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Despite the fact that awareness of HIV and AIDS transmission is pervasive, risky sexual behavior has been increasing in many parts of the world in recent years, with a concomitant rise in new cases of HIV and other sexually transmitted diseases.
October 2004, Vol. XXI, Issue 11
Human immunodeficiency virus/acquired immunodeficiency syndrome is an important public health problem throughout the world, with sex being the predominant mode of transmission of HIV. Despite the fact that awareness of HIV and AIDS transmission is pervasive, risky sexual behavior has been increasing in many parts of the world in recent years, with a concomitant rise in new cases of HIV and other sexually transmitted diseases (STDs) (Centers for Disease Control and Prevention, 2003; Desquilbet et al., 2002; Rosenberg and Biggar, 1998; Wolitski et al., 2001). The World Heath Organization (WHO) and Joint United Nations Programme on HIV/AIDS (UNAIDS) (2000) has recommended that surveillance of the HIV/AIDS epidemic should focus on populations most at risk of becoming newly infected with HIV-populations with high levels of risk behavior, including young people, men who have sex with men, and racial and ethnic minority heterosexual men and women.
Studies have shown that populations living with HIV and/or at risk for acquiring HIV are at elevated risk for psychiatric conditions (Bing et al., 2001; Lipsitz et al., 1994; Lyketsos et al., 1994; Williams et al., 1991). Thus, it is important to investigate the association between high-risk sexual behavior and psychiatric symptoms as part of the public health response to the HIV pandemic. While the findings have been mixed, a number of studies have found an association between elevated sexual risk behavior and the prevalence of psychiatric disorders (Axis I and Axis II) and psychiatric symptomatology. In this article, we review some of the major findings in this field, discuss hypothesized causal pathways for the association between psychopathology and sexual risk behavior, and address the implications for health care settings.
Psychoactive substance use and abuse have consistently been found to be associated with sexual risk behavior and the acquisition or transmission of STDs/HIV among men and women (Harvey and Spigner, 1995; Katz et al., 2000; Stall and Purcell, 2000; Wingood and DiClemente, 1998). Most of these studies assessed frequency and amount of use of alcohol and illicit substances and did not assess the presence or absence of substance use disorders. Substances that were most often cited as being related to sexual risk behavior include alcohol, marijuana, crack, cocaine, methamphetamines and other recreational drugs. Among adolescents, Boyer et al. (2000) found that alcohol and marijuana use were substantially more common among sexually experienced adolescents than the national average. It has been shown that cigarette, alcohol and marijuana use are significant predictors of risky sexual behavior (Cooper, 2002; Harvey and Spigner, 1995; Malow et al., 2001).
Numerous studies have reported an association between negative affective states and increased sexual risk behavior in both adolescents and adults. This association has been seen across a wide range of populations, including adult men and women (Kelly et al., 1993), men who have sex with men (Marks et al., 1998; Perdue et al., 2003), HIV-positive adults (Kelly et al., 1993; Parsons et al., 2003), minority women (Champion et al., 2002; Orr et al., 1994), opioid users (Camacho et al., 1996), young gay and bisexual men (Strathdee et al., 1998), and adolescents (Brooks et al., 2002). Most of these studies assessed severity of psychiatric distress (i.e., depression, anxiety, hostility) without diagnostic assessments of psychiatric disorders. However, a few studies have found an association between mood disorders and posttraumatic stress disorder and increased sexual risk behavior (Hutton et al., 2001; Ramrakha et al., 2000; Rogers et al., 2003).
Unfortunately, systematic comparisons have not yet been conducted regarding the associations of different types of mood disorders with sexual risk behaviors. According to the DSM-IV, one of the main features of a manic episode is often hypersexuality. However, unipolar depression is much more pervasive than bipolar disorder. Although many people with relatively severe unipolar disorders do have reduced libido, there are many other people with depression who have fluctuating levels of libido that may often be high enough to lead to risky sexual behavior. Furthermore, unipolar depression increases risk for suicidal and self-destructive behavior. People who are self-destructive are perhaps less likely to inhibit their sexual impulses, because if they do not care about life itself, they may reason that there is no reason to care whether they acquire an STD.
In a large cross-sectional birth cohort study, young adults diagnosed with substance dependence, schizophrenia spectrum, depressive, manic and antisocial disorders were more likely to engage in risky sexual intercourse, contract sexually transmitted diseases and have sexual intercourse at an early age (younger than 16) (Ramrakha et al., 2000). Furthermore, the likelihood of risky behavior was increased by psychiatric comorbidity. This study was one of the first to establish strong links between a wide range of psychiatric disorders and sexual risk behavior. More specifically, they found that compared to people without psychiatric disorders, those with anxiety disorders were more likely to report STDs; those with depressive, substance dependence and antisocial disorders were more likely to engage in sexual risk behaviors, report STDs and were younger at first sexual intercourse; those with mania were more likely to have engaged in risky sexual behavior and to report STDs; and those with symptoms in the schizophrenia spectrum were more likely to engage in sexual risk, report STDs and were younger at first sexual intercourse. The strongest association of risky sexual behavior was with disorders characterized by disinhibition or a pattern of impulsive behavior and comorbid psychiatric conditions. In particular, depression, substance dependence and antisocial disorders showed stronger associations with risky behavior compared with any single psychiatric disorder.
While many studies have found that sexual risk taking was associated with the presence of negative mood states and Axis I disorders, there have been studies that failed to find such an association. Dilley et al. (1998) found no association between depression scores and sexual risk among sexually active gay men. Dolezal et al. (2000) found positive self-esteem to be associated with greater sexual risk behavior and Robins et al. (1994) found an association between sexual risk and lower levels of psychological distress. Rubb et al. (1993) also found depressed ideation was associated with a reduced likelihood to engage in sexual risk behavior. Rogers et al. (2003) found two patterns of association between depressive disorders and sex behavior. Major depression was associated with reduced sexual activity, while dysthymic disorder was associated with an increased likelihood of unprotected sex.
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).
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).
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.
Sexual desire and behavior are normal aspects in the lives of most adolescents and adults, including those with chronic and persistent mental illness. It is important for primary care providers to address the mental health needs of their patients, with appropriated diagnosis and referral for treatment, and for all health care providers to address the sexual lives of their patients without shame, embarrassment or judgment. People who are vulnerable to engaging in risky sex behaviors can benefit from targeted counseling that increases risk perception, motivation for change, the acquisition of protective behavioral skills, and self-efficacy for enacting and maintaining healthy behaviors. Referrals for mental health supportive services are often necessary. Providers can play an important role in empowering their patients to reduce behaviors that carry with them significant risk for HIV and other STDs and to normalize the pursuit of satisfying and healthy sexual gratification.
Dr. Remien is a research scientist at New York State Psychiatric Institute, associate professor of clinical psychology (in psychiatry) at Columbia University and a licensed clinical psychologist practicing in New York. Dr. Remien is supported in part by the National Institute of Mental Health to the HIV Center for Clinical and Behavioral Studies at New York State Psychiatric Institute and Columbia University (P50-MH43520; center principal investigator: Anke A. Ehrhardt, Ph.D.).
Dr. Johnson is assistant professor of clinical psychology in the department of psychiatry at Columbia University and a research scientist at New York State Psychiatric Institute.