|
Multiple Sexual Partners Among U.S. Adolescents and Young Adults
By John S. Santelli, Nancy D. Brener, Richard Lowry, Amita Bhatt
and Laurie S. Zabin
Family Planning Perspectives
Volume 30, Number 6, November/December 1998
http://www.guttmacher.org/pubs/journals/3027198.html
Context:
Because many teenagers and young adults fail to use condoms
correctly and consistently, the number of sexual partners they
have is an important risk factor for sexually transmitted
diseases, including HIV. Identifying factors that are associated
with having multiple partners can help in the design of disease
interventions.
Methods:
Data on 8,450 males and females aged 14-22 who participated in
the 1992 Youth Risk Behavior Survey were used to examine the
prevalence of and factors associated with young people's having
multiple partners.
Results:
In all, 63% of female respondents and 64% of males were sexually
experienced. Among those who had had sex during the three months
before the survey, 15% and 35%, respectively, had had two or
more partners during that period. At each age, the majority of
sexually experienced respondents had had more than one lifetime
partner; between ages 14 and 21, the proportion who had had six
or more rose from 8% to 31% among females and from 14% to 45%
among males. In logistic regression analyses, alcohol use,
illicit drug use and young age at first coitus were associated
with increased odds that females had had two or more partners in
the previous three months, and being married lowered the odds;
black or Hispanic race or ethnicity, alcohol use and young age
at first coitus increased the odds for males, and being married
reduced the odds. As the number of reported alcohol-related
behaviors increased, the adjusted proportion of respondents who
had recently had multiple partners rose from 8% to 48% among
females and from 23% to 61% among men.
Conclusions:
The strong association between alcohol use and having multiple
sexual partners underscores the need to educate young people
about the effects of alcohol on partner choice and the risk of
infection with sexually transmitted diseases.
Family Planning Perspectives, 1998, 30(6):271-275
Sexually
transmitted diseases (STDs) are enormously costly to society in
terms both of human pain and suffering and of health care
expenditures. Among their consequences, STDs are potent
cofactors in the sexual transmission of HIV.1
Of an estimated 12 million new STD infections that occur each
year in the United States, three million occur among people
younger than 20, and another four million occur among those aged
20-25.2
The probability of acquiring an STD is the product of several
risk factors, including age at first coitus, number of
concurrent or sequential sexual partners, use of barrier methods
of contraception, partner choice, prevalence of the disease in a
community, access to health services for treatable STDs and
biological factors, such as cervical ectopy (extension of the
cervical mucosa around the opening of the cervix into the
uterus).3
An adolescent whose only lifetime sexual partner has ever had
other partners is also at risk for STDs, particularly if the
partner comes from a community with a high prevalence of
infection.
Having multiple sexual partners represents an important
behavioral risk factor for STDs among adolescents and young
adults, especially if they fail to use condoms correctly and
consistently. Most teenagers do not have multiple concurrent
sexual partners; however, because many adolescent relationships
are of short duration, teenagers often have multiple sequential
partners.
Previous research has demonstrated that adolescents are more
likely than adults to report having had multiple sexual partners
in the recent past.4
Adolescent males are more likely than adolescent females to
report multiple sexual partners and multiple concurrent
partners.5
The number of lifetime sexual partners among adolescents is
strongly related to the length of time since first coitus.6
Studies of primarily adult populations have identified several
demographic markers for multiple sexual partners; younger age
has consistently emerged as a risk marker. In the 1988 National
Survey of Family Growth, among women 15-44 years old, risk
factors for having more than one partner in the previous three
months included having been young at first coitus, being younger
than 30, being unmarried, living in an urban area, having an
income below 200% of the poverty line, working outside the home
and having no religious affiliation. Unmarried teenagers were
about as likely as unmarried women in their 20s to have had
multiple partners.7
Similarly, in the National AIDS Behavioral Surveys, risk factors
for multiple partners in the past year among 18-75-year-old men
and women included male gender, younger age, unmarried status,
urban residence and higher educational status (for whites).8
Because of difficulties in obtaining accurate reports about a
sexual partner's other relationships, few studies have been able
to measure the STD risk associated with having a sexual partner
who is not monogamous, although attempts have been made to
estimate this risk.9
For a variety of social, physiological and individual reasons,
alcohol and drug use among adolescents may influence sexual
behavior, including an individual's number of partners. Use of
alcohol and other substances has been associated with sexual
risk behavior in some studies,10
but most of these have focused on condom use. Prior use of
alcohol and drugs greatly increases the risk of early initiation
of sexual intercourse,11
and beginning intercourse at a young age, having multiple
partners and failing to use condoms are interrelated.12
Given the relationship between multiple sexual partners and
STDs, the purpose of our study was to examine potential risk
factors associated with having multiple sexual partners among
youth in the United States. Our analysis was guided by three
questions: What is the prevalence of having multiple partners
among U.S. adolescents and young adults? After controlling for
demographic factors, are young people's risk behaviors,
particularly alcohol or drug use and early onset of sexual
intercourse, associated with having multiple partners? Finally,
what is the relationship between a young person's number of
sexual partners and his or her condom use? (The last question is
important because individuals with multiple partners have the
greatest need to use condoms.)
METHODS
Data
Data for our analyses are from the 1992 National Health
Interview Survey (NHIS) and Youth Risk Behavior Survey (YRBS).
The NHIS is an annual household interview survey of the
civilian, noninstitutionalized population of the United States;
the survey uses a multistage probability cluster design to
obtain data representative of the U.S. population, and it
oversamples minority families.13
The 1992 YRBS was conducted as a supplement to the 1992 NHIS.
The 1992 NHIS enumerated all 12-21-year-olds from sampled
households, including those who were married and those who were
living away from their family of origin. YRBS respondents were
randomly selected from this list. Out-of-school youth were
oversampled; one in-school and up to two out-of-school youth
were selected from each family. A weighting factor was applied
to each YRBS record to adjust for oversampling and nonresponse.
The final sample was weighted to be representative of the
population of youth aged 12-21 residing in U.S. households.
Youth were surveyed approximately two months after the initial
household survey. Data collection used audio interview
technology; participants privately listened through headphones
to a tape recording of the questionnaire, and they recorded
their responses on a standardized answer sheet. This technique
was used to address young people's potential concerns about
confidentiality with in-home interviewing. Most data included in
our analysis were reported by the respondent, but the youth's
race, ethnicity, residence and marital status were reported by
the adult who completed the core NHIS interview.
Of the 13,789 youth aged 12-21 who were selected at the time of
the core survey, 10,645 (77%) were located and agreed to be
interviewed. Our analysis excluded the 2,195 respondents aged
12-13, because the survey for this age-group did not ask about
their sexual activity; the resulting sample consisted of 8,450
youth, including 126 who were 21 years of age at the time of the
core NHIS but had turned 22 by the time of the YRBS.
We limited our analysis of lifetime sexual partners to the 5,223
respondents who were sexually experienced (i.e., had ever had
sexual intercourse). Analyses related to the number of recent
sexual partners and condom use were restricted to the 4,075
young people who were currently sexually active (i.e., had had
intercourse in the previous three months). Specific analyses are
based only on respondents who answered the relevant questions.
ANALYTIC
TECHNIQUES
We used factor analysis to create scales for various risk
behaviors. We initially examined items related to drug and
alcohol use, weapon carrying and fighting, and age at first
sexual intercourse. Males and females showed similar factor
structures. Initial factor analysis suggested that risk
behaviors clustered into two factors: one for substance use and
one including weapon carrying, fighting and age at first
intercourse. The second factor showed poor internal consistency
and could not be used to create a homogeneous scale.
After orthogonal rotation, substance use could be divided into
two factors with eigen values of one or greater. The first
factor described alcohol use and included five items: ever-use
of alcohol, binge drinking (i.e., five or more drinks in a row)
in the past 30 days, alcohol or other drug use immediately
before the most recent intercourse, riding with a drinking
driver in the past 30 days and driving immediately after
drinking in the past 30 days. The second factor described
illicit drug use and included three items: ever-use of
marijuana, cocaine and other illicit drugs.
These factors were incorporated into scales for alcohol use (Cronbach
alpha=.70 for males and .63 for females) and illicit drug use (Cronbach
alpha=.71 for males and .68 for females). Scores were determined
by the number of behaviors in which the adolescent had
participated. A score of zero, for example, meant that none of
the behaviors applied.
Because the number of sexual partners is highly skewed, we
dichotomized each dependent variable and used logistic
regression to estimate the independent influence of the
predictors. The number of recent sexual partners was
dichotomized as one versus two or more. Lifetime partners was
dichotomized as 1-5 versus six or more. In building logistic
models, we first examined cross-tabulations to identify
potential independent predictors of multiple sexual partners.
We conducted separate analyses for males and females. Regression
analyses used SUDAAN software to account for the complex,
weighted sampling design. Variables evaluated as potential
predictors included demographic characteristics (age; race or
ethnicity; marital status; and urban, rural or suburban
residence), the scales for alcohol and illicit drug use, and a
sexual behavior variable (age at first coitus). Generally, we
entered demographic factors first into each logistic analysis.
We also assessed interactions between significant demographic
variables and each independent variable or scale.
We used direct standardization with sample weights in SUDAAN to
demonstrate the independent effect of the alcohol scale on
having multiple sexual partners in the previous three months.
Probabilities were standardized for age, race or ethnicity,
marital status and age at first intercourse. SUDAAN was used to
calculate 95% confidence intervals for estimates. All estimates
were based on weighted data.
RESULTS
In all, 63% of females and 64% of males in our sample were
sexually experienced (Table 1). Most sexually experienced
respondents (72% of females and 50% of males) reported having
had one partner in the past three months, although sizable
proportions reported no recent partners (15% and 24%,
respectively) or more than one (13% and 26%, respectively).
Among those who were currently sexually active, 35% of males and
15% of females reported two or more sexual partners in the
previous three months (not shown).
|
Table 1. Percentage of 14-22-year-old respondents who
were sexually experienced, and percentage distribution
of sexually experienced respondents, by number of
partners in the past three months, according to gender,
Youth Risk Behavior Survey, 1992 |
|
Measure |
Females (N=4,223) |
Males (N=3,949)</< td> |
|
% sexually experienced |
62.5 (±1.9) |
63.5 (±1.8) |
|
% distribution by no. of recent partners |
|
0 |
15.4 (±1.7) |
24.3 (±2.0) |
|
1 |
71.8 (±2.0) |
49.5 (±2.2) |
|
2 |
8.2 (±1.2) |
12.2 (±1.4) |
|
>=3 |
4.6 (±0.9) |
14.0 (±1.5) |
|
Total |
100.0 |
100.0 |
|
Note:
Figures in parentheses are 95% confidence limits. |
At every age, most sexually experienced young people reported
two or more lifetime partners (Table 2). A progression to
multiple lifetime partners was apparent even among 14- and
15-year-olds. The proportion of sexually experienced youth
reporting six or more lifetime sexual partners rose from 8% at
age 14 to 31% at age 21 among females and from 14% to 45% among
males. Correspondingly, the proportion reporting one lifetime
partner declined steadily with age. Among 21-year-olds, only 20%
of sexually experienced females and 13% of sexually experienced
males reported a single lifetime partner.
|
Table 2. Percentage distribution of sexually experienced
respondents, by lifetime number of sexual partners,
according to current age and gender |
|
No. of partners |
Age |
|
14 |
15 |
16 |
17 |
18 |
19 |
20 |
21 |
|
Females |
(N=101) |
(N=185) |
(N=260) |
(N=301) |
(N=320) |
(N=384) |
(N=508) |
(N=503) |
|
1 |
43.6 |
41.8 |
45.6 |
36.8 |
33.8 |
29.4 |
23.7 |
19.7 |
|
2 |
31.2 |
22.6 |
20.6 |
20.3 |
16.5 |
15.6 |
13.4 |
13.9 |
|
3 |
10.3 |
9.9 |
11.8 |
15.1 |
19.1 |
12.2 |
13.8 |
15.1 |
|
4 |
5.7 |
6.6 |
6.1 |
8.1 |
7.9 |
10.3 |
11.4 |
11.9 |
|
5 |
1.7 |
5.1 |
4.0 |
6.8 |
6.9 |
8.4 |
7.5 |
8.2 |
|
>=6 |
7.5 |
13.8 |
11.9 |
12.9 |
15.9 |
24.1 |
30.3 |
31.1 |
|
Males |
(N=134) |
(N=198) |
(N=269) |
(N=310) |
(N=329) |
(N=350) |
(N=429) |
(N=407) |
|
1 |
44.3 |
38.1 |
32.5 |
27.0 |
28.5 |
19.3 |
15.3 |
13.2 |
|
2 |
16.7 |
14.8 |
12.0 |
16.4 |
10.5 |
14.3 |
14.6 |
13.8 |
|
3 |
13.5 |
17.1 |
15.4 |
14.3 |
10.6 |
15.2 |
9.8 |
12.1 |
|
4 |
2.5 |
8.0 |
7.2 |
9.2 |
9.2 |
5.6 |
10.9 |
8.1 |
|
5 |
9.3 |
2.5 |
4.3 |
8.6 |
9.8 |
7.1 |
4.8 |
7.8 |
|
>=6 |
13.8 |
19.5 |
28.7 |
24.5 |
31.5 |
38.5 |
44.7 |
45.0 |
|
Total |
100.0 |
100.0 |
100.0 |
100.0 |
100.0 |
100.0 |
100.0 |
100.0 |
|
Note:
The number of 22-year-olds was too small for analysis. |
Next, we examined cross-tabulations between an individual's
number of recent sexual partners and potential risk factors (not
shown). For females and males, age at first intercourse, alcohol
use and illicit drug use were related to the number of sexual
partners in the past three months. The proportion who had had
multiple partners in the past three months increased from 7%
among currently sexually active females who reported no
alcohol-related behaviors to 61% among those who reported all
five behaviors; among males, these proportions were 28% and 65%,
respectively.
Married males and females had had fewer recent partners than
their single counterparts. Among females, age, race or ethnicity
and urban residence showed little relationship to the number of
recent partners. Black males and males living in urban areas
were somewhat more likely to report two or more partners than
were those in other racial or ethnic groups and residents of
nonurban areas.
Results of the first set of logistic regression analyses (Table
3) revealed that among those who were currently sexually active,
married females were significantly less likely than their
never-married counterparts to have had multiple partners in the
past three months (odds ratio, 0.4). Alcohol use substantially
raised the probability that a female had recently had multiple
partners; the odds ratio (1.7) indicates that for each
alcohol-related behavior a young woman reported, the likelihood
that she had had multiple partners increased by about 70%.
Illicit drug use also had a significant, although smaller,
effect (1.2). Finally, young women who first had sex before age
14 were about twice as likely to have had multiple partners as
were those whose first intercourse occurred at age 16 or later
(2.0).
|
Table 3. Odds ratios reflecting the likelihood that
currently sexually active respondents aged 14-22 had two
or more sexual partners in the past three months, by
various characteristics, according to gender |
|
Characteristic |
Females (N=2,049) |
Males (N=1,688) |
|
Age |
0.98 (0.91-1.06) |
0.98 (0.91-1.06) |
|
Race/ethnicity |
|
Black |
1.37 (0.94-1.98) |
2.81* (1.86-4.24) |
|
Hispanic |
1.11 (0.72-1.72) |
1.43* (1.02-2.00) |
|
White |
1.00 |
1.00 |
|
Residence |
|
Urban |
† |
1.22 (0.88-1.69) |
|
Rural |
† |
1.01 (0.73-1.39) |
|
Suburban |
† |
1.00 |
|
Marital status |
|
Married |
0.35* (0.22-0.55) |
0.11* (0.05-0.22) |
|
Widowed/divorced/separated |
0.80 (0.23-2.73) |
0.68 (0.17-2.64) |
|
Never-married |
1.00 |
1.00 |
|
Alcohol use score‡ |
1.68* (1.49-1.91) |
1.60* (1.44-1.77) |
|
Illicit drug use score§ |
1.22* (1.02-1.45) |
0.96 (0.83-1.12) |
|
Age at first intercourse |
|
=<13 |
1.98* (1.26-3.11) |
3.52* (2.46-5.04) |
|
14-15 |
1.25 (0.85-1.83) |
2.18* (1.56-3.03) |
|
>=16 |
1.00 |
1.00 |
|
*p<.05.†Residence was not statistically significant for
females and was therefore excluded from the analysis.
‡Six-point use scale with a range of 0-5. §Four-point
use scale with a range of 0-3. Notes: For
categorical variables, the reference group consists of
currently sexually active youth who had one partner in
the past three months. For age, the odds ratio
represents the change in likelihood associated with each
additional year of age; for the scored variables, the
odds ratio represents the change associated with each
one-point increase in the score. Figures in parentheses
are 95% confidence intervals. |
For currently sexually active males, many of the results were
similar to those for females. Being married lowered the
probability of having had multiple partners (0.1), and alcohol
use substantially increased the odds (1.6). Early initiation of
sexual intercourse raised the probability of multiple partners,
and the effect was greater than for females. However, several
notable differences also emerged. Black and Hispanic males were
significantly more likely than whites to report multiple
partners in the past three months (odds ratios, 2.8 and 1.4,
respectively); illicit drug use did not affect the odds.
Urban residence was not significant in the final calculations
for males. However, because of multicollinearity between race or
ethnicity and urban status, we reran the analyses with race or
ethnicity removed (not shown). In these calculations, urban
residents were significantly more likely than suburban males to
have had multiple partners (odds ratio, 1.5; p<.001).
The analyses estimating the effects of various factors on the
odds of having had six or more lifetime sexual partners yielded
generally similar results for each gender (Table 4). Alcohol use
and illicit drug use showed substantial impact for both (odds
ratios, 1.4-1.9). Older current age and earlier age at sexual
initiation significantly increased the odds of having had six or
more lifetime partners; this finding is not surprising, since
both of these factors increase the period of time that a person
has been sexually active. Black and Hispanic respondents were
significantly more likely than their white peers to report six
or more lifetime partners (odds ratios, 1.4-2.6), with one
exception: Hispanic females had a reduced probability of this
outcome (0.4).
|
Table 4. Odds reflecting the likelihood that sexually
experienced respondents aged 14-22 have had six or more
lifetime sexual partners, by various characteristics,
according to gender |
|
Characteristic |
Females (N=2,459) |
Males( N=2,263) |
|
Age |
1.39* (1.31-1.48) |
1.43* (1.35-1.52) |
|
Race/ethnicity |
|
Black |
1.69* (1.13-2.54) |
2.63* (1.91-3.62) |
|
Hispanic |
0.42* (0.24-0.73) |
1.39* (1.01-1.93) |
|
White |
1.00 |
1.00 |
|
Alcohol use score† |
1.40* (1.26-1.56) |
1.36* (1.23-1.50) |
|
Illicit drug use score‡ |
1.94* (1.69-2.22) |
1.49* (1.29-1.72) |
|
Age at first intercourse |
|
=<13 |
6.81* (4.57-10.15) |
12.54* (8.86-17.74) |
|
14-15 |
2.41* (1.81-3.20) |
4.99* (3.66-6.79) |
|
>=16 |
1.00 |
1.00 |
|
*p<.05. †Six-point use scale with a range of 0-5.
‡Four-point use scale with a range of 0-3. Notes:
See notes to Table 3. |
Next, using direct standardization, we adjusted for the
influence of age, race or ethnicity, marital status and age at
first intercourse to examine the independent influence of
alcohol on having multiple sexual partners. As the alcohol-use
scale increased, the probability of reporting multiple partners
rose dramatically (Table 5). Only 8% of currently sexually
active females reporting no alcohol-related behaviors had had
two or more sexual partners in the previous three months,
compared with 48% reporting all five behaviors; among males,
these proportions were 23% and 61%, respectively.
|
Table 5. Standardized percentage of currently sexually
active respondents aged 14-22 who had two or more sexual
partners in the past three months, by alcohol use score,
according to gender |
|
Alcohol use score |
Females |
Males |
|
0 |
8.0 (±4.9) |
23.3 (±5.6) |
|
1 |
8.4 (±2.0) |
23.8 (±3.6) |
|
2 |
12.4 (±3.2) |
28.5 (±3.7) |
|
3 |
20.1 (±3.7) |
38.1 (±5.0) |
|
4 |
27.3 (±5.3) |
39.6 (±5.1) |
|
5 |
47.8 (±6.0) |
60.8 (±6.8) |
|
Notes:
Percentages are standardized by age, race or ethnicity,
marital status and age at first sexual intercourse.
Figures in parentheses are 95% confidence intervals. |
Finally, we examined the association between having multiple
partners and condom use. Overall, 35% of currently sexually
active females and 53% of similar males said they had used
condoms at last intercourse (Table 6). Condom use at last
intercourse showed no relationship with the number of partners
in the past three months. Respondents who had not had sex in the
previous three months were more likely than those who were
currently sexually active to have used a condom the last time
they had intercourse (not shown).
|
Table 6. Percentage of currently sexually active
respondents aged 14-22 who used a condom at last
intercourse, by number of partners in the past three
months, according to gender |
|
No. of partners |
Females |
Males |
|
Total |
35.4 (±2.6) |
52.5 (±2.7) |
|
1 |
36.0 (±2.7) |
50.2 (±3.3) |
|
2 |
30.6 (±7.7) |
55.9 (±6.6) |
|
>=3 |
34.5 (±9.5) |
57.8 (±6.2) |
|
Note:
Figures in parentheses are 95% confidence intervals. |
DISCUSSION
Our analyses yield findings that will be of use to health care
practitioners and health educators seeking to reduce
adolescents' risk of infection with HIV and other STDs. We found
that most sexually experienced youth at every age have had two
or more lifetime sexual partners, and many have had six or more.
Many young people have recently had multiple sexual partners,
which should not be unexpected, given the instability of many
relationships among adolescents and young adults.
Consistent with earlier studies, involving primarily adult
samples,14
we find that demographic factors and early age at first
intercourse are associated with young people's odds of having
had multiple partners. Additionally, however, our analyses
reveal that alcohol and drug use are significant determinants of
their lifetime number of partners, and alcohol-related behavior
is one of the most important risk factors for multiple sexual
partners in the recent past.
The association between alcohol or other drug use and risky
sexual behavior may be explained through social, physiological
or individual mechanisms.15
Alcohol may disinhibit judgment and behavior via physiological
or socially learned mechanisms. Alternatively, a youth's
personal characteristics (e.g., a risk-taking personality
profile) or social environment (situational factors) may lead
both to alcohol or drug use and to risky sexual activity.
The relationship between alcohol use and multiple sexual
partners meets three criteria for suggesting causation on the
basis of epidemiologic data: a strong association, evidence of a
dose-response relationship and biological plausibility.16
We believe that these data are consistent with several
explanations for the effect of alcohol. Further research is
needed into the mechanisms by which alcohol influences the
initiation of new sexual partnerships.
Our finding of an association between a past event (early
initiation of intercourse) and current behavior (having multiple
partners in a three-month period) is consistent with findings
from other studies that age at first intercourse is a risk
marker for sexual risk behavior, such as failing to use condoms17
and having multiple sexual partners,18
long after sexual initiation. This association suggests the
influence of a relatively stable personality
characteristic—perhaps "unconventionality," as described in
problem behavior theory,19
or a biological predisposition to "sensation-seeking."20
The development of young adults' risk behaviors is influenced by
a complex set of biological, social environmental, perceived
environmental, personality and behavioral factors.21
Early initiation of intercourse has been related to sexual
abuse,22
which may influence personality variables such as self-esteem
and perceived value of health that, in turn, could influence
decisions about sexual partners.
Our data show both similarities and differences in numbers of
sexual partners by gender. Adolescent males were more likely
than females to report multiple partners, both in the past three
months and over their lifetime. Sexually experienced males were
also more likely to report having had no partners in the
previous three months. These patterns suggest fundamental
differences in the stability of relationships for males and
females, and may reflect different approaches to experiencing
and understanding sexual relationships. Despite these
differences, similar sets of risk factors were associated with
multiple partners among males and females.
In considering our results, it is important to be aware of
certain limitations of the analysis. The YRBS was designed as a
behavioral surveillance tool, not as a method of providing
in-depth information about particular behaviors. It offers
little information about peer norms, personality traits or
factors such as self-efficacy that may influence decision-making
about sexual partners, or same-sex sexual behaviors. In
addition, although the YRBS had good test-retest reliability,
self-reported sexual behaviors are difficult to validate.23
An important limitation of cross-sectional surveys that
enumerate respondents' recent or lifetime sexual partners is
that they do not distinguish between sequential and concurrent
partners. Further, an enumeration of sexual partners provides no
information about partner characteristics that may be related to
behavioral risk factors associated with STDs. Nor does the
number of sexual partners directly translate into the risk of
STD infection, which also depends on such factors as STD
prevalence and use of barrier protection. On the other hand, the
number of partners as a summary measure has emerged in many
studies as an important behavioral risk factor for STD
transmission.24
Another limitation of cross-sectional surveys is that whereas
they can find associations among behaviors, they cannot prove
causality.
Thus, although more research is needed, it is clear that health
care practitioners and health educators need to stress the
connections among alcohol use, multiple sexual partners and the
risk of infection with HIV and other STDs. Counseling and
education should help adolescents and young adults understand
the potentially negative effect of drinking on judgment about
partner choice and the connection between the use of alcohol or
other drugs and risky sexual behaviors in certain social
contexts.
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