Youth with externalizing disorders (e.g., attention-deficit disorder, conduct disorder, oppositional defiant disorder) are likely to be at elevated risk for unsafe sexual behavior for a number of reasons. Such youth may have difficulty attending to or absorbing information about the health risks of having multiple unsafe sexual partners. As described in the DSM-IV, individuals with these disorders are, in many cases, impulsive and prone to engage in a wide variety of sensation-seeking or risky experiences. They may associate with youth who encourage them to behave in an antisocial manner. In addition, they may resist the recommendations of adult authority figures. Many youth with disruptive behavior problems receive inadequate adult supervision and have more opportunities than other young people to engage in sexual behavior with several partners. As a result, youth with disruptive behavior disorders may tend to have a high number of lifetime unsafe sexual partners and be at elevated risk for STDs (Lavan and Johnson, 2002).
Personality Disorders, Traits
Numerous studies have indicated that personality disorders and maladaptive personality traits contribute to increased risk for sexual risk behavior. Research has indicated that traits characteristic of personality disorders, such as impulsivity, lack of empathy, failure to appreciate risks and egocentrism, are associated with sexual risk taking among adolescents (Boyer et al., 2000; Hollander and Rosen, 2000; Horvath and Zuckerman, 1993). Adolescents with elevated personality disorder symptom levels have been found to be more likely than adolescents without elevated personality disorder symptom levels to report a high number of sexual partners (Lavan and Johnson, 2002). Elevated antisocial, dependent and paranoid personality disorder symptom levels and certain specific antisocial, borderline, dependent, histrionic, narcissistic, obsessive-compulsive, paranoid and schizotypal personality disorder traits were independently associated with high-risk sexual behavior.
The DSM-IV Cluster B (antisocial, borderline, histrionic, narcissistic) personality disorders may be particularly associated with high-risk sexual behavior. Research has suggested that individuals with borderline personality disorder may be at elevated risk for unsafe sexual behavior and that this may be partially attributable to the co-occurrence of borderline personality disorder with substance use disorders and other mental disorders (Hull et al., 1993). Individuals with antisocial, histrionic and narcissistic personality disorders may be likely to engage in unsafe sexual behavior because they often tend to be impulsive, self-centered or have a lack of concern for the well-being of their sexual partners (Apt and Hurlbert, 1994; Harvey and Spigner, 1995; Hollander and Rosen; 2000).
Other Psychiatric Disorders
In addition to the above disorders, a variety of other psychiatric disorders may also be associated with sexual risk behavior. For example, several studies have documented high levels of sexual risk behaviors and HIV prevalence among men and women with severe and persistent chronic mental illness, including those with psychotic symptoms (Carey et al., 1997; Cournos and McKinnon, 1997; Rosenberg et al., 2001).
It is widely known that negative mood such as depression and anxiety is usually associated with a decrease in sexual interest and behavior (Kennedy et al., 1999; Schreiner-Engel and Schiavi, 1986). However, it seems that in some individuals there is evidence for increased sexual interest and responsiveness among people with affective disorders (Nofzinger et al., 1993). For them the tendency may be to use sex as a mood regulator. Bancroft and colleagues (2003) have put forth explanations within a framework in which sexual response depends on a balance of excitatory and inhibitory mechanisms in the brain. Thus, in the presence of anxiety or depression, the negative state of arousal can either lead to distraction from sexual activity with a focus on the mood-provoking stimuli or to sexual release as a means of reducing the negative arousal. In depression, there appear to be additional mediating mechanisms such as the need for validation through intimate contact versus a need to avoid intimate contact, depending on individual personality traits. Similarly, other researchers have hypothesized that some individuals with a depressive disorder are more likely to take sexual (and other) risks because they care less about potential negative consequences (Rogers et al., 2003) or due to sensation-seeking personalities (Dolezal et al., 2000; Horvath and Zuckerman, 1993).
Several reports have sought to explain the association between psychopathology and sexual risk behavior as being primarily related to vulnerability, especially in the context of psychosocial comorbidities (Beck et al., 2003; Champion et al., 2002; Hutton et al., 2001; Ramrakha et al., 2000; Wingood and DiClemente, 1998). In many of the populations studied there are multiple factors that are likely to contribute to the relatively high levels of HIV and STD risk behaviors. These include poverty, history of violence and childhood abuse (including sexual abuse), family substance use, history of incarceration, comorbid psychiatric conditions, poor access to quality health care, and stigma associated with minority status (i.e., racial and ethnic, sexual orientation, psychiatric illness). It is the combination of any of these factors or conditions that is hypothesized to make such groups vulnerable to risk, including risk for HIV and STDs.
In the absence of longitudinal studies with designs appropriated for systematic hypothesis testing, causal direction for the association between sexual risk behavior and psychopathology is unknown. For example, it may be that individuals with depression engage in risky sexual behavior and substance abuse secondary to feelings of hopelessness and worthlessness or as a means of self-medication. However, it is also possible that negative consequences from risky sexual scenarios may precipitate psychiatric distress or a depressive episode.
Whatever the precise causal pathway, the bottom line for all health care professionals is that there is substantial evidence that points to the greater likelihood of sexual risk behavior among populations of people who have elevated psychiatric symptomatology and/or psychiatric illness (Axis I and/or Axis II conditions). This sexual risk includes risk to self as well as risk to sex partners. This review is brief and not comprehensive; there are likely to be associations between sexual risk behavior and psychiatric conditions other than those covered here. Additional systematic research is needed in this broad domain, along with in-depth analyses of possible causal pathways, including longitudinal studies of the phenomenon.