Article Abstract

Article Abstract

Online ISSN: 1099-176X Print ISSN: 1091-4358
The Journal of Mental Health Policy and Economics
Volume 16, Issue 4, 2013. Pages: 187-208
Published Online: 1 December 2013

Mental Health and Risky Sexual Behaviors: Evidence from DSM-IV Axis II Disorders

Johanna Catherine Maclean,¹* Haiyong Xu,² Michael T. French,³ Susan L. Ettner⁴

¹Ph.D., Assistant Professor, Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
²Ph.D., Assistant Researcher, Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at the University of California Los Angeles, CA, USA
³Ph.D., Professor and Director, Health Economics Research Group, Department of Sociology, and Department of Public Health Sciences, University of Miami, FL, USA
⁴Ph.D., Professor; Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine and Department of Health Services, Jonathan and Karin Fielding School of Public Health at the University of California Los Angeles, CA, USA.

* Correspondence to: Johanna Catherine Maclean, Ph.D., Assistant Professor, Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania; 1316 Blockley Hall, 423 Guardian Drive, Philadelphia PA, 19104, USA.
Tel.: +1-215-746 8682
Fax: +1-215-746 8209
E-mail: macleanc@upenn.edu

Source of Funding: None declared.

Abstract

In this study we examine the associations between DSM-IV Axis II personality disorders (A2) and risky sexual behaviors as measured by early initiation into sexual activity, and past regular use of alcohol before sex and sexually transmitted disease diagnosis. A2 disorders are a poorly understood, yet prevalent and disabling class of mental health conditions. Common features include poor impulse control, addiction, social isolation, and elevated sexual desires, although the defining features vary across disorder. Thus, A2s are conceptually linked with risky sexual behaviors. We find that A2 disorders are generally associated with an increase in the probability of risky sexual behaviors among both men and women, and the associations vary substantially across specific disorders. Inclusion of A1 disorders (e.g., depression, substance abuse) in our regression models attenuates estimated associations for some risky sexual behaviors among men, but not for women. These findings have implications for sexual health intervention development.

Background: Several economic studies link poor mental health and substance misuse with risky sexual behaviors. However, none have examined the relationships between DSM-IV Axis II mental health disorders (A2s) and risky sexual behaviors. A2 disorders are a poorly understood, yet prevalent and disabling class of mental health conditions. They develop early in life through an interaction of genetics and environment, and are persistent across the life course. Common features include poor impulse control, addiction, social isolation, and elevated sexual desires, although the defining features vary substantially across disorder.

Aims of the Study: To investigate the association between A2 disorders and three measures of risky sexual behavior.

Methods: We obtain data on adults age 20 to 50 years from Wave II of the National Epidemiological Survey of Alcohol and Related Conditions (NESARC). Our outcome measures include early initiation into sexual activity, and past year regular use of alcohol before sex and sexually transmitted disease diagnosis. NESARC administrators use the Alcohol Use Disorder and Associated Disabilities Interview Schedule to classify respondents as meeting criteria for the ten A2 disorders recognized by the American Psychiatric Association. We construct several measures of A2 disorders based on the NESARC administrators' classifications. Given their comorbidity with A2 disorders, we explore the importance of Axis I disorders in the estimated associations.

Results: We find that A2 disorders are generally associated with an increase in the probability of risky sexual behaviors among both men and women. In specifications that disaggregate disorders into clusters and specific conditions, the significant associations are not uniform, but are broadly consistent with the defining features of the cluster or disorder. Inclusion of A1 disorders attenuates estimated associations for some risky sexual behaviors among men, but not for women.

Discussion: We find positive associations between A2 disorders and our measures of risky sexual behaviors. Our findings are subject to several data limitations, however. The NESARC lacks information on more advanced risky sexual behaviors and our measure of early initiation into sexual activity is retrospective. Identifying the causal effects of mental health and risky sexual behaviors is complicated due to bias from reverse causality and omitted variables. We believe these sources of bias are less of a concern in our study, however. Specifically, A2 disorders develop early in life and pre-date the risky sexual behaviors, thus negating reverse causality. Because the NESARC contains a rich set of personal characteristics, we are also able to minimize potential omitted variable bias.

Implications for Health Care Provision and Use: A2 disorders are significantly associated with risky sexual behaviors, which could lead to greater utilization and cost of health care services.

Implication for Health Policies: Health care providers should consider A2 disorders when developing health promotion recommendations as these disorders may place individuals at elevated risk for unsafe sexual behaviors.

Implications for Further Research: Future studies should examine the causal mechanisms between A2 disorders and risky sexual behaviors.

Received 8 May 2013; accepted 2 October 2013