Alcohol use and unintended sexual consequences among women attending an urban STI clinic

Introduction

Alcohol use has been linked to a variety of risky sexual behaviors (Corte, 2005), (Logan, Cole, & Leukefeld, 2002). Women who drink alcohol are more likely to have sex with multiple or casual sex partners (Cooper, 2002), engage more frequently in anal intercourse (Hutton, McCaul, Santora, & Erbelding, 2008), may be less likely to use condoms, and are more likely to be victims of sexual assault (Maria Testa & Livingston, 2009). Women attending STD clinics may be particularly vulnerable to the sexual consequences associated with drinking, as they report higher levels of hazardous alcohol use, increased frequency of risky sexual behaviors, and are connected to higher risk sexual networks (Hutton, McCaul, Santora, & Erbelding, 2008) (Scott-Sheldon, Senn, Carey, Urban, & Carey, 2013). This illustrates the importance of understanding the link between alcohol use and sexual activity among this clinic population.

Qualitative analyses among adolescents, men who have sex with men (MSM), and college students have provided important insight into the complex relationship between alcohol use and sexual behavior. Such qualitative explorations inform our understanding of how individuals experience and perceive the sexual consequences of drinking and the broader contexts in which these events occur. These studies illustrate that alcohol is perceived by adolescents as having a variety of roles in sexual consequences, ranging from impaired assessment of a person's attractiveness to complete loss of control and alcohol related amnesia (Coleman & Cater, 2005). Adolescents view alcohol as facilitating and excusing desired sexual interactions, while also impairing decision-making and increasing vulnerability to unwanted sexual advances (Livingston, Bay-Cheng, Hequembourg, Testa, & Downs, 2012). Meanwhile, qualitative studies among MSM have found that alcohol use facilitates engaging in stigmatized sexual behaviors (Parsons et al., 2004), and may be a barrier to discussing PrEP with casual partners (Mimiaga, Closson, Kothary, & Mitty, 2014). Among college students qualitative studies focused on the role of alcohol in sexual violence illustrate how alcohol use interacts with gender norms to facilitate sexual victimization (Cowley, 2013).

Although past qualitative analyses have shed light on the complex relationship between sexual health and alcohol use, qualitative explorations of this link among adult urban women are sparse. Our prior qualitative work among women attending an urban STI clinic specifically focused on sex-related alcohol expectancies and illuminated reasons why women drink, including to increase sexual desire and sexual power (Hutton et al., 2014). The next step in this work is to examine what precise sexual events occur when women drink that may lead to emotional or physical harms. The purpose of this study was to qualitatively explore the subjective experiences of unintended sexual events occurring while drinking among urban women attending a public STI clinic. Further insight into alcohol use and its perceived role in these events is an essential step to informing both quantitative analyses and future interventions seeking to reduce the harm associated with drinking.

METHODS

Study Design, setting and participants

We performed a secondary data analysis of 20 semi-structured, face-to-face in-depth interviews conducted between December 2009 and August 2010 with 20 sexually active adult women attending a Baltimore City Health Department STI Clinic.

We purposively sampled women age 18 or greater, presenting for care in the STI clinic, whom reported either binge drinking (4 or more drinks on one occasion) in the past six months or engaging in vaginal or anal intercourse while under the influence of alcohol. Providers at the clinic were provided with inclusion criteria, and all participants were recruited through provider referral. No participants were excluded from the study. Informed consent was obtained in a private room by a research coordinator. Participants were told that the purpose of the study was to understand the reasons they may drink alcohol before or during social situations or situations with a sexual partner and how alcohol affects their decisions in risky situations. The study purpose, procedures and risks were reviewed with participants as described in the informed consent form (ICF). Their understanding of study purpose, procedures and risks was then assessed through a predetermined set of standard questions.

Participants received $35.00 for their time and transportation. No women refused to participate in the study. We collected demographic information and administered the Alcohol Use Disorders Identification Test-C (AUDIT-C) (Reinert & Allen, 2007). Interviews were conducted by a female clinical psychologist (HH) or a female physician (GC). Interviews were conducted using a semi-structured guide, which allowed for probing and clarification regarding alcohol and sexual activity (Bernard 2010). Interviews lasted on average one hour. The guide queried situations or moods that increased the likelihood of drinking alcohol, alcohol and sexual risk behaviors, condom and sex partners, and consequences of alcohol use. Participants were continuously enrolled until thematic saturation was obtained for the primary research question. Saturation was defined as the point at which no new information or themes were observed in the data (Greg Guest, 2006). The study was approved by the Johns Hopkins University School of Medicine Institutional Review Board and the Baltimore City Health Department.

Data analysis

Interviews were audio-recorded and transcribed verbatim. Transcribed interviews were reviewed and coded iteratively until saturation was reached using a grounded theory approach (Charmaz, 2006). Data were initially organized in ATLAS-ti (2010) qualitative software. Two graduate-level research assistants with advanced training in qualitative interviewing coded the data. Concepts were viewed as grounded in the data, leading successive phases of analysis to identify themes as they emerged through a process of coding.

On secondary analysis, a medical student with previous qualitative experience (DL) and a nurse practitioner (TA) queried codes related events occurring while drinking (including sexual, social and violent events). These events were used to guide the creation of a second codebook. Codes in the first five interviews were categorized, collapsed and reordered to create a secondary, agreed upon, codebook. Memos were created and shared, further informing the codebook and the themes that emerged. Codes fell into one of four categories: perceived physiological effects of alcohol (termed “states”), including alcohol's affect on moods, awareness, and judgment; individual events occurring while drinking (termed “events”), including sexual, violent, and social events; longer term consequences of these events (termed “outcomes”), including emotional, legal, and health consequences; and factors other than alcohol consumption that played a role in events (termed “influences”), including environmental factors and actions of others. Remaining interviews were coded iteratively, whereby new domains that emerged across interviews subsequent to the development of codebook led to additions and alterations to the codebook that was then re-applied to interviews. Data were managed in excel. All discrepancies were resolved with consensus.

The research team then analyzed all events and selected those that had potential sexual health consequences, including STIs, unintended pregnancy, and sexual trauma. “Outcomes” codes from the interviews guided this selection, and there was consensus among researchers as to which events had immediate relevance to sexual health. Individual events were then analyzed as to whether they were desired or undesired, and intended or unintended. Ambiguous codes were labeled as such. Sexual events that were both undesired and unintended were used to generate themes. Accounts of violent rape were coded and analyzed separately.

In the final phase, the themes that emerged were linked to corresponding “states” and “outcomes” codes to allow for more in-depth exploration of the themes. An additional theme arose from the “influence” code, which we have included in our analysis due to its ubiquity and relevance to the identified themes. Overall intercoder agreement was 85%.

RESULTS

The 20 participants were African American women with a median age of 24.5 years (SD=9.67). Ninety-five percent (95%) had completed high school or the equivalent. Their average AUDIT-C (Reinert & Allen, 2007) score was 7.1 (SD=2.81); a score of 3 indicates a strong likelihood of hazardous alcohol consumption. Ten percent of participants scored between 0 and 2 on the AUDIC-C, 40% between 3 and 5, and 50% scored ≥6 (indicating high risk drinking). In the past 3 months, 19 of 20 women had engaged in anal or vaginal intercourse. Of these, 19 women had sex with somebody they consider to be a main partner, 7 with a casual partner, and 4 with an unknown partner.

Five major unintended sexual consequences emerged from the interviews: alcohol and new partners, alcohol and alternative sexual activities, alcohol and unprotected sex, alcohol and blacked out sex, and alcohol and rape. All events occurred with males with the exception of an identified alternative sexual activity, group sex. Themes often overlapped, and sexual victimization was a common thread throughout multiple themes. An additional theme, “alcohol and prey,” emerged as an important precursor to many of the sexual events described, and will thus be examined first in order to provide context for the remainder of the results.

Alcohol and prey

Most participants described that drinking, and sometimes simply being in a bar, made them prey to male predators. As one participant explained, when a woman drinks, “she might as well put the target on her back, because you're definitely vulnerable at that point”(4).

Participant 17 explained this vulnerability to targeting that many participants spoke of:

Yeah, girls like easier when they're drunk...And when you're easy, you can easily persuade us, manipulate us. All that. When you're drunk. You just say whatever that click inside. (17)

Participants said that men were keenly aware of this fact, and would take advantage of women who were drunk. Men were described as “opportunists” and “vultures” who specifically target women who have been drinking:

Some guys will not come up to a girl, will not pay attention to a girl, until he knows that she's had drinks because then it's not the same result as if she was sober when he talks to her...it's open season. (1)

Not only were men said to target women who were already drinking, but also took an active role in getting women drunk. Participant 5 described men as “roaches” who “feed” and then “wait for the food to come out.”

They think if they get you drunk enough they have a chance of taking you home....That's the mission for the guys in the bar, to see who they can take home, and for a woman your mission should be to not get that wasted, that somebody can just take you home... A battle....And this guy will put two drinks in your hands at one time, but before you can finish this one he's bringing you another one and he'll sit there all night, you know, small conversation. ‘You want another one? You good? You're sure? You want a shot?’ You know, all night, and they'll sit like vultures and wait and see who's stumbled off the bed frame or who falls down the steps and they're usually the victims. (5)

Although some participants enjoyed the attention and free drinks from men, others explained its dangerous consequences:

But not knowing that this man is buying you this drink to get in your pants, and you know, he's buying a big bottle so you can get really, really wasted----then you wake up with your pants down and he's gone, nowhere to be found. (10)

Participants were more vulnerable when alone, and thus were more likely to be targeted when at a bar or a club alone, without friends.

...You're by yourself, you have no one watching your back, you know, and then the guys in the establishment, they're watching all that and they realize, ‘okay, we got one.’ (19)

Alcohol and sex with new partners

Women reported having sex with new partners—often strangers—while under the influence of alcohol. These were usually individuals who they wouldn't have had sex with had they been sober.

I've had sex with guys that if I'm sober, I wouldn't even speak to. (16)

Many participants spoke about how alcohol made men appear more physically attractive:

I've heard the saying where when it's light when you're in a club and you're drinking, a person who looks so good, how do you say? Just look like whatever, a million bucks. You wake up next to him in the morning he looks like ten cent. They don't look good no more because you're not drunk any more.... It's not night lights any more, so now you can see.... (11)

Alcohol led participants to make assumptions about new partners, in turn, making them less concerned about the consequences of leaving a bar with a stranger than they would have otherwise been.

The liquor is telling them, ‘Girl, he okay. He don't got no AIDS. He probably got children.’ They don't care....They're so caught up in the heat of passion. And in their eyes, he ain't got no flaws. He ain't got nothing. Nothing wrong with him. He the perfect man. (2)

Other participants said that it was alcohol's effect on their own sexual desire that made them more likely to have sex with new partners when drinking:

... If you're already drunk off of alcohol, somebody may touch you and it may turn you on...It could be an ugly person who can touch you, and he could be the ugliest dude in the world where if you were sober, you wouldn't dare. (11)

Yet, participants’ descriptions of having sex with new partners were rarely in terms of alcohol's effect on women's decision-making, preferences, or desires alone. Participant 18 explained how men use women's vulnerability to manipulate them:

Because she can't say yes, and she can't say no. She can't say whether she want it and whether she does not want it. She can probably say to herself, ‘I'm horny,’ and maybe the guy hear...’I know that she's easy, so I can get her, quick.’ (18)

One participant—after waking up next to a man she was no longer attracted to sober— explained what it felt like the following morning:

...the regret and the consequences come to mind. Like what the hell was this? Like get out, like that type of thing...I cannot believe I just did that. (13)

Alcohol and alternative sexual activities

Every participant felt that alcohol use resulted in their engaging in types of sexual activity that they wouldn't have engaged in sober--most commonly anal sex, “rough” sex, group sex and oral sex. While some participants said they desired certain types of sexual activity when drunk, these new types of sexual activity were often not due to participants’ new or heightened desires, but rather an increased willingness to appease a partner.

I never did anal sex until I was drunk one time. So (alcohol) will do that...It's like with alcohol, I don't know...I ain't going to say it's hard to say no, but you're more likely to say yeah.... Like because, you know, that might ask and you'll be like, nah, kind of not want to do it. And they'll just keep, you know, begging and trying to persuade them. And eventually, you're like okay, I'll try it. (16)

Participant 2 discussed how alcohol makes one do “crazy things you don't want to do” like anal sex or S&M (sadomasochism), even if “your body is rejecting it saying it's not (okay).” She then described the “numbing” effect of alcohol on the body:

But then your body get this numbness to it .... So anything that you're not willing to do...it could be painful and as long as it's not too much pain to you, in your mind, you're just feeling numbness. That's all you feel is pleasure. (2)

Similar to the previous theme, men were often described as taking advantage of women in order to try sexual acts that women may oppose sober. One participant described this in terms of anal sex:

You know, they'll let them do that when, if they were sober, oh, no, we're not going there, but they're drunk out of their mind and the guy just totally just takes advantage of them and does whatever--and they have no means to say stop, anything like that, because they're so out of it. (19)

Participants commonly described how sex became more rough or aggressive with alcohol. Rough and aggressive sex included pulling hair, scratching backs, using handcuffs, fighting, and choking. Sometimes, rough sex was the result of both partners becoming more aggressive. As one participant explained, men may “entice women with the alcohol to get them to be more aggressive in the bedroom” (4).

Yet, participants also described being solely on the receiving side of the aggression. In this context, men were rougher during sex than they would be if sober because the alcohol made women less likely to resist the aggression.

Some guys like to be real rough. They like, you know, they know, she's drunk, she can't do nothing, so I'm going to take advantage of her. So, he'll tend to get, you know, choke up a little bit, it ain't choking her to hurt her, it's choking her to make him feel better. Like, you know, that's what he likes. (10)

This same participant recognized the danger of rough sex:

Yeah, it could get dangerous. Like I said, a guy don't know his own strength.....You know, he don't know his own strength, and about women being so weak and vulnerable... (10)

Alcohol and blacked out sex

Many participants discussed alcohol related amnesia. There were many personal accounts of participants “blacking out” and waking up uncertain about the past night's activities. Participants woke up uncertain where they were, whom they were with, whether they had had sex, or whether the sex had been protected.

So, you basically don't have a thought or a memory of what's going on, or how you doing it, or why you doing it. You just know that the liquor is tasting good, you drinking it, and you were blank in your mind. But, when you wake up, you don't remember what happened last night. (18)

Although blacked out sex wasn't always viewed negatively when it occurred with a sexual partner, participants expressed regret and emotion surrounding blacking out with a stranger.

You just feel like, like, real, you feel bad, because you know, you don't know this person, you don't know their name, you wake up in a bed next to them, like, who is this? And, just be feeling like, kind of, I don't know how to describe it, just I don't know. Bad, because you just drunk too much, don't even know who you woke up with the next day. (9)

Other times, participants felt a great deal of anxiety after blacking out, largely over what sexual activities took place and whether it was protected.

Then you feel bad, wash yourself in the morning, and you're thinking like ‘What? Did I use a condom? Did I give him some head? Hopefully I didn't.’ You know. (5)

You trying to be remembering, figuring out what you did or what you didn't do...It's like a state of panic for a minute until you can get yourself together and recall the night before, if you can recall the night before....It's like waking up from all being in a coma or something. (6)

Alcohol and unprotected sex

Every participant said unprotected sex was more likely to occur when drinking. Often, participants said that alcohol made them less concerned about the consequences of unprotected sex:

It makes you more subject to say yes instead of saying no, and not even think about using protection or the consequences. Once you're drinking, consequences go out the door. (6)

Participants often spoke of the worry and intense fear following an unprotected sexual encounter, even if it didn't result in an STI or pregnancy.

I just didn't think about it. He didn't think about it until I realized, you know, it was over. Then I realized he didn't put a condom on so it was like...Hopefully I didn't get knocked up or get a disease. And that's scary because until your pregnant...or until you get another check up the first tingle you get you are running to the doctor.’ (5)

Another participant described similar feelings of worry after having unprotected sex:

I've had one sexual experience where I had drank to the point where I knew I was too far gone, and we had sex and I didn't even think about asking about a condom. It was just in the motions of I'm aroused...And, of course, the day after, it was like, ‘Oh crap,’ and immediately went to the clinic. Oh no, I can't. This is bad. Bad, bad decision. (1)

Alcohol and rape

As this analysis was looking at unintended, unwanted events occurring when drinking, in all of the themes that emerged, there were events that likely met legal and research definitions of alcohol-involved rape. However, participants seldom used the word rape to describe incidences of incapacitated rape. One participant acknowledged this and explained:

I think it's common to be raped and not even really admit that you have been raped, not even knowing if you've been raped. You just think he was rough with you or something. And because you were drunk, they just think they were taken advantage of instead of just being raped. (6)

Another participant echoed this sentiment:

You don't know what's going on. It's not clicking in your head, oh, you're assaulting me. (18)

Although incapacitated rape was seldom referred to with the word “rape”, participants were more likely to label forcible rape as such. One participant described the inherent danger in leaving the bar incapacitated with a stranger when you aren't sober enough to fight for yourself:

You can even get yourself raped and beat up real bad or even killed--because you're not in your right frame of mind and everything is like a blur, you know. So they can really escalate and then you don't know your partner, you wind up in places that you shouldn't even be at, half the time you don't even know where you're at... and the next thing you know, you're in a situation that you can't get out of, about time you realize what's going on, you know, you're so drunk, you can't even fight them off... (19)

Another participant described how having sex with a stranger can lead to rape.

...The various things about alcohol is that you can go all the way or you can have a moment of clarity and say no... So, men they're not going to hear no....They're going to hear ‘well, she wanted it. And I gave it to her’...While you're saying no all the time....And so, if you undress and unclothe and you start and then you have a moment of clarity, then it's hard for them to stop because that was their motive and hidden agenda from the beginning....So, they're not going to stop. (7)

A few participants described personal accounts of forcible rape in which they believed alcohol played a role by increasing their likelihood of being in a risky situation— either alone on the streets or with a dangerous stranger.

I had missed my ride. So, I got a ride with this guy that I didn't know... And, he knew that I was drunk, so instead of him taking me to where I wanted to go, he took me back to his house, and he raped me. (18)

Another participant was attacked on the street by a group of teenagers after she left a club.

I walked a little ways trying to catch a cab and I ended up getting raped...I was kind of beating myself up about it ...I shouldn't have been drunk like that, you know, I was drunk ....And the police officers made me feel bad because they were like ‘Well, were you looking for drugs’ or you know, and I was like ‘Sir, what part do you not get? I was catching a cab to go home.’ (5)

Discussion

This qualitative study highlights the spectrum of unintended sexual consequences of alcohol use experienced by urban women attending an STI clinic. Five major unintended sexual consequences emerged from the interviews: alcohol and new partners, alcohol and alternative sexual activities, alcohol and unprotected sex, alcohol and blacked out sex, and alcohol and rape. Becoming “prey” was a common precursor to the other consequences of alcohol use described by women and sexual victimization was pervasive throughout these interviews.

Our primary analysis of these data focused on sex related alcohol expectancies (SRAEs), or women's beliefs about effects of alcohol consumption on sexual behavior (Hutton et al., 2014). Some enhancement SRAEs that emerged included increased sex drive and pleasure from sex and increased boldness and power during sex. While positive experiences likely inform these SRAEs, they stand in stark contrast to the unintended sexual events that emerged in this secondary analysis. This illustrates how perilous alcohol use can be in particular contexts, regardless of expectations women may have for the contrary.

Sexual victimization, including rape, attempted rape, verbally coerced intercourse, and unwanted sexual contact, permeated throughout almost all of the themes. “Alcohol and prey” emerged as an independent theme that helped explain the context in which this victimization occurred. Participants felt that alcohol played a role in unintended sexual events not simply by affecting their own judgment or desires, but rather by making them vulnerable to male targeting and pressure. Men were described as “vultures” who not only targeted women who were already drinking, but also took an active role in getting women drunk. Experimental studies have shown that men rate women who are drinking as being more sexually available (George, Cue, Lopez, Crowe, & Norris, 1995). Research has also illustrated a number of ways in which perpetrators intentionally use alcohol to facilitate sexual assault, including opportunistic preying on incapacitated persons and pressure to consume alcohol (Koss et al., 2007). A recent observational study of sexual aggression in clubs and bars found that individuals initiating sexual aggression were more invasive when targets were intoxicated, regardless of their own level of intoxication, further supporting the idea that women are intentionally targeted when drinking (Graham et al., 2014). Interestingly, although becoming “prey” commonly preceded the sexual events identified by participants, few participants described the events as rape. The most recent version of the Sexual Experiences Survey (SES) assesses alcohol-involved rape in surveys with the phrase: “taking advantage of me when I was too drunk or out of it to stop what was happening”(Koss et al., 2007). Although defining alcohol-involved rape is complex and debated, using the SES framework, alcohol-involved rape was ubiquitous throughout most of the themes identified.

Sex with new partners and strangers emerged as one of the consequences experienced by women when drinking alcohol. Prior studies among single adult women have demonstrated that a woman is more likely to have sex with a man she just met when alcohol is involved (Maria Testa & Lorraine, 1997). Our research further elucidates this, suggesting that becoming prey contributes to increased likelihood of sex following alcohol consumption. In addition to becoming prey, our results illustrate that other factors, including decreased partner selectivity also play a role. This is consistent with quantitative analyses. Alcohol has been found to be associated with impaired judgment and risk assessment (George & Stoner, 2000), (Maria Testa, 2011). An experimental study found that single, young women rate hypothetical male characters in vignettes more positively and anticipated less risk when under the influence of alcohol (M Testa, Livingston, & Collins, 2000). Alcohol's effect on subjective sexual arousal may also play a role in sexual risk taking (George et al., 2009), supporting participant claims of increased sexual desire following drinking. These potential effects of alcohol on participants—impaired judgment, increased sexual arousal, and decreased partner selectivity—become dangerous when placed in the context of male targeting of women, and research has documented that repercussions of rape are substantial regardless of whether acknowledged by the victim (Koss et al., 2007). In addition to increasing women's vulnerability to violence and rape, sex with new or unknown partners in the context of alcohol use may increase participant vulnerability to STIs and HIV, as research suggests that alcohol use and partner type interact to affect condom use. Although condom use generally increases during sexual encounters with non-primary sexual partners, research also shows that that when drinking occurs preceding or during such encounters, women report less condom use (Scott-Sheldon et al., 2009).

Blacked-out sex, or alcohol-related amnesia following a sexual encounter, also emerged as an unintended consequence occurring while drinking. The majority of research on blacking out has been conducted among adolescents, college students, or hospitalized males (Mundt, Zakletskaia, Brown, & Fleming, 2012) (White, Signer, Kraus, & Swartzwelder, 2004). Our study illustrates that adult women attending STI clinics also experience alcohol related amnesia, resulting in sexual activity that cannot be remembered the following day. Participants described waking up uncertain where they were, whom they were with, whether they had had sex, or whether the sex had been protected. These events were particularly concerning for alcohol-involved rape, yet similar to sex with new partners, they were seldom acknowledged by participants as such.

In our study, women also reported that alcohol use resulted in their engaging in sexual activities that they may have avoided when sober, including rough or aggressive sex, and anal sex. While our previous analysis found that some women intentionally drink to engage in anal sex (Hutton et al., 2014), participants also described being so drunk that they were less likely or even unable to physically or verbally resist a man's attempt to engage in anal sex. Other participants discussed how alcohol made them more likely to engage in “rough” sex (including pulling hair, hitting and choking) or BDSM (Bondage/Discipline-dominance/Submission-sadism/Masochism). Past research has identified “rough sex” as a risk factor for condom breaking (Rugpao et al., 1997), (Bradley et al., 2012), yet, rough sex remains largely undescribed in peer reviewed literature. That said, many BDSM experts acknowledge that substance abuse negates consent (Bonomi, Altenburger, & Walton, 2013), and rough sex in the context of drinking becomes especially difficult to interpret as consensual, and undoubtedly carries greater risks, as acknowledged by one of the participants. This is a topic that warrants further investigation, particularly as violence against women becomes increasingly depicted in popular culture, normalizing violence in sexual acts (Bonomi et al., 2014).

The final major theme identified in our study was rape. Participants saw forcible rape as distinct from incapacitated and alcohol-facilitated rape, and a few participants described instances of forcible rape in which they believed alcohol played a role, largely by increasing their likelihood of leaving a bar alone or with a stranger. This demonstrates that the role of alcohol is perceived as multifaceted, and its effects on both the woman's judgment and the behaviors of the perpetrator are both felt to increase one's risk of experiencing rape. Moreover, because sexual vulnerability associated with drinking alcohol may reflect risk associated with the settings in which alcohol is consumed (Maria Testa, Hoffman, & Livingston, 2010), individuals drinking in certain risky environments may be at an increased risk for sexual victimization. Although urban social environments are not well studied, research has begun to document high levels of sexual victimization in urban nightclubs (Kavanaugh, 2013)(Graham et al., 2014), which our results corroborate and further extend to what happens when women leave these environments.

Our themes have remarkable overlap with qualitative findings among adolescents, MSM, and college students. Themes that have emerged in these previous studies include, among others, increased vulnerability to unwanted sexual advances, engaging in stigmatized sexual behaviors, impaired assessment of a person's attractiveness, and the role of alcohol in sexual violence (Coleman & Cater, 2005) (Cowley, 2013)(Livingston et al., 2012)(Mimiaga et al., 2014)(Parsons et al., 2004). Thus, it appears that unwanted sexual experiences occurring in the context of alcohol consumption cuts across sexual orientation, age and environment. Yet, our results also demonstrate nuanced experiences and perceptions that may not be generalizable to these other populations, such as the way in which “rough sex” blurs the line between incapacitated and forcible rape.

Our study has limitations. This study was conducted at a single site at an urban STI clinic among a population reporting high-risk sexual activity and binge drinking. Thus, these findings cannot be applied to other populations. Yet, the fact that all participants were attending an STI clinic may be used to pave the way for tailored, targeted interventions at non-traditional health settings. Moreover, although not inclusion criteria, all of the participants we enrolled were African American and primarily had sex with men. Although this does not capture the full range of women who attend urban STI clinics, it does reflect this reflect the demographic of the women who attend this STI clinic. Another limitation is that this study examined very broadly the role of alcohol in sexual consequences, and did not stratify each unintended event by contextual factors such as severity of alcohol use or the presence of an alcohol use disorder, level of intoxication, location of alcohol consumption, or partner type. All of these factors undoubtedly affect the sexual consequences that emerged, and should be further studied in quantitative analyses.

Implications for policy and/or practice

Policy initiatives and interventions are needed to reduce alcohol-related sexual harms among urban women. Existing interventions to date have been piloted primarily on college campuses (Potter, Moynihan, Stapleton, & Banyard, 2009). Given that themes emerging in this study overlap with findings among other populations, existing alcohol interventions may be able to be tailored for delivery in alternate settings such as urban STI and other community clinics. Particularly promising are those interventions aimed at addressing the discrepancy between what women expect to happen when they drink (alcohol expectancy) and what may actually end up occurring. A meta analysis found that such “expectancy challenge” interventions resulted in lower reported positive alcohol expectancies, reduced alcohol use, and reduced frequency of heavy drinking among college students (Scott-Sheldon, Terry, Carey, Garey, & Carey, 2012).

Yet, consequences associated with risky drinking cannot be addressed by focusing solely on the alcohol consumption and behaviors of women. Given that the vast majority of consequences identified were in part the result of being targeted by others, interventions geared towards men will be crucial to reducing sexual consequences occurring while drinking. Qualitative studies among men attending urban STI clinics will help better understand how men experience and perceive of alcohol and sex, and may inform more complete interventions.

Conclusion

We found that among this sample of women attending an urban STI clinic, alcohol use was associated with a variety of unintended sexual consequences. These findings extend work done among college students and MSM to urban women, primarily drinking in bar settings, who accessed a public STI clinic. Furthermore, these results illustrate how perilous alcohol use can be in particular contexts, and reflect ways in which alcohol may be related to a woman's risk for emotional and physical harms including sexual victimization and exposure to HIV and other STIs.