762 JOURNAL OF STUDIES ON ALCOHOL AND DRUGS / SEPTEMBER 2009
Alcohol Consumption, Drug Use, and Condom Use
Among STD Clinic Patients*
LORI A. J. SCOTT-SHELDON, PH.D.,† MICHAEL P. CAREY, PH.D.,† PETER A. VANABLE, PH.D.,†
THERESA E. SENN, PH.D., PATRICIA COURY-DONIGER, F.N.P.-C.,† AND MARGUERITE A. URBAN, M.D.†
Center for Health and Behavior, Syracuse University, 430 Huntington Hall, Syracuse, New York 13244-2340
ABSTRACT. Objective: Research on the association between substance
use and sexual risk behavior has yielded a complex pattern of fi ndings.
Such inconsistent fi ndings may refl ect method variance, including fac-
tors such as gender of the participant, nature of the sexual event, partner
characteristics, and type of substance used. The purpose of this study
was to investigate the association between substance use and unprotected
sex independently for alcohol, drugs, or combined substance use and
to examine partner characteristics as a moderator of this association.
Method: Participants (N = 1,419; 48% women) were recruited from
a publicly funded sexually transmitted disease clinic and were asked
to complete an audio computer-assisted self-interview regarding their
most recent sexual experience, including nature of the event, substance
use, and partner characteristics. Results: Analyses showed that alcohol
use was related to condom use when gender and partner type were con-
sidered; thus, for women, but not for men, partner type interacted with
alcohol consumption such that condom use was less likely when alcohol
consumption preceded sex with nonprimary partners (drinking was
unrelated to condom use with primary partners). Subsequent analyses
examining partner substance use showed that women, but not men, who
reported both they and their nonprimary partners were drinking during
sex were less likely to use a condom. Conclusions: At the event level,
alcohol consumption among sexually transmitted disease clinic patients
is associated with condom use, but this association differs by gender
and partner characteristics. Findings suggest the need to strengthen sub-
stance-use components in sexual risk reduction interventions for women
and their partners. (J. Stud. Alcohol Drugs 70: 762-770, 2009)
sexually transmitted diseases (STDs) remain a public health
concern. Surveillance efforts suggest an estimated 19 mil-
lion new infections in the United States per year (Centers
for Disease Control and Prevention, 2008). In 2006, more
than 45,000 (of 56,300) new cases of HIV/AIDS have been
attributed to sexual transmission; in addition, more than 1
million cases of chlamydia and 355,991 cases of gonorrhea
were reported in 2007 (Centers for Disease Control and Pre-
vention, 2008, 2009). Worldwide, an estimated 340 million
new cases of curable STDs and 2.7 million new cases of HIV
(primarily attributable to sexual transmission) occurred annu-
ally (Joint United Nations Programme on HIV/AIDS, 2008;
World Health Organization, 2001). Untreated STDs can
result in pelvic infl ammatory disease, chronic pelvic pain,
and infertility among women and epididymitis and urethritis
among men (Centers for Disease Control and Prevention,
ESPITE PUBLIC HEALTH EFFORTS to provide in-
dividuals with information about sexual risk reduction,
2008) and also can facilitate the transmission of HIV (Eng
and Butler, 1997; Fleming and Wasserheit, 1999).
To prevent sexual transmission of HIV, the Centers for
Disease Control and Prevention recommends early STD
diagnosis and treatment in conjunction with a targeted HIV
prevention plan (Centers for Disease Control and Prevention,
1998, 2007). Research with STD clinic patients can facili-
tate HIV prevention. Indeed, identifying factors related to
sexual risk among STD clinic patients is important because
(1) STD patients, compared with the general population, are
more likely to acquire multiple nonviral STDs (i.e., “STD
repeaters”); (2) STD patients with repeat STDs may sustain
an outbreak in a community (Leichliter et al., 2007); and (3)
STD acquisition requires unprotected sexual behavior that
puts people at risk for acquiring HIV.
Patients in STD clinics often report other health-related
problems, such as high levels of alcohol and drug use that
may exacerbate their risk for HIV and/or STDs (Appel et
al., 2006; Cook et al., 2006; Mackenzie et al., 1998). Several
studies have examined the association between substance
use and risky sexual behavior among various populations
(e.g., adolescents, men who have sex with men); however,
evidence of an association has been mixed (Cooper, 2002;
Leigh, 2002; Leigh and Stall, 1993; Weinhardt and Carey,
2000). Studies examining the association between risky sex-
ual behavior and the overall frequency of substance use show
higher rates of unprotected sex, sex with multiple partners,
and STD diagnoses among STD clinic patients who report
grant R01-MH068171 to Michael P. Carey.
P. Carey at the above address or via email at: email@example.com or mpcarey@
syr.edu. Michael P. Carey and Peter A. Vanable are also with the School of
Medicine and Dentistry, University of Rochester, Rochester, NY. Patricia
Coury-Doniger and Marguerite A. Urban are with the School of Medicine
and Dentistry, University of Rochester, Rochester, NY.
Received: December 23, 2008. Revision: April 16, 2009.
*This research was supported by National Institute of Mental Health
†Correspondence may be sent to Lori A. J. Scott-Sheldon or Michael
SCOTT-SHELDON ET AL. 763
high levels of substance use (Cachay et al., 2004; Cook et
al., 2006; Kim et al., 2003). In these studies, it is unclear
whether participants engage in risky sexual behavior because
they are drinking or as a result of some additional factor that
facilitates both risk behaviors.
Examining sexual behavior during a specifi c sexual event
(i.e., at the event level) provides a more precise gauge of the
association between substance use and risky sex. The few
studies examining event-level data from STD patients have
found mixed results. For example, substance use concurrent
with sex has been associated with sexual risk among male,
but not female, patients (Fortenberry et al., 1997; Weinstock
et al., 1993). Mixed results are consistent with the broader
event-level literature (Leigh, 2002), prompting researchers
to seek potential moderators (e.g., gender, partner type,
partner substance-use status) of the risky sex–substance use
association and other factors that may infl uence the asso-
ciation, such as differentiating between alcohol use and the
use of specifi c types of drugs (Leigh et al., 2008a). Given
the discrepant fi ndings, further research examining both the
direct and moderated effects of substance use on risky sexual
behavior at the event level is warranted to better understand
sexual risk taking in this subgroup.
Prior event-level research suggests several possible mod-
erators of the association between risky sexual behavior
and substance use. First, several studies suggest that partner
type (i.e., primary vs nonprimary) infl uences the association
(Brown and Vanable, 2007; Vanable et al., 2004). Event-level
studies among gay and bisexual men (Gillmore et al., 2002;
Vanable et al., 2004), college students (Brown and Vanable,
2007; Labrie et al., 2005), and drug users (Arasteh et al.,
2008; Leigh et al., 2008a) and a national survey of U.S.
adults (Schafer et al., 1994) have shown an increase in the
probability of unprotected sex concurrent with substance use
with nonprimary sexual partners. Some studies have shown
a decrease in the probability of unprotected sex concurrent
with substance use with nonprimary partners (Leigh et al.,
2008b), whereas other studies have shown no impact of
partner type on the association between substance use and
risky sexual behavior (Gillmore et al., 2002). Moreover, the
infl uence of partner type on the risky sex–substance use as-
sociation tends to vary by gender, indicating an increased
probability among men (Labrie et al., 2005; Leigh et al.,
2008a; Vanable et al., 2004) but a decreased probability
among women (Leigh et al., 2008b) with nonprimary sexual
partners. Second, recent research among intravenous drug
users suggested that risky sexual behavior increases when
both partners are intoxicated with alcohol (Arasteh et al.,
2008). Furthermore, this association between partner drink-
ing and condom use interacted with partner type such that,
when both the intravenous drug users and their nonprimary
partner were drinking, they were less likely to use a condom.
Third, studies examining the infl uence of substance use on
risky sex often exclude drug use or combine alcohol and
other drug use in analyses (Leigh, 2002). Because, as Leigh
(2002) suggests, different types of substances have unique
pharmacological effects, situation-specifi c uses, and different
reasons for use, the risky sex–substance use association may
differ by type of substance, consistent with recent research
(Leigh et al., 2008a). Finally, results from meta-analytic and
literature reviews have found an inconsistent association
between substance use and risky sex with respect to gender
(Cooper, 2002; Leigh, 2002; Weinhardt and Carey, 2000).
Because women, compared with men, have less control over
condom use (Campbell, 1995; Karlamangla et al., 2006;
Pearson, 2006), more self-regulation and greater social skills
are required for women to infl uence the use of condoms dur-
ing sex. Drinking or drug use may impair women’s capacity
to negotiate condom use; hence, the association may be more
pronounced for women rather than men.
The current study uses event-level methodology to ex-
amine the association between risky sexual behavior and
substance use among STD clinic patients. Specifi cally, we
examine situational (partner characteristics: primary vs
nonprimary partners and none, one partner, or both partners
using substances), contextual (type of substance use: alco-
hol use, drug use, or combined alcohol and drug use), and
individual (gender: men, women) factors that may infl uence
the association of substance use to risky sex. Examining the
association between sexual behavior and substance use, in-
cluding factors known to be related to risky sexual behavior,
can guide intervention development to avert new infections
among STD clinic patients.
Participants and procedures
clinic in Rochester, NY, were recruited between March
2004 and June 2006 for a randomized clinical trial evaluat-
ing intervention programs to reduce sexual risk among STD
patients (Carey et al., 2008b). To be eligible for the random-
ized clinical trial, patients needed to report being age 18 or
older, engaging in risky sexual behavior during the past 90
days (e.g., vaginal or anal sex without a condom; having
more than one sexual partner; having an STD; or having a
sex partner who had other partners, injected drugs, or was
diagnosed with HIV or other STDs), and having a willing-
ness to be tested for HIV . Patients were excluded if they were
infected with HIV (HIV-positive patients were referred for
more comprehensive services appropriate to their needs),
mentally impaired, receiving inpatient substance-abuse treat-
ment, or planning on moving within the next year.
Eligible patients (n = 2,691) met with a research assistant
in a private examination room and were given details about
the study; those who remained interested (n = 1,559 patients)
provided written consent. The vast majority (82%) of patients
Patients attending a publicly funded, “walk-in” STD
764 JOURNAL OF STUDIES ON ALCOHOL AND DRUGS / SEPTEMBER 2009
who declined cited lack of time as the reason for declination.
Consenting to the trial was associated with female gender,
nonwhite race, having less education, being a returning pa-
tient, and having a greater number of sexual partners in the
past 3 months (Carey et al., 2008a).
Consenting patients completed an audio computer-assisted
self-interview on a laptop computer and were reimbursed
$20 for their time. Of the 1,559 patients who consented, 14
withdrew, 8 tested positive for HIV and were referred for
more comprehensive services, and 54 were part of a pilot
sample, leaving 1,483 participants (46% female, 64% Black,
mean age = 29 years) who contributed data for the current
analyses. The study protocol was approved by institutional
review boards of the participating institutions, and, to protect
participant privacy, a Federal Certifi cate of Confi dentiality
gender, ethnicity, age), most recent sexual behavior, and ad-
ditional measures (e.g., sex-related behavioral skills) as part
of the larger randomized clinical trial. Most recent sexual
behavior was assessed through a series of items. Patients
were asked whether their most recent sexual experience was
with a primary partner (defi ned as a close partner, such as
a husband/wife, boyfriend/girlfriend whom they really care
about) or an outside partner (i.e., any other sexual partner in
the past 3 months, besides the primary partner), when this
sex event occurred, the type of sex (vaginal, anal, and/or
oral), whether condoms were used, and whether they or their
partner used alcohol and/or drugs before sex (“Did you use
[Was your sexual partner using] alcohol [drugs] before you
had sex?”). Participants were given defi nitions of sexual
terms (e.g., vaginal sex). A series of items were used to as-
sess global alcohol- and drug-use patterns. With respect to
the previous 3 months, participants were asked how many
days per week they drank alcohol, the number of alcoholic
beverages consumed per drinking day, and the frequency of
heavy drinking (using standard defi nitions of heavy drinking;
cf. Wechsler et al., 2002). Drug use (1) versus no drug use
(0) was indicated by responding “yes” to having used any of
the following substances in the past 3 months: marijuana,
crack cocaine, cocaine powder, nitrite inhalants, metham-
phetamines, heroin, or Ecstasy. Participants who indicated
any drug use (e.g., indicated “yes” for marijuana) were
categorized as using drugs. All questions have been used in
previous research (Carey et al., 1997, 2000, 2004).
Baseline surveys assessed demographic information (e.g.,
Data management and analysis
events given the relatively lower risk of HIV transmission
through oral sex (Campo et al., 2006). For all analyses, re-
Data analyses were restricted to vaginal and/or anal sex
sults are based on variables that combine vaginal and anal
sex; participants reporting only oral sex are not included (n
= 41). Thus, the term sex refers to vaginal and/or anal sex.
Because condom use was assessed separately for both vagi-
nal and anal sex, some participants reported using a condom
for only one of the two types of sex during the most recent
sexual occasion. For those patients (n = 9), condom use was
coded as none, given that lack of condom use for either vagi-
nal or anal sex confers risk of STD or HIV transmission.
Summary statistics (frequencies, means and standard
deviations) were used to describe characteristics of the
last sexual occasion for the overall sample and by gender.
Differences between women and men were examined us-
ing chi-square analysis (for dichotomous and polytomous
measures) or t tests (for continuous measures). To test our
predictions, we used logistic regression analyses to examine
the association between substance use (alcohol, drugs, and
combined use) and condom use. Specifi cally, the probability
of condom use (yes, no) was predicted from substance use
(alcohol, drugs, or combined use) concurrent with sex (yes,
no) and partner type (nonprimary, primary) for the 1,419 pa-
tients reporting a sex event. We modeled substance use with
three separate models to examine the effects of each type of
substance (alcohol or drug use alone), as well as the effects
of combined substance use on condoms. Because partner
type and alcohol use (but not drug use) differed by gender,
all analyses were conducted separately for women and men,
resulting in six separate models. For all analyses, data were
examined for outliers using the studentized residual statistic,
with a recommended cutoff of ±3.0 for large sample sizes
(Cohen et al., 2003). All data analyses were conducted using
SPSS Version 16 (SPSS Inc., Chicago, IL).
Characteristics of the sample
excluded because they reported having only oral sex (n =
41) or not having sex at the most recent sexual occasion (n
= 21), or did not respond (n = 2). At the most recent sexual
occasion, our fi nal sample of 1,419 patients reported 1,383
vaginal, 140 anal, and 793 oral sex events. Many of the par-
ticipants (n = 820) reported engaging in more than one type
of sex (vaginal, anal, and oral) during the last event. Primary
sexual partners accounted for 61% of sexual events, whereas
39% of the sexual events were with nonprimary partners. A
total of 519 (37%) participants reported vaginal and/or anal
sexual events concurrent with alcohol and/or drugs.
At the global level, participants (n = 1,419) reported
drinking an average (SD) of 1.73 (1.88) days per week, con-
suming an average of 2.69 (2.81) drinks in a typical drinking
day, and reported 3.57 (5.63) occasions of heavy drinking in
the past 3 months. Fifty-two percent reported using illegal
Of the 1,483 patients attending an STD clinic, 64 were
SCOTT-SHELDON ET AL. 765
drugs in the past 3 months, mostly marijuana use (90%). Of
the participants (n = 519) reporting concurrent sex and alco-
hol and/or drug use, 252 consumed alcohol, 119 used drugs,
and 148 used both alcohol and drugs (900 did not report
using alcohol or drugs). Table 1 reports a summary of the
fi nal sample of 1,419 participants’ behavioral characteristics
at the most recent sexual occasion by gender.
Condoms were used in 27% of the sexual events (22% of
events with primary partners and 34% of events with nonpri-
mary partners). The proportion of patients reporting condom
use did not vary as a function of ethnicity, employment, or
income (all ps < .05) but did vary according to age, educa-
tion, and marital status. Patients who reported condom use
were younger (mean age = 24.66 [7.67] years) than patients
who did not use a condom (mean age = 29.84 [9.89] years,
p < .001). Condom use was more likely to be reported by
patients who had a least some college education (30%) than
by patients who had a high school education or less (25%;
p = .04). Finally, patients who were currently single (28%)
were more likely to use a condom at the last sexual occasion
than those who were married (16%; p = .01). We controlled
for age, education level, and marital status in the analyses.
ability of condom use (yes, no) from substance use concur-
rent with sex (yes, no). In preliminary analyses, we examined
bivariate associations between condom use and substance use
(alcohol, drugs, or combined use), followed by multivariate
models that included partner type (nonprimary, primary) as
an event-level variable. Our initial analyses indicated that
neither alcohol use, nor drug use, nor combined substance
use was associated with condom use for either women or
Logistic regression analyses were used to predict the prob-
TABLE 1. Characteristics of the most recent sexual occasion (N = 1,419)
(n = 675)
(n = 744)
% or % or
n mean (SD)
n mean (SD)
When last event occurred
Past 3 months
Type of sexb
Used condom, vaginal sex
Used condom, anal sex
Alcohol concurrent with sex
Number of alcoholic beverages
Drug use concurrent with sex
Partner used alcohol before sex
Partner used drugs before sex
aChi-square or independent t test for gender differences; bsome participants (n = 820) re-
ported more than one type of sex at last occasion.
TABLE 2. Odds ratio (OR) and 95% confi dence interval (CI) of condom use at last sex
OR (95% CI)
OR (95% CI)
Alcohol consumption concurrent with sex
Drug use concurrent with sex
Alcohol and drug use concurrent with sex
Alcohol consumption concurrent with sex
Drug use concurrent with sex
Alcohol and drug use concurrent with sex
Notes: Separate logistic regression analyses were used to examine alcohol consumption, drug use, and
combined substance use as predictors of condom use at last sexual event for women and men. All sub-
stance-use variables were dummy coded (1 = yes, 0 = no).
aAdjusted for age, education, and marital status.
766 JOURNAL OF STUDIES ON ALCOHOL AND DRUGS / SEPTEMBER 2009
men (see Table 2). Among women, condoms were used in
27%, 26%, and 26% events concurrent with alcohol, drugs,
or combined substance use, respectively, and 26% of events
when no alcohol, drugs, or combined substances were used.
For men, condoms were used in 29% of all events concur-
rent with alcohol and/or drug use and 29% of events when
no alcohol, drugs, or combined substances were used.
in the model, controlling for age, marital status, and edu-
cation level. (Because restricting analyses to heterosexual
patients did not change the fi ndings, we report results from
all patients engaging in vaginal and/or anal sex.) In these
analyses, we included partner type and each substance-use
classifi cation as main effects, as well as the partner type by
Table 3 summarizes analyses that included partner type
TABLE 3. Logistic regression analyses examining the effects of substance use and partner type on condom use at last
sex by gender
Predictor AOR (95% CI)
p AOR (95% CI)
Alcohol use concurrent with sex
Alcohol Use × Partner Type
(n = 554) (n = 597)
Drug use (nonalcohol) concurrent with sex
Drug Use (nonalcohol) × Partner Type
Combined substance use
Substance use concurrent with sex
Substance Use × Partner Type
(n = 520) (n = 498)
(n = 511) (n = 536)
Notes: Age is a continuous variable and was centered; all other variables were dummy coded (education: 1 = high school
degree or less, 0 = at least some college; marital status: 1 = currently single, 0 = married; alcohol, drug, or substance
use concurrent with sex: 1 = yes, 0 = no; partner type: 1 = nonprimary, 0 = primary). AOR = adjusted odds ratio; CI =
confi dence interval.
FIGURE 1. Proportion of women patients reporting condom use concurrent with alcohol consumption or when no alcohol was consumed by partner type
SCOTT-SHELDON ET AL. 767
TABLE 4. Logistic regression analyses examining the effects of substance use, partner type, and partner use on condom use at
last sex by gender
Predictor AOR (95% CI)
p AOR (95% CI)
Alcohol use concurrent with sex (none)a
Alcohol use concurrent with sex (one partner)
Alcohol use concurrent with sex (both partners)
Alcohol Use (none) × Partner Typea
Alcohol Use (one partner) × Partner Type
Alcohol Use (both partners) × Partner Type
(n = 450) (n = 499)
Drug use (nonalcohol) concurrent with sex (none)a
Drug use (nonalcohol) concurrent with sex (one partner)
Drug use (nonalcohol) concurrent with sex (both partners)
Drug Use (nonalcohol) × Partner Type (none)a
Drug Use (nonalcohol) × Partner Type (one partner)
Drug Use (nonalcohol) × Partner Type (both partners)
(n = 430) (n = 413)
Combined substance use
Substance use concurrent with sex (none)a
Substance use concurrent with sex (one partner)
Substance use concurrent with sex (both partners)
Substance Use × Partner Type (none)a
Substance Use × Partner Type (one partner)
Substance Use × Partner Type (both partners)
(n = 511) (n = 536)
Notes: Age is a continuous variable and was centered; all other variables were dummy coded (education: 1 = high school degree
or less, 0 = at least some college; marital status: 1 = currently single, 0 = married; alcohol, drug, or substance use concurrent with
sex by partners: 2 = both partners, 1 = one partner, 0 = no partners; partner type: 1 = nonprimary, 0 = primary). AOR = adjusted
odds ratio; CI = confi dence interval.
substance-use interaction terms to test for potential partner
type differences in the association of substance use to sexual
risk. For men, the odds of condom use were not related to
alcohol consumption, drug use, or combined alcohol and
drug use (regardless of partner type; ps > .05). In all three
models, the odds of condom use increased when men had
sex with nonprimary versus primary partners (adjusted odds
ratios [ORs]: 2.06-2.08, ps = .001). No signifi cant interac-
tions between substance use (alcohol, drugs, or combined
substances) were found among men.
Among women, the association between type of substance
and condom use was more complex. Type of substance use
(alcohol, drug, or combined substances) alone was not re-
lated to condom use; rather, alcohol consumption interacted
with partner type (adjusted OR = 0.21, p < .01). Consistent
with our hypotheses, women were less likely to use a con-
dom with nonprimary partners when drinking (9 of 42 oc-
casions) versus when no alcohol was consumed (48 of 122
occasions) (OR = 0.42, 95% confi dence interval [CI]: 0.19-
0.96; see Figure 1). For sexual events with primary partners,
there were no differences in the proportion of women using
condoms when drinking (18 of 57 occasions) versus no al-
cohol use (70 of 333 occasions) (OR = 1.73, 95% CI: 0.94-
3.22; see Figure 1). For all three models, the odds of condom
use increased when women had sex with nonprimary versus
primary partners (adjusted ORs: 2.46-2.47, ps < .001).
Examining participant and partner’s substance use.
Because the risk of unprotected sex may be exacerbated by
a partner’s substance use concurrent with sex, exploratory
analyses examined whether both partners, one partner, and
no partners were using substances before the sexual event.
In these exploratory analyses, we excluded the subset of
participants (alcohol: n = 238; drug use: n = 236) who were
unsure of their partner’s substance use concurrent with sex
768 JOURNAL OF STUDIES ON ALCOHOL AND DRUGS / SEPTEMBER 2009
(i.e., responded “unknown”). In three separate models (strati-
fi ed by gender), the probability of condom use (yes, no) was
predicted from participant–partner substance use (alcohol,
drugs, and combined use by both partners, one partner only,
or no partners) concurrent with sex (yes, no) and partner
type (nonprimary, primary) using logistic regression analy-
ses (Table 4). Among women, both participant and partner
alcohol consumption (but not drug or combined substance
use) interacted with partner type (adjusted OR = 0.16, 95%
CI: 0.05-0.56, p < .01). Women who reported both they and
their nonprimary partners were drinking before sex were less
likely to use a condom. No signifi cant interactions between
substance use (alcohol, drugs, or combined substances) were
found among men.
between risky sexual behavior and substance use among
patients attending an STD clinic. Results indicate an associa-
tion between unprotected vaginal and/or anal sex (i.e., less
condom use) following substance use, but this association
emerged only for alcohol consumption and varied by gender
and partner characteristics. In bivariate analyses, substance
use (alcohol, drugs, or combined use) was not associated
with condom use for both women and men. Multivariate
analyses showed a more complex pattern. Consistent with
the bivariate analyses, condom use was unrelated to alcohol,
drug, or combined substance use alone for both women and
men. Condom use was associated with nonprimary versus
primary sexual partners. However, among women, but not
men, partner type interacted with alcohol consumption such
that less condom use occurred when drinking preceded sex
with nonprimary partners. Further analyses showed that,
when a woman and her nonprimary partner were drinking
concurrent with sex, they were less likely to use condoms
Consistent with prior research among samples of college
students, intravenous drug users, and men who have sex
with men (Arasteh et al., 2008; Brown and Vanable, 2007;
Corbin and Fromme, 2002; Labrie et al., 2005; Vanable et
al., 2004), these results confi rm that partner type and part-
ner drinking moderates the association between substance
use and risky sexual behavior. However, evidence for the
interaction of partner type/drinking and alcohol use was
found only for women, not for men. In our study, events
concurrent with alcohol use were reported by 26% of the
women with nonprimary partners versus 15% of women with
primary partners. (For women who reported if their partner
was using alcohol before sex, alcohol consumption by both
partners before sex was reported by 28% of the women
with nonprimary partners vs 14% of women with primary
partners.) It is likely that alcohol may be used as a means to
reduce social inhibitions, thereby contributing to unplanned
Using event-level methods, we examined the association
sex with new partners (Mckirnan et al., 1996; Simbayi et
al., 2006). In contrast, alcohol use is less likely to infl uence
decisions to use condoms, given that sexual scripts are al-
ready well established among primary partners (Lansky et
al., 1998; Macaluso et al., 2000). Because men have direct
control over condom use, alcohol use may exert less infl u-
ence over their condom use. In contrast, gender-based power
imbalances may be exacerbated when women drink (Amaro,
1995; Wingood and Diclemente, 1998). Prior research sug-
gests that gender-based power imbalances may inhibit or
impair women-initiated negotiation strategies with sexual
partners (Pulerwitz et al., 2002; Wingood and Diclemente,
1998). Our exploratory analyses, however, show condom
use is less likely when women and their nonprimary part-
ners are drinking but not when only one partner is drinking.
Further examination among women with only one drinking
partner showed that male partners were drinking in 85%
of the primary and 74% of the nonprimary relationships.
It is plausible that gender-based power imbalances may in-
hibit women’s ability to negotiate condom use regardless of
drinking status. For women, this is particularly detrimental
because women’s risk of contracting HIV or STDs through
heterosexual contact is estimated to be eight times greater
than that for men (Padian et al., 1997).
Previous research has shown a link between non-alcohol-
related drug use and risky sexual behavior among nonpri-
mary partners (Leigh et al., 2008a; Schafer et al., 1994). Our
results suggest that drug use, either alone or in combination
with alcohol use, is not universally associated with condom
use at the event level. However, the frequency of drug use
alone (13% women, 11% men), or in combination with
alcohol use (11% women, 17% men), concurrent with sex
was reported by a minority of the participants, limiting our
ability to fully evaluate the risks associated with other drug
use (including specifi c types of drugs used). Instead, our
fi ndings suggest that alcohol consumption alone is more
closely related to risky sexual behavior among women STD
clinic patients. We did not assess specifi c type of drugs used
at the event level; thus, it is possible that our combined
drug-use measure restricted our ability to detect specifi ed
drug use–risky sexual behavior links. Indeed, recent research
found use of certain types of drugs, such as amphetamines—
but not heroin, crack/cocaine, or marijuana—was related to
risky sexual behavior among a sample of drug-offending
men (Leigh et al., 2008a).
terpreting our fi ndings. First, as with any study conducted at
a single site, the sample may not be representative of all STD
clinic patients. Second, data were gathered from self-reports
and may contain errors or be vulnerable to self-presentation
biases. However, our focus on the most recent event should
The limitations of this study should be considered in in-
SCOTT-SHELDON ET AL. 769
minimize recall diffi culties, and the use of audio computer-
assisted self-interview optimized patient privacy. Third, we
examined a discrete event rather than multiple events; assess-
ment of a single event increases precision and minimizes the
cognitive burden, time commitment, and potential reactivity
on participants, but it may not be representative of patients’
typical sexual behavior. Multiple-event methods, such as
diary methods, may provide more information regarding par-
ticipants’ sexual behavior, but there is insuffi cient evidence
to conclude that multiple-event methods are less burdensome
and/or reactive than other methodology (for a discussion,
see Bolger et al., 2003; Reis and Gable, 2000). Fourth, we
measured the association between condom use and any al-
cohol use instead of alcohol intoxication (cf. Arasteh et al.,
2008). Pharmacological effects of differing amounts of al-
cohol (e.g., a single serving vs fi ve or more standard drinks)
preceding sex may alter its effect on sexual behavior. Fifth,
we did not assess specifi c drugs used, limiting information
regarding drug-specifi c effects. Finally, we did not assess
other individual characteristics (e.g., personality traits) that
may help to explain the association between substance use
and risky sexual behavior.
particular, these fi ndings suggest that risk reduction strate-
gies for women should address the important role of alcohol
use, especially in the context of nonprimary partnerships. In-
terventionists might seek to increase awareness of the effects
of alcohol use on decision-making and interpersonal skills;
for example, providing a skills-based intervention for women
that targets specifi c situations wherein alcohol consumption
and the opportunity to have sex co-occur (e.g., meeting new
partners at a bar). Skills-based interventions for women
could focus on condom-use preparations (e.g., carrying con-
doms), moderation strategies to reduce alcohol consumption
(e.g., alternating drinks of water), planning sexual risk avoid-
ance strategies (e.g., eroticizing condom use), identifi cation
of high-risk sexual situations (e.g., parties, bars, clubs), and
rehearsing (overlearning) sexually assertive responses to
unprotected sex. Intervention strategies can help women to
reduce their risk for HIV and other STDs.
This research carries implications for risk reduction; in
team: Mary-Leah Albano, LuAnne Cori, Nicoy Douglas, Joyce Jones, Tracy
Montesano, and Tricia Santa-Ferrara.
We thank the participants, clinic nurses and staff, and our research
AMARO, H. Love, sex, and power: Considering women’s realities in HIV
prevention. Amer. Psychol. 50: 437-447, 1995.
APPEL, P.W., PICULELL, R., JANSKY, H.K., AND GRIFFY, K. Assessing alcohol
and other drug problems (AOD) among sexually transmitted disease
(STD) clinic patients with a modifi ed CAGE-A: Implications for AOD
intervention services and STD prevention. Amer. J. Drug Alcohol Abuse
32: 225-236, 2006.
ARASTEH, K., DES JARLAIS, D.C., AND PERLIS, T.E. Alcohol and HIV sexual
risk behaviors among injection drug users. Drug Alcohol Depend. 95:
BOLGER, N., DAVIS, A., AND RAFAELI, E. Diary methods: Capturing life as it
is lived. Annual Rev. Psychol. 54: 579-616, 2003.
BROWN, J.L. AND VANABLE, P.A. Alcohol use, partner type, and risky sexual
behavior among college students: Findings from an event-level study.
Addict. Behav. 32: 2940-2952, 2007.
CACHAY, E., MAR-TANG, M., AND MATHEWS, W.C. Screening for potentially
transmitting sexual risk behaviors, urethral sexually transmitted infec-
tion, and sildenafi l use among males entering care for HIV infection.
AIDS Patient Care STDS 18: 349-354, 2004.
CAMPBELL, C.A. Male gender roles and sexuality: Implications for women’s
AIDS risk and prevention. Social Sci. Med. 41: 197-210, 1995.
CAMPO, J., PEREA, M.A., DEL ROMERO, J., CANO, J., HERNANDO, V., AND BAS-
CONES, A. Oral transmission of HIV, reality or fi ction? An update. Oral
Dis. 12: 219-228, 2006.
CAREY, M.P., BRAATEN, L.S., MAISTO, S.A., GLEASON, J.R., FORSYTH, A.D.,
DURANT, L.E., AND JAWORSKI, B.C. Using information, motivational
enhancement, and skills training to reduce the risk of HIV infection
for low-income urban women: A second randomized clinical trial. Hlth
Psychol. 19: 3-11, 2000.
CAREY, M.P., CAREY, K.B., MAISTO, S.A., GORDON, C.M., SCHRODER, K.E.,
AND VANABLE, P.A. Reducing HIV-risk behavior among adults receiving
outpatient psychiatric treatment: Results from a randomized controlled
trial. J. Cons. Clin. Psychol. 72: 252-268, 2004.
CAREY, M.P., MAISTO, S.A., KALICHMAN, S.C., FORSYTH, A.D., WRIGHT, E.M.,
AND JOHNSON, B.T. Enhancing motivation to reduce the risk of HIV
infection for economically disadvantaged urban women. J. Cons. Clin.
Psychol. 65: 531-541, 1997.
CAREY, M.P., SENN, T.E., VANABLE, P.A., COURY-DONIGER, P., AND URBAN,
M.A. Do STD clinic patients who consent to sexual health research
differ from those who decline? Findings from a randomized controlled
trial with implications for the generalization of research results. Sex.
Transm. Dis. 35: 73-77, 2008a.
CAREY, M.P., VANABLE, P.A., SENN, T.E., COURY-DONIGER, P., AND URBAN,
M.A. Evaluating a two-step approach to sexual risk reduction in a pub-
licly-funded STI clinic: Rationale, design, and baseline data from the
Health Improvement Project-Rochester (HIP-R). Contemp. Clin. Trials
29: 569-586, 2008b.
CENTERS FOR DISEASE CONTROL AND PREVENTION. HIV Prevention Through
Early Detection and Treatment of Other Sexually Transmitted Dis-
eases—United States: Recommendations of the Advisory Committee for
HIV and STD Prevention. MMWR 47 (RR-12): 1-31, 1998.
CENTERS FOR DISEASE CONTROL AND PREVENTION. The Role of STD Preven-
tion and Treatment in HIV Prevention, CDC Fact Sheet, Atlanta, GA:
Centers for Disease Control and Prevention, 2007.
CENTERS FOR DISEASE CONTROL AND PREVENTION. Sexually Transmitted
Disease Surveillance 2007, Atlanta, GA: Division of STD Prevention,
Centers for Disease Control and Prevention, 2008.
CENTERS FOR DISEASE CONTROL AND PREVENTION. HIV/AIDS Surveillance
Report: Cases of HIV Infection and AIDS in the United States and De-
pendent Areas, 2007, Vol. 19, Atlanta, GA: Centers for Disease Control
and Prevention, 2009.
COHEN, J., COHEN, P., WEST, S.G., AND AIKEN, L.S. Applied Multiple Re-
gression/Correlation Analysis for the Behavioral Sciences, 3rd Edition,
Mahwah, NJ: Lawrence Erlbaum, 2003.
COOK, R.L., COMER, D.M., WIESENFELD, H.C., CHANG, C.C., TARTER, R.,
LAVE, J.R., AND CLARK, D.B. Alcohol and drug use and related disorders:
An underrecognized health issue among adolescents and young adults
770 JOURNAL OF STUDIES ON ALCOHOL AND DRUGS / SEPTEMBER 2009 Download full-text
attending sexually transmitted disease clinics. Sex. Transm. Dis. 33:
COOPER, M.L. Alcohol use and risky sexual behavior among college students
and youth: Evaluating the evidence. J. Stud. Alcohol Supplement No.
14, pp. 101-117, 2002.
CORBIN, W.R. AND FROMME, K. Alcohol use and serial monogamy as risks
for sexually transmitted diseases in young adults. Hlth Psychol. 21:
ENG, T.R. AND BUTLER, W.T. The Hidden Epidemic: Confronting Sexually
Transmitted Diseases, Washington, DC: National Academies Press,
FLEMING, D.T. AND WASSERHEIT, J.N. From epidemiological synergy to public
health policy and practice: The contribution of other sexually transmitted
diseases to sexual transmission of HIV infection. Sex. Transm. Infect.
75: 3-17, 1999.
FORTENBERRY, J.D., ORR, D.P., KATZ, B.P., BRIZENDINE, E.J., AND BLYTHE, M.J.
Sex under the infl uence: A diary self-report study of substance use
and sexual behavior among adolescent women. Sex. Transm. Dis. 24:
GILLMORE, M.R., MORRISON, D.M., LEIGH, B.C., HOPPE, M.J., GAYLORD, J.,
AND RAINEY, D.T. Does “high=high risk”? An event-based analysis of
the relationship between substance use and unprotected anal sex among
gay and bisexual men. AIDS Behav. 6: 361-370, 2002.
JOINT UNITED NATIONS PROGRAMME ON HIV/AIDS (UNAIDS). 2008 Report
on the Global AIDS Epidemic, Geneva, Switzerland: Joint United Na-
tions Programme on HIV/AIDS (UNAIDS), 2008.
KARLAMANGLA, A., ZHOU, K., REUBEN, D., GREENDALE, G., AND MOORE, A.
Longitudinal trajectories of heavy drinking in adults in the United States
of America. Addiction 101: 91-99, 2006.
KIM, A.A., KENT, C.K., AND KLAUSNER, J.D. Risk factors for rectal gonococ-
cal infection amidst resurgence in HIV transmission. Sex. Transm. Dis.
30: 813-817, 2003.
LABRIE, J., EARLEYWINE, M., SCHIFFMAN, J., PEDERSEN, E., AND MARRIOT, C.
Effects of alcohol, expectancies, and partner type on condom use in col-
lege males: Event-level analyses. J. Sex Res. 42: 259-266, 2005.
LANSKY, A., THOMAS, J.C., AND EARP, J.A. Partner-specifi c sexual behaviors
among persons with both main and other partners. Fam. Plann. Perspect.
30: 93-96, 1998.
LEICHLITER, J.S., ELLEN, J.M., AND GUNN, R.A. STD repeaters: Implications
for the individual and STD transmission in a population. In: ARAL, S.O.,
DOUGLAS, J.M., JR., AND LIPSHUTZ, J.A. (Eds.) Behavioral Interventions
for Prevention and Control of Sexually Transmitted Diseases, New York:
Springer, 2007, pp. 354-373.
LEIGH, B.C. Alcohol and condom use: A meta-analysis of event-level studies.
Sex. Transm. Dis. 29: 476-482, 2002.
LEIGH, B.C., AMES, S.L., AND STACY, A.W. Alcohol, drugs, and condom use
among drug offenders: An event-based analysis. Drug Alcohol Depend.
93: 38-42, 2008a.
LEIGH, B.C. AND STALL, R. Substance use and risky sexual behavior for
exposure to HIV: Issues in methodology, interpretation, and prevention.
Amer. Psychol. 48: 1035-1045, 1993.
LEIGH, B.C., VANSLYKE, J.G., HOPPE, M.J., RAINEY, D.T., MORRISON, D.M., AND
GILLMORE, M.R. Drinking and condom use: Results from an event-based
daily diary. AIDS Behav. 12: 104-112, 2008b.
MACALUSO, M., DEMAND, M.J., ARTZ, L.M., AND HOOK, E.W., 3RD. Partner
type and condom use. AIDS 14: 537-546, 2000.
MACKENZIE, T.D., STEINER, J.F., DAVIDSON, A.J., MARINE, W.M., AND JUDSON,
F.N. Tobacco use and other risk behaviors among adolescents in an STD
clinic. Prev. Med. 27: 792-797, 1998.
MCKIRNAN, D.J., OSTROW, D.G., AND HOPE, B. Sex, drugs and escape: A
psychological model of HIV-risk sexual behaviours. AIDS Care 8:
PADIAN, N.S., SHIBOSKI, S.C., GLASS, S.O., AND VITTINGHOFF, E. Heterosexual
transmission of human immunodefi ciency virus (HIV) in northern Cali-
fornia: Results from a ten-year study. Amer. J. Epidemiol. 146: 350-357,
PEARSON, J. Personal control, self-effi cacy in sexual negotiation, and con-
traceptive risk among adolescents: The role of gender. Sex Roles 54:
PULERWITZ, J., AMARO, H., DE JONG, W., GORTMAKER, S.L., AND RUDD, R.
Relationship power, condom use and HIV risk among women in the
USA. AIDS Care 14: 789-800, 2002.
REIS, H.T. AND GABLE, S.L. Event-sampling and other methods for studying
everyday experience. In: REIS, H.T. AND JUDD, C.M. (Eds.) Handbook
of Research Methods in Social and Personality Psychology, New York:
Cambridge Univ. Press, 2000, pp. 190-222.
SCHAFER, J., BLANCHARD, L., AND FALS-STEWART, W. Drug use and risky
sexual behavior. Psychol. Addict. Behav. 8: 3-7, 1994.
SIMBAYI, L.C., MWABA, K., AND KALICHMAN, S.C. Perceptions of the combi-
nation of HIV/AIDS and alcohol as a risk factor among STI clinic at-
tenders in South Africa: Implications for HIV prevention. Social Behav.
Pers. 34: 535-544, 2006.
VANABLE, P.A., MCKIRNAN, D.J., BUCHBINDER, S.P., BARTHOLOW, B.N., DOUG-
LAS, J.M., JR., JUDSON, F.N., AND MACQUEEN, K.M. Alcohol use and high-
risk sexual behavior among men who have sex with men: The effects of
consumption level and partner type. Hlth Psychol. 23: 525-532, 2004.
WECHSLER, H., LEE, J.E., NELSON, T.F., AND KUO, M. Underage college
students’ drinking behavior, access to alcohol, and the infl uence of
deterrence policies: Findings from the Harvard School of Public Health
College Alcohol Study. J. Amer. Coll. Hlth 50: 223-236, 2002.
WEINHARDT, L.S. AND CAREY, M.P. Does alcohol lead to sexual risk be-
havior? Findings from event-level research. Annual Rev. Sex Res. 11:
WEINSTOCK, H.S., LINDAN, C., BOLAN, G., KEGELES, S.M., AND HEARST, N.
Factors associated with condom use in a high-risk heterosexual popula-
tion. Sex. Transm. Dis. 20: 14-20, 1993.
WINGOOD, G.M. AND DICLEMENTE, R.J. Partner infl uences and gender-related
factors associated with noncondom use among young adult African
American women. Amer. J. Commun. Psychol. 26: 29-51, 1998.
WORLD HEALTH ORGANIZATION. Global Prevalence and Incidence of Selected
Curable Sexually Transmitted Infections: Overview and Estimates, WHO
Document No. WHO/HIV_AIDS/2001.02, Geneva, Switzerland: World
Health Organization, 2001.