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. Author manuscript; available in PMC: 2020 Sep 18.
Published in final edited form as: J Child Adolesc Subst Abuse. 2019 May 13;28(2):113–118. doi: 10.1080/1067828x.2019.1610679

Problem Solving Reduces Sexual Risk Associated with Sensation Seeking, Substance Use, and Depressive Symptoms Among African-American Adolescents

Eugene M Dunne 1,2, Alyssa L Norris 1,2, Daniel Romer 3, Ralph J DiClemente 4, Peter A Vanable 5, Robert F Valois 6, Larry K Brown 2, Michael P Carey 1,2,7
PMCID: PMC7500528  NIHMSID: NIHMS1534015  PMID: 32952380

Abstract

Objective:

African-American adolescents experience higher rates of sexually transmitted infections (STIs) compared to same-age Caucasian peers. Substance use, sensation seeking, and depression have all been linked to risky sexual practices. Theory suggests that problem-solving skills may help to buffer against these risk factors.

Method:

To test this hypothesis, we used data from African-American adolescents (N = 1018; M age = 16.7, SD = 1.1; 58% female) who participated in a prevention trial.

Results:

Nearly half of the sample (47%) reported lifetime marijuana use, while 13% reported drug use prior to most recent sexual encounter. Sexual sensation seeking was directly associated with drug use prior to sex (β = 1.13, b = 0.13,
SE = 0.02, p < .001) and lower problem-solving skills (β = −0.08, b = −0.06,
SE = 0.02, p = .01). Problem-solving skills were associated with drug use prior to sex (β = 0.92, b = −0.08, SE = 0.03, p = .004), such that those with greater problem-solving skills were less likely to report drug use prior to most recent sex. Lastly, problem solving skills mediated the association between sexual sensation seeking and drug use prior to sex, though the effect was small (β = 0.01, 95% CI: .001, .01).

Conclusions:

Problem-solving skills can have a protective influence on risky behavior for adolescents. Future research might examine the utility of strengthening problem-solving skills in order to reduce STI/HIV risk among African American adolescents.

Keywords: Adolescents, drug use, sexual sensation seeking, problem-solving

INTRODUCTION

Approximately half of newly diagnosed sexually transmitted infections occur among adolescents and young adults between the ages of 15 and 24 (Satterwhite et al., 2013). African American adolescents and young adults experience significant sexual health disparities, with higher rates of sexually transmitted infections compared to Caucasian Americans (Forhan et al., 2009; Mojola & Everett, 2012). Specifically, African American adolescents between the ages of 15 and 19 experience five times the rate of chlamydia, nine times the rate of syphilis, and twelve times the rate of gonorrhea compared to Caucasian adolescents (Centers for Disease Control and Prevention, 2017). Risky sexual behavior (e.g., condomless sex, concurrent partnerships) is the leading cause for sexually transmitted infections and unintended pregnancy, including HIV; therefore, it is critical to understand factors associated with adolescents’ engagement in such behavior.

Sexual sensation seeking in adolescents has been found to be associated with increased number of sexual partners, unprotected sexual intercourse, sex while high on alcohol or drugs, and higher rates of substance use (Oshri, Tubman, Morgan‐Lopez, Saavedra, & Csizmadia, 2013; Seth et al., 2011). Alcohol and other drug use is frequently associated with risky sexual behavior. A study of adolescent African-American females found that 38% reported having sex while under the influence of alcohol or drugs in the past sixty days (Seth et al., 2011). Further, substance use increases disinhibition (Skosnik, Spatz-Glenn, & Park, 2001) and risky decision making (Lane, Cherek, Tcheremissine, Lieving, & Pietras, 2005) among adolescents, thus increasing the likelihood of sexual risk. Adolescents reporting marijuana use prior to sex are less likely to report condom use, particularly when engaging in sexual activity with a partner they just met (Bryan, Schmiege, & Magnan, 2012). Furthermore, marijuana use before sex is associated with a more pleasurable experience per self-report (Sumnall, Beynon, Conchie, Riley, & Cole, 2007), which may reinforce this risky behavior.

Given these associations between substance use and risky sexual behavior, it is important to identify risk and protective factors that impact risky sexual decision-making. Mental health (e.g., depression) and personality factors (e.g., impulsivity, sensation seeking) are associated with both substance use and risky sexual behaviors. While the empirical literature is inconclusive, there is a growing literature that among adolescents, depression has been associated with inconsistent condom use, multiple partnerships, and sexual encounters while high on alcohol or drugs (Brawner, Gomes, Jemmott, Deatrick, & Coleman, 2012; Brown et al., 2006; Khan et al., 2009). A recent study found that the association between depressive symptoms and sexual risk was moderated by partner type (steady vs. casual), such that depressive symptoms were not associated with sexual risk in the context of a committed romantic relationship (Mendle, Ferrero, Moore, & Harden, 2013). Furthermore, depression appears to be a stronger predictor of sexual risk for female adolescents compared to males (Paxton & Robinson, 2008). Qualitative interviews with female African American adolescents suggest that sexual encounters may serve to “comfort” or self-medicate depressive symptoms, including loneliness and isolation (Brawner et al., 2012). With regards to substance use, depression appears to increase the risk of marijuana use among African American adolescent males (Repetto, Zimmerman, & Caldwell, 2008).

Theoretically, personal vulnerabilities to engaging in risky behavior are thought to be attenuated by the presence of individual (and social) protective factors. One identified protective factor is problem-solving skills, which has been found to reduce the risk of drug use prior to sexual behavior among adolescents (Teva, Bermúdez, & Buela-Casal, 2010). Problem-solving skills in the context of peer pressure is likely critical for impacting adolescent sexual risk behavior. Social norms, such as perceived condom use among peers, are a strong predictor of reported condom use among African American adolescents (Romer et al., 1994). A recent study of adolescent African American males found that peer norms were associated with number of sexual partners and condomless sexual encounters (Jones, Salazar, & Crosby, 2017). Taken together, problem-solving skills aimed at resisting peer influence may be valuable at reducing STIs and unplanned pregnancies. However, empirical research investigating the protective effects of problem-solving skills has been limited and demonstrated mixed results. For instance, problem solving appears to mediate the impact of personality factors on adolescent drug use, though the authors did not detect significant mediation of the relationship between sensation seeking personality and drug use (Jaffee & D’Zurilla, 2009). Additionally, extant research suggests that adolescents and young adults with depression may experience cognitive and motivational deficits that impair problem-solving skills (Kaslow, Tanenbaum, Abramson, Peterson, & Seligman, 1983). Although problem-solving in the context of social pressure might be an important target for prevention efforts, research is needed to clarify its relation to sexual risk behavior. To our knowledge, no study has investigated the effect of problem-solving on the association between sexual sensation seeking and sexual risk behavior among adolescents.

The current secondary data analysis aimed to examine associations among sexual sensation seeking, problem-solving, and self-reported drug use prior to most recent sexual encounter among African American adolescents. We use event-level data (i.e., “the last time you had sex…”) because this methodologic approach can provide more precise information compared to traditional cross-sectional methods (e.g., past month frequency). Based upon prior theory and research, we hypothesized that sexual sensation seeking and depressive symptoms would be positively associated with drug use prior to sex, whereas problem-solving would be negatively associated with drug use prior to most recent sex. We hypothesized that participants identified as being both high on sensation seeking and low on problem-solving skills would be at greatest risk of self-reported drug use prior to most recent sexual encounter. Lastly, we explored the potential mediating effect of problem-solving skills on the association between sensation seeking and drug use prior to sex.

METHOD

Sample

This study utilized data from a multi-site HIV-risk reduction intervention study, Project iMPPACS (“in Macon, Providence, Philadelphia, Atlanta, Columbia, and Syracuse”). The controlled prevention trial tested a multilevel intervention comprised of a mass media campaign and a small group, sexual health promotion intervention (Hennessy et al., 2013; Romer et al., 2009). Project iMPPACS included 1654 participants at baseline, of which 1518 were retained at 18-month follow up (92%). Male participants were slightly more likely to be lost to follow up.

The present sample (N = 1018) was restricted to African American adolescents who endorsed lifetime history of engaging in vaginal sex and who completed the 18-month follow up assessment, as this was the single time-point for measurement of a key factor (sexual sensation seeking) related to the specific aims of the current analyses. Participants provided written consent if they were 18 years of age at study enrollment, while adolescents under age 18 provided assent and parents/guardians provided consent. All study procedures were approved and monitored by Institutional Review Boards (IRBs) of the participating organizations.

Measures

Demographic Characteristics

Participants reported demographics, including age, sex, and racial/ethnic status.

Sexual Sensation Seeking

The nine-item Sexual Sensation Seeking scale (SSS) scale (Spitalnick et al., 2007) was specifically designed for adolescent African Americans. Examples of items include, “I enjoy having sex on the spur of the moment,” “Having sex with a new partner is exciting to me,” and “When it comes to sex, I’m willing to try anything.” Participants responded on a 4-point Likert scale ranging from “strongly disagree” to “strongly agree,” with higher scores indicating greater endorsement of sexual sensation seeking behavior. Internal consistency was α = .79.

Problem Solving

A six-item problem-solving scale assessed adolescents’ ability to work through problems when pressured by peers. Items on the current scale were representative of measures used to assess social problem-solving (D’Zurilla & Maydeu-Olivares, 1995; D’Zurilla & Nezu, 1990), with the additional focus on peer pressure, as this has been associated with increased sexual risk behavior (Romer et al., 1994). Each item began with the stem, “When pressured by friends to do things you don’t want to do, how often do you…” and concluded with different problem-solving skills, including delaying decision making, trying to get more details about the situation, weighing the positive and negative outcomes of the situation, and asking others for advice. Response options were presented on a 4-point Likert-type scale ranging from “never” to “always.” Higher scores indicate greater problem-solving skills.

Examination of the six items revealed two problem-solving skills that did not adequately load on the overall factor: “How often do you go with your gut” and “How often do you go with it, knowing you can change your mind later.” After retaining the four items with adequate loadings (communalities > .40) (Clark & Watson, 1995; Costello & Osborne, 2005), the problem-solving scale showed internal consistency of α = .83.

Depression

Depression was assessed using the short form of the Center for Epidemiological Studies – Depression scale (CES-D), which is among the most commonly used depression scales in public health research due to its strong psychometric properties (Radloff, 1977). The CES-D short form (Santor & Coyne, 1997) is an 8-item measure and uses a 4-point Likert-type scale, with higher scores indicating greater depressive symptoms. In the current sample, internal consistency of (α = .89) was observed for the CES-D short form

Substance Use Behavior

Participants self-reported lifetime and recent alcohol and drug use. Drug use prior to most recent vaginal sex encounter was assessed with a dichotomous (yes/no) response format. While the specific type of drug used prior to sex was not identified in the self-report item, all participants who endorsed drug use prior to sex reported a history of marijuana use, and only six participants also reported use of other substances (i.e., cocaine or speed). Questions were adapted from the Youth Risk Behavior Survey (YRBS) developed by the Centers for Disease Control and Prevention (Kolbe, Kann, & Collins, 1993). The YRBS items on sexual risk-taking and substance use had Kappa statistics ranging from 71.7 – 91.1 (Brener et al., 2002).

Statistical Analyses

Analyses were conducted using SPSS Version 22 (IBM Corp., 2013). Univariate analyses were conducted to ensure adequate psychometric properties of scales. A single participant had missing data on the Sexual Sensation Seeking Scale and was not included in the final analyses. Bivariate analyses (t-tests, chi-squares, correlations) examined associations among independent and dependent variables. To explore the potential mediating effect of problem-solving skills on the association between sexual sensation seeking and sexual risk, we used the PROCESS macro in SPSS with 5000 bootstrapped samples and bias-corrected confidence intervals (Hayes, 2016). Study site and intervention condition were included in regression analyses to account for potential effects. Relevant covariates were also included in the model based on significant associations with primary independent and dependent variables.

RESULTS

Participant Characteristics

Table 1 displays participant characteristics. Participants (N = 1018) ranged in age from 14 to 19 (M age = 16.6, SD = 1.1) at the time of the 18-month follow-up assessment. The majority (58%) of participants were female, while 41% were male. Approximately 63% of the sample reported a history of alcohol use. Less than 8% reported alcohol use prior to most recent sex. Nearly half of the sample (47%) reported lifetime marijuana use, while 129 (13%) adolescents reported drug use prior to most recent sexual encounter.

Table 1.

Sample Characteristics (N=1018)

N %
Sex
  Male 422 42
  Female 596 58
Study Site
  Syracuse, NYa 266 26
  Macon, GAa 277 27
  Providence, RIb 221 22
  Columbia, SCb 254 25
Small-Group Intervention
  Experimental Group 501 49
  Control Group 517 51
Marijuana Use, Lifetime
  No 325 32
  Yes 693 68
Drug Use Before Last Sex
  No 889 87
  Yes 129 13
Alcohol Use Before Last Sex
  No 938 92
  Yes 80 8
M SD
Age (Years) 16.7 1.1
Depression (CES-D), M (SD) 11.7 4.8
Sexual Sensation Seeking 17.2 4.7
Problem Solving 8.9 3.6
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Note: SSS = Sexual Sensation Seeking; CES-D = Center for Epidemiologic Studies Depression Scale

a

= intervention city

b

= control city

Bivariate Associations

Bivariate analyses (Table 2) suggest that male participants were more likely to report drug use prior to most recent sexual encounter. Further, youth reporting drug use prior to sex reported higher scores on sexual sensation seeking and depressive symptoms but lower scores on problem-solving skills.

Table 2.

Bivariate associations with drug use prior to sex.

r p
Male .111 <.001
Age .069 .027
Location −.013 .679
Intervention Condition −.003 .923
Marijuana Use, Lifetime .279 <.001
Problem-Solving −.073 .020
Sexual Sensation Seeking .198 <.001
Depression (CES-D) .118 <.001
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Note: CES-D = Center for Epidemiologic Studies Depression Scale

Mediation Analyses

Using the PROCESS macro (Hayes, 2016), problem-solving was explored as a mediator of the association between sexual sensation seeking and drug use prior to recent sex (Figure 1). First, sexual sensation seeking was directly associated with drug use prior to sex, such that youth higher in sexual sensation seeking were more likely to use drugs prior to sex (β = 1.13, b = 0.13,
SE = 0.02, p < .001). In the model including the mediator (Figure 1), sexual sensation seeking remained significantly associated with drug use prior to sex directly (b = 0.12, p < .001), but also indirectly via problem solving skills (β = 0.01, 95% Confidence Intervals: .001, .01). Specifically, sexual sensation seeking was associated with lower problem-solving skills (β = −0.08, b = −0.06,
SE = 0.02, p = .01), which were in turn associated with drug use prior to most recent sexual encounter (β = 0.92, b = −0.08, SE = 0.03, p = .004), such that those with greater problem-solving skills were less likely to report drug use prior to most recent sex. Overall, the mediated model accounted for 12% of the variance in drug use prior to most recent sex (Nagelkerke R2 = 0.12)

Figure 1.

Figure 1

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Problem-solving mediates association between sexual sensation seeking and drug use prior to sex.

DISCUSSION

The current study examined risk and protective factors associated with sexual risk behavior in a large sample of urban African-American adolescents. Participants were more likely to report drug use prior to most recent sex if they reported more depressive symptoms, greater sexual sensation seeking, and lower problem-solving skills. Further, problem solving skills mediated the impact of sexual sensation seeking on drug use prior to sex, suggesting that problem solving skills may represent a modifiable target for STI and HIV prevention interventions for African-American adolescents. Based on our review of the literature, the present study is among the first to document that problem-solving skills are associated with reduced risk of drug use prior to sex among high sensation seeking adolescents. Previous research has noted the utility of problem-solving in reducing substance use behavior among adolescents (Jaffee & D’Zurilla, 2009); this work extends that finding to sexual health behavior.

Problem solving skills are a potential direct, proximal target for intervention work with at-risk individuals (e.g., those high in sexual sensation seeking). Problem-solving skills related to social pressure may be particular relevant for adolescents, as peer influence is among the strongest predictors of sexual risk behavior for this group (Jones et al., 2017; Romer et al., 1994). Cognitive behavioral problem-solving therapy (PST) may be an effective approach to managing high-risk adolescents. PST has been found to reduce depressive symptoms among adolescents and young adults, with strong effect sizes when compared to no-treatment (e.g., wait-list) controls (Eskin, Ertekin, & Demir, 2008). A meta-analysis reviewing PST across all age groups concluded that PST was as effective as other psychological interventions and medications for treating depression (Bell & D’Zurilla, 2009). Although traditional cognitive behavioral therapy (CBT) focuses on identifying and restructuring maladaptive cognitions, PST aims to promote more effective coping through a systematic behavioral approach to problem solving (D’Zurilla & Goldfried, 1971). PST includes several steps, such as (a) identifying and defining the problem, (b) generating possible solutions, (c) evaluating possible solutions, (d) decision making, and (e) evaluating the outcome of the decision. D’Zurilla and Goldfried (1971) describe PST as a form of “self-control training,” thus making it particularly relevant when addressing problems related to impulsivity or sensation seeking. Future research should consider whether PST is efficacious in buffering against sexual sensation seeking tendencies and reducing sexual risk behaviors among African American adolescents.

The present findings should be considered in light of several limitations. First, the data were collected as part of a multi-site longitudinal project and the current study presents only cross-sectional associations from the 18-month follow up assessment. No causal associations can be inferred from these data. As a secondary analysis, the findings are also limited in that the assessment battery was not specifically designed to address the aims of the present study. The use of self-report is also a limitation of the study, as participant responses may be biased or represent an underreporting of risky behavior. Ideally, this limitation was minimal with the use of ACASI rather than person-to-person responding. Lastly, although the sample was geographically diverse, the results may not be representative of adolescents residing in areas other than those included in the study (northeast and southeast U.S. cities).

The present study highlights the significance of sexual sensation seeking behavior among African American adolescents at heightened risk for STIs, including HIV, through sex while under the influence of drugs. Problem-solving skills appear useful in protecting adolescents against this risk behavior, as they may be better apt to negotiate safer sexual encounters. Future studies should continue to examine the associations among adolescent sexual sensation seeking behavior, drug use prior to sex, depressive symptoms, and problem-solving skills. Additionally, prevention interventions based on problem-solving skills may be beneficial for African American adolescents at risk for STI/HIV infection.

Acknowledgments

Funding Statement: The parent study was conducted through the iMPPACS network supported by the National Institutes of Mental Health (Grant Number 1-UO1-MH66802; Pim Brouwers, NIMH Project Officer) at the following sites and local contributors: Columbia, SC (MH66803; Robert F. Valois [PI], Naomi Farber, Andre Walker); Macon, GA (MH66807; Ralph DiClemente [PI], Gina Wingood, Laura Salazar, Rachel Joseph, Delia Lang); Philadelphia, PA (MH66809; Daniel Romer [PI], Sharon Sznitman, Bonita Stanton, Michael Hennessy, Susan Lee, Eian More, Ivan Juzang, Thierry Fortune); Providence, RI (MH66785; Larry K. Brown [PI], Christie Rizzo, Nanetta Payne); and Syracuse, NY (MH66794; Peter A. Vanable [PI], Michael P. Carey, Rebecca Bostwick). Eugene M. Dunne, PhD and Alyssa L. Norris, PhD were supported by the Adolescent/Young Adult Biobehavioral HIV Training Grant (T32MH078788; Larry K. Brown, PI) from the National Institute of Mental Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

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