Relationship Between Alcohol Consumption and Risky Sexual Behaviors Among Adolescents and Young Adults: A Meta-Analysis
Abstract
Objectives: Adolescents exposed to alcohol have increased risky sexual behaviors (RSBs); however, the association between alcohol consumption and RSBs has to be systematically and quantitatively reviewed. We conducted a meta-analysis of the literature to systematically and quantitatively review the association between alcohol consumption and RSBs in adolescents and young adults.
Methods: We searched for qualified articles published from 2000 to 2020 and calculated pooled odds ratios (ORs) using the random-effect model. We also conducted meta-regression and sensitivity analyses to identify potential heterogeneity moderators.
Results: The meta-analysis of 50 studies involving 465,595 adolescents and young adults indicated that alcohol consumption was significantly associated with early sexual initiation (OR = 1.958, 95% confidence interval (CI) = 1.635–2.346), inconsistent condom use (OR = 1.228, 95% CI = 1.114–1.354), and having multiple sexual partners (OR = 1.722, 95% CI = 1.525–1.945).
Conclusion: Alcohol consumption is strongly associated with RSBs, including early sexual initiation, inconsistent condom use, and multiple sexual partners among adolescents and young adults. To prevent the adverse consequences of alcohol consumption, drinking prevention programs should be initiated at an early age and supported by homes, schools, and communities.
Introduction
Alcohol consumption in adolescence can affect hormone secretion and the brain, disrupting secondary sex characteristics and damaging brain cells (1). Alcohol consumption at an early age causes disability and accounts for 13.5% of deaths among those aged 20 to 39, causing social and economic losses across our society along with health issues (2). According to the World Health Organization (WHO), 26.5% of all adolescents aged 15–19 years of age worldwide are current drinkers, which is approximately 155 million adolescents. The highest prevalence rates of current drinking are in the WHO European Region (43.8%), followed by the Region of the Americas (38.2%) and the Western Pacific Region (37.9%). While heavy episodic drinking (HED) is less common among adolescents than in the total population, it peaks at the age of 20–24 years, with prevalence rates among drinkers in this age group higher than in the total population, except in the Eastern Mediterranean Region. Among current drinkers aged 15–24 years, prevalence of HED is high among men, with some studies reporting rates as high as 54.2% (3).
Alcohol consumption during adolescence is one of the factors that increase risky sexual behaviors (RSBs) (4, 5). Adolescents with substance abuse issues, specifically alcohol abuse, had approximately twice as many sexual partners and were 70% more likely to be diagnosed with sexually transmitted diseases (STDs) than adolescents without substance abuse issues (6). According to the literature on the relationship between alcohol consumption and early sexual experience in middle school students: Yu et al (7) reported a 2.35-fold increase in early sexual initiation when drinking alcohol, Hong et al (8) reported a 1.43-fold increase, Ayhan et al (9) reported a 2.13-fold increase, and Bersamin et al. (10) reported a 7.4-fold increase.
Depending on the study, the age of first sexual experience among adolescents varies, with Korean adolescents having their first sexual experience at 13.2 years old on average (11), specifically 12.1 years for boys and 13.9 years for girls. Ayhan et al (9) indicated that the first sexual experience occurred before the age of 14 in most studies. In particular, 13.4% of female adolescents had their first sexual experience after drinking alcohol (5). This early sexual debut increases the risk of unwanted pregnancy and STDs (12). Adolescents not using a condom during sexual experiences was reported at 34.4% in a study by Wilson, Asbridge et al (13), 46.9% in a study by Rios-Zertuche et al (14), and 41.1% in a study by Mlunde et al (15), thereby demonstrating that the rate of condom use among adolescents is very low. Alcohol consumption in adolescents is one of the factors for increasing inconsistent condom use, and Sanchez et al (16) reported that 57.1% of adolescents with drinking alcohol experience did not use condoms during sexual intercourse. The most used definition of binge drinking in research is based on the National Institute on Alcohol Abuse and Alcoholism (NIAAA)’s definition of a pattern of drinking that brings a person’s blood alcohol concentration (BAC) to 0.08 g/dL or higher, which is typically reached after consuming 4 drinks for women or 5 drinks for men within 2 h (17). This definition is consistent with that used by Wilson et al (13) who found that binge drinking, as defined by the NIAAA, increased inconsistent condom use by 1.1 times among adolescents, and Sanchez et al (16) reported this to be 1.27 times. Inconsistent condom use in adolescents can increase the prevalence of STDs and lead to teenage pregnancies (18).
Alcohol consumption in adolescents increases the probability of having more than three sexual partners by 3.37 times (19). Particularly, compared to female adolescents, male adolescents have a 2.9-fold increase in the likelihood of having multiple sexual partners (13). Moreover, the number of sexual partners increased by 2.41 times in current binge drinkers compared to current light drinkers. Drinking alcohol during adolescence increases the likelihood of regretting having sexual intercourse (19), and if they continue to abuse alcohol after adolescence, these sexual behaviors will likely continue into adulthood (20).
Therefore, alcohol consumption during sexual intercourse reduces sexual inhibition and increases RSBs by impacting adolescents’ judgment. However, studies analyzing the relationship between alcohol consumption and RSBs among adolescents have measured alcohol consumption in various ways according to fragmentary questions, amount of alcohol consumption (glass) or frequency of alcohol consumption, and time point (past alcohol consumption and current alcohol consumption). As the results differ by sex, it is difficult to synthesize and summarize the factors affecting alcohol consumption. Additionally, no meta-analysis has integrated each sex behavior by separating early sexual debut, inconsistent condom use, and multiple sexual partners for RSBs, which has a higher risk of STDs and teenage pregnancies—rather than integrating alcohol consumption and sexual experience. Thus, this study conducted a meta-analysis to identify the integrated effect of alcohol consumption in adolescents and young adults on the three types of RSBs and to determine whether the effect differs according to sex (male and female). Additionally, this study focused on analyzing the relationship between early sexual initiation, inconsistent condom use, and multiple sexual partners among RSBs due to alcohol consumption, and aimed to provide the derived results as fundamental data for health education and program development for safe sexual behaviors and prevention of alcohol consumption among adolescents and young adults.
Methods
Design
We conducted a systematic review and meta-analysis, following the protocol reported in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) Statement (21). The study protocol was registered with the PROSPERO database under the registration number CRD42022301637.
Search Strategy
Eight electronic bibliographic databases were used: Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library, EBSCO, PubMed, PsycINFO, Web of Science, Database Periodical Information Academic (DBpia, Korea), and Research Information Sharing Service (RISS, Korea). These were chosen since they comprehensively covered relevant literature in our field of study. Additionally, CINAHL, Cochrane Library, and PsycINFO are well-known and widely used databases in healthcare and psychology research, respectively. Korean databases, DBpia and RISS, allowed us to retrieve relevant studies published in the Korean language.
We conducted a comprehensive literature review using two search strategies. The first strategy was to select studies that investigated the relationship between alcohol consumption and RSBs and included alcohol consumption as an independent variable affecting RSBs from large systematic reviews of RSB-related factors in individuals, peers, schools, and communities. We used the general keywords “factor(s) AND sexual behavior” or “risky sexual behavior” and “adolescent(s) or young adult(s)” through the title and abstract fields to identify relevant articles published between January 2000 and July 2020. The process of literature search, screening, and selection is presented in a separate research article (Ahn and Yang, 2022) for more detailed information. In the systematic review (Ahn and Yang, 2022), we included studies that examined the relationship between self-esteem and RSBs. However, for this meta-analysis, we selected studies that investigated the association between alcohol consumption and RSBs. This distinction is highlighted in the study inclusion criteria and is further explained in Figure 1.
FIGURE 1
Flow chart of the selection process of studies included in the meta-analysis (Worldwide, 2001–2021).
The second search strategy used specific keywords to identify relevant articles. For example, in PubMed, we searched for articles using the following search terms: “Young Adult” [Mesh] OR “young adult*” OR “Adolescent” [Mesh] OR “adolescent*” OR “teen*” OR “youth*”), AND condom use (“Unsafe Sex” [Mesh] OR “unsafe sex” OR “unprotected sex” OR “high-risk sex” OR “unprotected intercourse” OR “condomless sex” OR “condom use” OR “condom compliance”) OR early sexual initiation (“Coitus” [Mesh] OR “Coitus” OR “First intercourse” OR “Sexual intercourse” OR “early sexual debut” OR “early sex*” OR “early sexual initiation”) OR multiple sexual partner (“Sexual Partners” [Mesh] OR “sexual partner*” OR “sex partner*” OR “multiple sexual partner*” OR “multiple sex partner*”).
Inclusion/Exclusion Criteria
Full-text versions of the retrieved articles were screened based on the pre-specified inclusion and exclusion criteria. The inclusion criteria were as follows: 1) target population aged 15–24; 2) investigating the association between alcohol consumption and RSBs; and 3) defined early sexual debut as initiation before the age of 14 years. The exclusion criteria were: 1) if the target populations were sexual minority youth (e.g., gay, bisexual, lesbian, homosexual, men who have sex with men, or transgender); specific population (homeless, juvenile, or military); 2) focusing on HIV (human immunodeficiency virus), STI (Sexually transmitted infections), or other mental health problems; 3) did not report the odds ratio of early sexual debut, inconsistent condom use, multiple sexual partners separately; 4) did not report direct alcohol consumption association; and 5) insufficient information to calculate effect size or insufficient effect size to convert to odd ratio. We excluded studies that focused on sexual minority youth because our primary focus was on the general adolescent population. While we acknowledge the importance of understanding the relationship between alcohol consumption and risky sexual behavior among sexual minority youth, we considered that the sexual behavior of sexual minority individuals might differ from that of heterosexual individuals.
Finally, we identified 50 articles through the two search strategies, with 24 and 26 articles selected through the first and second strategies, respectively. This comprehensive approach enabled us to identify all relevant studies published between January 2000 and July 2020 that investigated the relationship between alcohol consumption and RSB.
Data Extraction
Two independent researchers (CS and TK) conducted data extraction and study quality assessment, with a third researcher (YY) providing oversight to ensure accuracy and consistency. Any discrepancies between the two researchers were resolved through discussion and consensus. A standardized form was used to extract the following information: first author, year of publication, study country, total sample size, participant characteristics (e.g., mean age, gender distribution), measurements of alcohol consumption, and RSBs. OR and 95% CI for each type of RSB were abstracted by three researchers using a structured coding sheet. To reduce potential confounding variables and observational bias, adjusted estimates that controlled for demographic, individual, peer, school, and community variables were extracted if available. If multiple models were presented, we selected estimates from the last model that controlled for the most variables. This meta-analysis adhered to the Meta-Analysis of Observational Studies in Epidemiology Checklist, and the study selection flowchart was adapted from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement (22, 23).
Quality Assessment
The methodological quality of the primary studies in this meta-analysis was assessed using the Newcastle-Ottawa Scale (NOS) adapted for cross-sectional studies (24). The assessment tool consisted of seven items: selection (representativeness of the sample, sample size, non-respondents, ascertainment of the exposure (risk factor), comparability, and outcome (assessment of the outcome and statistical test). For each item criterion, a maximum of five points for selection, two points for comparability, and three points for outcome could be given and then summed to a maximum of 10 points. Quality assessment results were evaluated as “good” if the NOS score was 7 points or higher, “fair” if the score was 5 points or higher or less than 7 points, and “poor” if the score was less than 5 points. Each of the two researchers independently conducted the quality assessment of the studies included in the analysis, and the final assessment scores were obtained after discussing a few discrepancy items.
Data Analysis
The data analysis was conducted using Comprehensive Meta-Analysis (CMA) Version 3 software (Biostat, Englewood, NJ, United States). Odds ratios and corresponding 95% confidence intervals were used to estimate the association between alcohol consumption and RSBs (early sexual initiation, inconsistent condom use, and multiple sexual partners). The extent of heterogeneity among the primary studies was assessed using Cochrane’s Q test (reported with x2 and p values) and Higgins I2 value (25). An I2 value of up to 25% indicated low heterogeneity, 50% indicated moderate heterogeneity, and ≥75% indicated high heterogeneity (25). Publication bias was evaluated using a funnel plot, trim-fill analysis, and Egger’s regression test. Sensitivity analysis was conducted by removing each study and examining the effect size (26). The random effects model was used for the meta-analysis, and a meta-regression analysis was performed with sex as a control variable. The level of significance for all analyses in this study was determined using a two-tailed p value of <0.05 with 95% confidence intervals.
Results
Characteristics of Primary Studies
Fifty studies were included in the meta-analysis based on the selection criteria of this study and the Newcastle-Ottawa Scale (NOS) assessment (Table 1). These studies were published between 2002 and 2021, and among the included studies, most were published in 2009, 2013 (n = 6 studies), followed by 2010 (n = 5 studies), 2017 (n = 4 studies), 2018 (n = 4 studies), and 2021 (n = 4 studies). Most published studies were written in English (n = 47 studies), and three were written in Korean; among the 50 articles, most studies were conducted in the United States (n = 23 studies), and seven were conducted in Europe (Croatia, Finland, Ireland, and the United Kingdom) and Asia (South Korea, China, Hong Kong, and Japan).
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