Sex, Alcohol and Sexually Transmitted Diseases: A National Survey.(Statistical Data Included)

The analysis of a representative national survey of households provides strong evidence that alcohol overshadows illicit drug use as a risk factor for sexually transmitted diseases (STDs). Men and women who report a history of STDs are significantly more likely to have a history of problem drinking, independent of high-risk sexual activities and demographic characteristics. However, a high rate of change in sexual partners over the past five years also increases the chance of STD infection. Sexual orientation is a major STD risk factor among men but not among women. Although both black men and black women are at greater risk of STDs than are those in other racial or ethnic groups, results indicate that black women's greater likelihood of having sex with men who have multiple partners, rather than their own rates of partner change, makes the crucial difference between their risk and that of white women.

(Family Planning Perspectives, 26:257-263, 1994)

Much attention is being paid to the increase in sexually transmitted diseases (STDs) in the United States. Unlike other industrialized nations, where STD prevalence rates have remained low, America is currently experiencing a rapid rise in the incidence of the "classic" STDs, such as gonorrhea, syphilis, chlamydia and genital herpes. In 1990. an estimated 12-13 million cases of STDs were diagnosed, including four million new cases of chlamydia, three million of trichomonas and 1-2 million each of genital herpes and warts. (1) Although rates of infection with Neisseria gonorrhoeae have continued the decline that began in the 1970s, the number of gonorrheal infections involving strains resistant to antibiotics has accelerated recently, (2) and current estimates indicate that more than 10% of gonorrheal infections nationwide are resistant to penicillin. (3)

Perhaps most striking is the astronomical rise in cases of syphilis during the past few years, specifically the increase between 1985 and 1989 from 11.4 reported cases per 100,000 population to 18.4 per 100,000. (4) According to recent prevalence estimates, at least 30 million Americans are infected with genital herpes, and 24-40 million people are infected with human papillomavirus, the virus that produces genital warts. Asymptomatic chlamydial infection occurs in up to 5% of women and about 10% of men, and 2.5 million women are estimated to contract chlamydia each year. (5) Gonorrhea and chlamydia are especially dangerous to women, since they are often asymptomatic or produce ambiguous symptoms: One study found that 80% of women diagnosed for chlamydia were asymptomatic. (6)

One reason for the renewed concern about STDs is the mounting evidence of a direct biomedical association between STDs and human immunodeficiency virus (HIV) infection. Infection with STDs that create ulcers (i.e., syphilis, chancroid, herpes and perhaps chlamydia), as well as possibly the discharges from gonorrhea, chlamydia and trichomonas, are thought to increase one's vulnerability to HIV infection. (7) There is also strong evidence that STDs and HIV infection share the same cofactors, especially among heterosexuals. In fact, the World Health Organization Global Programme on AIDS recently made STD tracking and prevention a major priority.

A second reason for the increased focus on STDs is their serious implications for women's reproductive health. Between 10% and 40% of women with an untreated chlamydial or gonorrheal infection can develop pelvic inflammatory disease, which in turn can lead to infertility, tubal pregnancy and fetal wastage, as well as to infections in the offspring of infected mothers. Syphilis increases a woman's risk of miscarriage and stillbirth and leads to syphilis infection of the newborn. In fact, if rates of congenital syphilis are added to current rates of syphilis infection, overall syphilis rates are even higher. (8) Even when it is asymptomatic, genital herpes can be transmitted to the newborn and can infect the infant's central nervous system. An estimated 65% of untreated infected infants will die and fewer than 10% of surviving infants with central nervous system infection will develop normally. (9)

The role that frequent change of sexual partners plays in STD transmission is well established: Having a greater number and variety of sexual partners increases one's likelihood that any randomly chosen partner will be infected, especially a partner who can be considered a member of a "core group" of those who transmit STDs. Increases in STD rates in the general population have been attributed to the behavior of subgroups of individuals who have more than the average number of sexual partners.

Recent national surveys indicate that the vast majority of Americans have a very low rate of change in partners, with 88% having had either no partner or only one in the last year. However, about 10% of Americans report having had 2-4 partners during the last 12 months. (10) Because STDs are spread into the general population by sexual contact between members of such a core group and individuals outside the core, research and social policy have been focused on determining the size of the core group and the demographic and behavioral characteristics associated with high rates of change in sexual partners.

Attention must also be directed to the implications of the large gender gap in patterns of sexual behavior, women's greater likelihood of remaining infected for longer durations and differential access to medical diagnosis and treatment. Women have far fewer sexual partners than men, begin sexual activity at a much later age, and in adulthood are more likely than men to be monogamous. (11) Since many STDs are asymptomatic, women may remain infected longer than men, and thus may transmit the disease to a partner regardless of their rates of partner change. Diagnosis and treatment for STDs depends to a large extent on the type of health facility a woman visits, her geographic location, her race or ethnicity, her pregnancy status and a variety of other factors. (12) Thus, patterns of STD rates among Americans reveal as much about gender differences in social relationships and in personal behavior as they do about the transmission of viruses and bacteria.

The central role of drug use in high-risk sexual behavior is also widely acknowledged, especially among high-risk subgroups. Inner-city residents, among whom STD rates have reached epidemic proportions, are characterized as having a pattern of trading sex for drugs, especially crack cocaine. (13) Heavy drinking has been implicated in the spread of AIDS in subgroups of homosexual men engaging in sexual risk-taking, (14) although research on drinking and disease transmission has been masked by the greater concern with the role of drugs.

Media campaigns on AIDs prevention focus specifically on educating the public about the connection between drinking, drug use and high-risk sex. One argument is that drinking during sexual encounters leads to irresponsible sexual behavior, such as the indiscriminate choice of sexual partners, engaging in prostitution to purchase drugs, and a reduced likelihood of using condoms to protect against STDs. The empirical support for this argument, however, is not entirely dear. (15)

The purpose of this article is to examine the demographic and behavioral context of STD rates in the American population. The data set provides a unique opportunity to investigate the relationships between drinking, high-risk sex and STDs, since it is the only national study to have investigated American drinking patterns and drug use in conjunction with sexual behavior and STD history. Studies of STD cofactors typically rely on convenience samples for whom medical diagnoses are available, such as women attending family planning clinics, local community samples and high-risk groups. Although the Centers for Disease Control and Prevention routinely publish the number of new cases of reportable diseases, they exclude not only chiamydia, but also many STD cases diagnosed by private practitioners, who do not always report them. Moreover, not all states report all STDs, so that CDC reports do not offer comprehensive coverage of STD incidence and prevalence throughout the U. S. population.…