otherwise be difficult to isolate. Carefully
designed field experiments (cf., MacDonald et al.,
1996) and intervention studies (cf., Dermen and Thomas,
2000) have been underutilized to date, yet hold substantial
promise for exploring causal processes in an externally valid
manner. To be maximally informative, however, such studies
should be theoretically informed and focus on testing
relevant mediation and moderation hypotheses.
Finally, future studies examining the link between drinking
and risky sexual behavior should include data from both
partners. Because sexual behavior is played out in intimate,
interpersonal contexts and requires mutual action, gaining
the perspective of only one partner is inherently limited.
This may be especially true in the present arena where alcohol
effects on risky sexual behaviors appear to depend
heavily on individual meanings ascribed (presumably by
both partners) to the focal behavior.
Measurement issues. The majority of studies to date have
focused on global assessments of alcohol use and risky sexual
behavior and ignored theoretical variables that might mediate
or moderate the links between them. The present review suggests
that continued progress in this area depends on more
refined assessments of all three sets of variables.
First, assessment of alcohol use can be improved in at
least two important ways. Unlike most studies where drinking
is assessed for the participant only, a separate measure
of partner alcohol use should be obtained. Given the unique
effects of male and female partner use previously discussed
(Cooper and Orcutt, 1997), this simple step seems crucial.
In addition, future researchers should attempt to measure
situation-specific expectancies (Dermen and Cooper, 1994)
or reasons for drinking (Cooper, 1994) on a given occasion.
Only by directly assessing what the individual expects
to happen as a result of drinking in a given situation
(expectancies), or hopes to gain by drinking in that situation
(motives), can we begin to unravel the differential effects
of drinking on risky sexual behavior, both across
persons and within persons across situations.
Second, several recommendations for improved assessment
of risky sexual behaviors also can be offered. Direct
assessment of conflict about engaging in the focal behavior
appears critical. Toward this end, Cooper and colleagues
(Cooper and Orcutt, 1997; Dermen and Cooper, 2000) developed
a simple but promising approach in which individuals
rate the degree to which they felt conflicted,
uncertain or ambivalent about engaging in a given behavior
on a specific occasion (e.g., using a condom at last
sex). As previously discussed, conflict ratings were found
to moderate alcohol effects on intercourse probability and
condom use in theoretically consistent manners. Ratings of
costs and benefits associated with these behaviors also were
shown to discriminate among qualitatively different forms
of conflict—namely, conflict in which costs outweigh benefits
versus benefits outweigh costs. Our research suggests
that this distinction provides leverage for discriminating between
situations where drinking leads to behavioral inhibition
versus disinhibition (Cooper and Orcutt, 1997) and
should therefore be included whenever possible.
Future assessments of sexual risk taking should move
beyond their near-exclusive focus on condom use. This approach,
while tapping the most essential element from an
AIDS prevention perspective, leaves unmined important aspects
of the sexual encounter that in and of themselves
pose risk or help to define risk from the individual's perspective.
For example, an individual may not construe failure
to use a condom as risky or may not experience conflict
about nonuse if other birth control is used. Also, failure to
use protection cannot be construed as risky if one is intentionally
trying to conceive. Thus assessing pregnancy intentions
as well as other forms of birth control use should
provide crucial insights into the individual's psychological
experience of the situation.
Although rarely included in prior research, more careful
attention to risk discussion as an outcome appears warranted.
A recent meta-analysis (Sheeran et al., 1999) found
that communication between partners about condom use
was the single strongest predictor of condom use (r = .46)
among 56 different variables examined. At the same time,
asking a partner about his or her past sexual experiences
may inadvertently lead to increased risk taking because
people sometimes intentionally misrepresent their past sexual
experiences to have sex (Cochran and Mays, 1990). These
considerations suggest the need for separate assessments of
discussion of protective behaviors and discussion of other
risk topics.
The heterogeneity of alcohol effects on risky behaviors
observed in the present review underscores the need to assess
multiple risk behaviors as well as to develop differentiated
hypotheses regarding links between drinking and
individual risk behaviors. Indeed, the fact that risk behaviors
themselves are related to one another in complex ways
suggests the need to move toward multivariate models in
which alcohol use is embedded within a network of interrelated
risk behaviors (cf., Cooper and Orcutt, 2000).
Finally, greater attention needs to be paid to the relationship
context, even in studies where data are collected
from only one partner. In past research, participants have
typically been asked to describe the nature of the relationship
with their partner at the time of intercourse, for example,
on a scale ranging from someone they just met to a
fiancé or spouse. Alternatively, participants may be asked
how long they have known, dated or been with their partner
or to rate how well they know their partner. Although
such assessments appear to sort individuals reliably along a
crude intimacy continuum, they fail to capture the rich psychological
terrain that characterizes most sexual relationships.
Thus, to the extent possible, measures aimed at assessing
a broader range of relationship dimensions and
functioning (e.g., interdependency, power, passion, trust,
commitment) should be included. Of course, such assessments
assume that a relationship of at least some duration
exists between the two partners. When this is not the case,
assessing the individual's goals or intentions vis-à-vis the
partner or the specific sexual encounter may adequately
capture his or her orientation to the relationship.
Despite the potential of data such as these to illuminate
crucial aspects of the link between drinking and risky sexual
behavior, they are not without their limitations. Retrospective
reports of perceived aspects of events or relationships,
particularly when collected substantially after the fact, are
highly subjective and vulnerable to distortion. However, by
comparing retrospective self-reports of experiences obtained
from both partners, or by comparing retrospective reports
to diary data, we may begin to identify aspects of sexual
experience that are more (and less) reliably indexed by retrospective
self-reports, as well as variations in assessment
procedures that enhance the accuracy of such reports.
Implications for intervention. The present review has a
number of important implications for intervention. First,
existing evidence supports the plausibility of multiple causal
models. The existence of multiple models underscores the
need for caution in interpreting evidence of covariation between
these behaviors as prima facie evidence for a causal
link. It also highlights the need for diverse methodological
approaches for exploring alternative models and raises the
possibility that different intervention strategies will be optimally
effective among individuals or subgroups for whom
different causal processes predominate. Among people who
chronically drink and engage in risky behaviors, for example,
the relationship between alcohol use and sexual risk
taking may primarily arise from an underlying common
cause or causes. For such individuals, more universal change
strategies targeting the hypothesized common cause (e.g., a
risk-seeking propensity) should be maximally efficacious.
In contrast, carefully designed intervention studies aimed
at reducing drinking in settings where drinking and potential
partners co-occur (e.g., in college bars) could provide
important insights into the nature of situational processes
that give rise to the link between drinking and risky sex, as
well as lower sexual risks associated with drinking for those
individuals who are vulnerable to acute intoxication effects,
situational influences or both.
In short, future intervention studies should attempt to
match individuals to different intervention approaches on
the basis of theoretical considerations about plausible underlying
causes. A series of well-controlled, theoretically
informed trials would not only shed light on the nature of
multiple causal processes that underpin the link between
alcohol and risky sex, but also provide a set of effective
intervention strategies that could be targeted for use with
different audiences. Although the main findings of Project
MATCH (Project MATCH Research Group, 1997, 1998)
did not support the notion of patient-treatment matching, it
is possible that the basis for matching to treatments in that
study was not sufficiently sensitive to variations in underlying
causal structures. Accordingly, careful efforts to identify
reliable markers of different underlying process models
will be needed to maximize the likelihood of success of
such an endeavor.
In sum, the relationship between alcohol use and risky
sexual behavior appears to be both complex and highly
circumscribed. Nevertheless, the fact that this relationship
appears most potent in the context of new or casual dating
and sexual relationships heightens the importance of this
issue among college students who, on average, have more
than eight new sex partners over their 4 years in college
(see Table 1). Because of limited drinking and sexual experience
typical of most students prior to college, and the
unprecedented freedoms to experiment that college environments
typically provide, college students—more so than
most other groups—may combine drinking and sex in ways
that jeopardize their mental and physical well-being.
Acknowledgments
Special thanks are extended to Sharon Wilsnack, Patrick Johnson, Kenneth
Sher, Vivian Faden and the remaining members of the Panel on
College-Age Drinking for their guidance on this project. Thanks also to
Howard Tennen for thoughtful comments on an earlier version of this
article.
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*Preparation of this article was supported by National
Institute on Alcohol Abuse and Alcoholism grant R01-08047.