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International Journal of Sexual Health logoLink to International Journal of Sexual Health
. 2021 Apr 22;33(2):123–130. doi: 10.1080/19317611.2020.1864558

Associations between Cannabis Use and Sexual Risk Behavior among Women under Community Supervision: A Brief Report

Melissa N Slavin a,✉, Karli Hochstatter a, Shane W Kraus b, Mitch Earleywine c, Nabila El-Bassel a
PMCID: PMC8345327  NIHMSID: NIHMS1699382  PMID: 34367401

Abstract

Objectives

Cannabis use and sexual risk behavior have been found to co-occur, but more research on these associations is needed among criminal justice-involved women (i.e., courts, jails, or prisons).

Methods

Regression models examined past 90-day cannabis use on unprotected sex, multiple sexual partners, and STIs/HIV among 306 women under NYC community supervision, adjusting for alcohol, other illicit substances, and socio-demographics.

Results

Cannabis use, but not alcohol or other illicit substance use, was positively associated with having unprotected sex and multiple sexual partners, but not STIs or HIV.

Conclusions

Criminal justice-involved women may benefit from sexual risk reduction interventions incorporating cannabis content.

Keywords: cannabis, sexual risk behavior, criminal justice

Introduction

Research has established associations between substance use and sexual risk behavior (SRB), including unprotected sex, initiation of sexual activity at an earlier age, and having multiple sexual partners (Ritchwood, Ford, DeCoster, Lochman, & Sutton, 2015). While meta-analytic work has revealed similar effects of different substances on SRB, most research has focused on alcohol, followed by “hard drugs” (e.g., opiates, amphetamines, barbiturates, and stimulants), multiple drugs, and cannabis use, respectively (Ritchwood, Ford, DeCoster, Lochman, & Sutton, 2015). The smaller body of work that has focused on cannabis (specifically delta-9-tetrahydrocannabinol-THC-the active physiological ingredient in cannabis) and SRB has found associations among diverse populations. These participants include college students (e.g., Bon, Hittner, & Lawandales, 2001), treatment-seeking polysubstance users (Andrade, Carroll, & Petry, 2013), and adolescents (Thamotharan, Grabowski, Stefano, & Fields, 2015), including those involved in the criminal justice (CJ) system ((involvement with courts, jails, or prisons; e.g., Schmiege & Bryan, 2016). In fact, cannabis may have a stronger influence on SRB than alcohol among CJ-involved populations (e.g., Hendershot et al., 2010). Cannabis is also linked to sexually transmitted infections (STIs) and human immunodeficiency virus (HIV), sometimes in a dose-dependent fashion with amount and frequency of use (Smith et al., 2010).

There are several explanations for relationships between cannabis and SRB, including factors that influence both behaviors, such as sensation-seeking and impulsive decision-making, or common social contexts or lifestyles (Donohew et al., 2000). Additionally, situational effects of THC can influence memory, inhibition, and decision-making (Lane, Cherek, Tcheremissine, Lieving, & Pietras, 2005). Some individuals report “aphrodisiac” effects of cannabis, including enhanced responsiveness to sexual touch and an increase in positive mood and relaxation (Gorzalka, Hill, & Chang, 2010). Individuals’ sex-related expectancies toward cannabis may also influence its relationship to SRB, sometimes moderating the relationship, with individuals who hold higher sex-related expectancies toward cannabis more likely to have unprotected sex when intoxicated (Hendershot et al., 2010).

Understanding links between cannabis and SRB among people in the CJ system is particularly important. CJ-involved individuals use cannabis at greater rates than non-institutionalized populations, with one survey reporting 77% of prisoners from 2007–2009 having used cannabis (Bronson, Stroop, Zimmer, & Berzofsky, 2017). Although some research has examined these relationships among adjudicated adolescents, consisting of mostly boys (e.g., Rosengard et al., 2006), less work has examined women, who may show stronger associations of substance use and SRB than men (Ritchwood et al., 2015). Women represent a growing proportion of the CJ system, with the number of incarcerated women increasing by more than 750% between 1980 and 2017 (The Sentencing Project, 2018), largely due to drug-related crimes (Greenfeld & Snell, 2000). Additionally, CJ-involved women are approximately 15 times more likely to be infected with HIV than women in the general population, in addition to having a greater likelihood of HIV than incarcerated men (De Groot & Uvin, 2005). Specifically, Black women are disproportionally affected, accounting for 57% of new HIV diagnoses in 2018 (Centers for Disease Control and Prevention [CDC], 2018).

This current study examined effects of past 90-day cannabis use on unprotected sex, likelihood of having multiple sexual partners, and STIs/HIV among a sample of CJ-involved women, comprised primarily of Black women (68%), with high rates of HIV (14%) and STIs (26%). We adjusted for alcohol and other illicit substance use, as well as age, race/ethnicity, employment status, and education. Based on the literature, we hypothesized that women who used cannabis in the past 90 days (compared to those who did not) would be more likely to have unprotected sex with primary, casual, and paying partners, and have multiple sexual partners. We did not have specific hypotheses relating to alcohol or other illicit substance use. Second, we hypothesized that women who used cannabis in the past 90 days (compared to those who did not), and women who used other illicit substances in the past 90 days (compared to those who did not), would be more likely to have STIs and HIV. Third, we hypothesized that Black and Latina women would be more likely to have STIs and HIV compared to women who identified as “other race/ethnicity” (Tillerson, 2008; Vega, Rodriguez, & Gruskin, 2009). Fourth, we hypothesized a significant positive correlation between age and unprotected sex (Paterno & Jordan, 2012) and a significant negative correlation between age and STI diagnoses (CDC, 2013). We did not have specific hypotheses regarding employment and education due to mixed findings in the literature (Ritchwood, Ford, DeCoster, Lochman, & Sutton, 2015).

Methods

Participants

The baseline assessment of the HIV prevention intervention, “Women on the Road to Health” (“WORTH”; El-Bassel et al., 2014), supplied data from 2009–2012. The Columbia University Institutional Review Board (IRB) and the Center for Court Innovation IRB approved all procedures. As with the original intervention, 1,104 women were screened from New York City community courts and probation sites to identify 306 women at high risk for SRB and substance use, as detailed in the original study (El-Bassel, et al., 2014).

Study Variables

Socio-Demographics

Socio-demographics were adjusted for in analyses, including age, race/ethnicity (Black, Latina, Other), employment status (unemployed vs. employed), and education (high school diploma/GED versus no high school diploma/GED). Women ranged from age 18 to 62 (M = 41.5, SD = 10.5). Two hundred and eight (68%) of the women were Black, 47 (15%) were Latina, and 51 (17%) identified as another race/ethnicity. Twenty-five (8%) women were employed. One hundred seventy-six (58%) women had a high school diploma or GED. All other socio-demographics are reported in the original study (El-Bassel et al., 2014).

Past 90-Day Substance Use

Participants completed a 1.5-hour computer-assisted self-interview (CASI) at baseline. The Risk Behavior Assessment (Booth, Mikulich-Gilbertson, Brewster, Salomonsen-Sautel, & Semerik, 2004; Needle et al., 1995) assessed HIV risk behaviors and substance/alcohol use historically and within 90 days. Substance/alcohol use were queried dichotomously, with the question, “Have you used [the following below] in the past 90 days?” a) smoked cannabis, b) other federally illicit substances, including: heroin, cocaine, crack, speedball, crystal methamphetamine, non-prescribed stimulants or opiates, ecstasy, or other substances, c) alcohol (beer, wine, or liquor). One hundred seventeen women (38.2%) reported using cannabis, 124 (40.5%) reported using other illicit substances and 174 (56.9%) reported consuming alcohol.

Sexual Outcomes

Self-report data were examined on sexual behaviors with primary intimate partners, other (non-paying) casual partners, and paying partners within the past 90 days, including the number of unprotected vaginal and anal sex acts and whether or not participants had multiple male sex partners. Biological assays were used to detect HIV and three STIs (e.g., chlamydia, gonorrhea, and trichomoniasis). Forty-three women (14.6%) were diagnosed as having HIV and 81 (26.5%) as having an STI at the time of the assessment.

Analyses

We used generalized linear regression models based on robust maximum likelihood estimation with cannabis, alcohol, other illicit substances, age, race/ethnicity, employment status, and education as predictors. We used negative binomial regressions to determine effects of predictors on unprotected sex with women’s main, casual, and paying partners (Hypothesis 1 and 4) and logistic regressions to determine effects of predictors on likelihood of having multiple sexual partners (Hypothesis 1) as well as STIs and HIV (Hypothesis 2 and 3). We determined significance at p<.05.

Results

See Table 1 for means of SRB and STI/HIV diagnoses stratified by substance use status. See Table 2 for results of significant predictors for each regression analysis. In the first analysis, women reporting cannabis use had increased odds of having unprotected sex with their primary partners than women who did not report cannabis use. No other substance use variables were significant. Additionally, Black and Latina women (compared to “other race/ethnicity”) had decreased odds of engaging in unprotected sex with primary partners. An increase in age was associated with decreased odds of engaging in unprotected sex with primary partners.

Table 1.

Means/ Percentages and Standard Deviations of Past 90 Day Sexual Outcomes According to Substance Use Status.

Substance Use Status Mean number of unprotected vaginal and anal intercourse acts with primary partner
Cannabis Use vs. Nonuse  29.37 (63.43) vs. 14.23 (23.33)
Alcohol Use vs. Nonuse  19.96 (37.80) vs. 20.10 (50.83)
Other Illicit Drug Use vs. Nonuse  23.47 (59.28) vs. 17.67 (28.88)
  Mean number of unprotected vaginal and anal intercourse acts with casual partners
Cannabis Use vs. Nonuse  5.32 (19.38) vs. 2.26 (8.49)
Alcohol Use vs. Nonuse  3.18 (8.92) vs. 3.77 (18.32)
Other Illicit Drug Use vs. Nonuse  2.65 (10.48) vs. 3.97 (15.62)
  Mean number of unprotected vaginal and anal intercourse acts with paying partners
Cannabis Use vs. Nonuse  2.96 (10.74) vs. 1.83 (9.30)
Alcohol Use vs. Nonuse  2.02 (6.71) vs. 2.58 (12.94)
Other Illicit Drug Use vs. Nonuse  2.10 (5.85) vs. 2.37 (11.88)
  Had multiple sexual partners
Cannabis Use vs. Nonuse  79% vs. 58%
Alcohol Use vs. Nonuse  71% vs. 59%
Other Illicit Drug Use vs. Nonuse  71% vs. 62%
  Positive STI status
Cannabis Use vs. Nonuse  32% vs. 23%
Alcohol Use vs. Nonuse  30% vs. 21%
Other Illicit Drug Use vs. Nonuse  25% vs. 27%
  HIV-Positive status
Cannabis Use vs. Nonuse  15% vs. 14%
Alcohol Use vs. Nonuse  13% vs. 15%
Other Illicit Drug Use vs. Nonuse  20% vs. 10%
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Table 2.

Significant Regression Estimates of Past 90 Day Substance Use on Sexual Outcomes Adjusting for Demographics*.

Variables Estimate [ 95% CI] p-Value
Number of unprotected vaginal and anal intercourse acts with primary partner Incident Rate Ratio  
 Past 90 Day Cannabis Use  1.63 [1.10, 2.41] .014
 Age  0.97 [0.95, 0.99] .002
 Black Women  0.45 [0.27, 0.74] .002
 Latina Women  0.35 [0.19, 0.63] <.001
Number of unprotected vaginal and anal intercourse acts with casual partners Incident Rate Ratio  
 Past 90 Day Cannabis Use  3.09 [1.53, 6.28] .001
 Past 90 Day Opioid Use  0.51 [0.26, 1.01] .052
 Black Women  0.25 [0.12, 0.53] <.001
Number of unprotected vaginal and anal intercourse acts with paying partners Incident Rate Ratio  
 Past 90 Day Cannabis Use  3.06 [1.54, 6.06] .025
 Age  1.08 [1.02, 1.13] .004
 Black Women  0.31 [0.12, 0.82] .018
Had multiple sex partners Odds Ratio  
 Past 90 Day Cannabis Use  3.66 [1.84, 7.28] <.001
 Employed  3.53 [1.07, 11.64] .038
Sexually Transmitted Infections Odds Ratio  
 Black Women  2.42 [1.25, 4.72] .009
HIV Odds Ratio  
 Past 90 Day Other Illicit Substance Use  2.36 [0.99, 5.61] .052
 Black Women  4.59 [0.99, 21.31] .052
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Note. *Demographics refers to age, race/ethnicity, employment status, and education.

In the second analysis, women reporting cannabis use had increased odds of having unprotected sex with casual partners than women who did not report cannabis use. Women reporting opioid use had decreased odds of having unprotected sex with casual partners than women who did not report opioid use. Additionally, Black women (compared to “other race/ethnicity”) had decreased odds of engaging in unprotected sex with casual partners.

In the third analysis, women reporting cannabis use had increased odds of having unprotected sex with paying partners than women who did not report cannabis use. No other substance use variables were significant. Additionally, Black women (compared to “other race/ethnicity”) had decreased odds of engaging in unprotected sex with paying partners. An increase in age was associated with increased odds of engaging in unprotected sex with primary partners.

In the fourth analysis, women reporting cannabis use had increased odds of having multiple sexual partners than women who did not report cannabis use. No other substance use variables were significant. Additionally, being employed (versus unemployed) was associated with increased odds of having multiple sexual partners.

In the fifth analysis, Black women (compared to “other race/ethnicity”) had increased odds of having an STI. No substance use variables were significant. In the sixth analysis, women reporting other illicit substance use had increased odds of having HIV than women who did not report other illicit substance use. Black women (compared to “other race/ethnicity”) also had increased odds of having HIV.

Discussion

This paper addressed an important gap in the sexual risk-reduction literature by examining effects of cannabis on SRB, STIs and HIV, adjusting for alcohol and other illicit substance use and socio-demographics among a high-risk sample of adult women in the CJ system. Consistent with our first hypothesis, women who used cannabis in the past 90 days (compared to those who did not) were more likely to have unprotected sex with their primary partners, casual partners, and paying partners, as well as have multiple sexual partners. Alcohol or other illicit substances did not significantly predict any of these SRB in our analyses, except for a negative association between other illicit substance use and unprotected sex with casual partners. Inconsistent with our second hypothesis, cannabis was not associated with STIs or HIV, although other illicit substance use was positively associated with HIV. Consistent with our third hypothesis, Black women (compared to “other race/ethnicity” women) had higher odds of having HIV and STIs, although Latina women did not have higher odds of being diagnosed with either (compared to “other race/ethnicity” women). Consistent with our fourth hypothesis, women who were older in age (versus younger women) had a greater likelihood of unprotected sex with paying partners. Nevertheless, this relationship was reversed with primary partners, with women who were older in age (versus younger women) having a lower likelihood of unprotected sex with primary partners. Age was not associated with STIs or HIV.

Links between cannabis use and SRB among CJ-involved women are consistent with research on adolescents within the CJ system, focusing mainly on boys (e.g., Bryan et al., 2012; Rosengard et al., 2006). Sexual risk-reduction interventions that incorporate cannabis content, such as discussing connections between individuals’ and their partners’ cannabis use and sexual risk behavior (Bryan et al., 2018) or challenging sexual-related cannabis-outcome expectancies (Gunn et al., 2016; Hendershot et al., 2010) may prove effective among women in the CJ system, as it has for adolescents. For example, Bryan et al. (2018) determined that a sexual risk-reduction intervention including alcohol and cannabis content resulted in greater reductions in STIs (3.9%) than a sexual risk-reduction intervention alone that included only alcohol content (10.2%) or no substance use content (12.4%) among adolescents at juvenile detention facility. In this current study, cannabis did not significantly predict STIs or HIV, although 32% of women who used cannabis had an STI versus 23% of women who did not use cannabis. The non-significant link may be due to the more stringent way in which substance use and STIs were tested (past 90-day use and current STI diagnosis), versus lifetime substance use and ever being diagnosed with an STI. Other illicit substance use significantly predicted HIV status, likely due to injection drug use.

Regarding sociodemographic predictors, Black women were less likely than “other race/ethnicity” women to have unprotected sex with primary, casual, and paying partners. Latina women were also less likely than “other race/ethnicity” women to have unprotected sex with primary partners. Despite Black women’s lower sexual risk behaviors in our study, they had a greater likelihood of having STIs and HIV, consistent with our fourth hypothesis. A systematic literature examining racial disparities in HIV/AIDS incidence among women in the U.S suggests that Black women are no more likely to have unprotected sex, have multiple sexual partners, or use drugs than women of other races/ethnicities but are 20 times more likely than White women and 4 times more likely as Latina women to have HIV (Tillerson, 2008). In fact, Black women often report significantly higher levels of protected sex than White women, consistent with our study (Paterno & Jordan, 2012). Thus, Black women may be at high-risk for STIs and HIV even when their behavior is considered low risk, whereas White women’s risk increases when their behavior is defined as high risk (Hallfors et al., 2007). Therefore, Black women may receive more benefit from sexual risk-reduction interventions that target social-structural factors that consider historical and cultural influences on health, including cultural norms and values, policies, socioeconomic status, and discrimination rather than individual risk factors (Ware, Thorpe, & Tanner, 2019). Furthermore, a more comprehensive approach to sexual health interventions should take into account various traumas (e.g., sexual assault; being arrested) that may relate to substance use and sexual risk that have been found to be more prevalent among Black women and other minority groups than White women (Jones et al., 2015). Additionally, a more holistic and asset-based approach to sexual health, emphasizing sexual and relationship satisfaction and sexual communication could be useful in both reducing adverse health outcomes and promoting healthy sexuality (Ware, Thorpe, & Tanner, 2019).

Lastly, although research suggests an often positive relationship between age and unprotected sex (Paterno & Jordan, 2012) which informed our fourth hypothesis, our study revealed mixed findings depending on partner type. Women younger in age were more likely to have unprotected sex with primary partners and women older in age were more likely to have unprotected sex with paying partners. Nevertheless, age did not predict diagnoses of STIs or HIV. Thus, it is important for healthcare providers to understand the importance of inquiring about unprotected sex as well as as provide education and help reduce barriers to receiving STI/HIV treatment across women of all ages.

The current study is not without limitations. First, the cross-sectional design prevents inferring causality in the relationship between cannabis use and SRB, and so future research should employ event-level analyses among CJ-involved women to gain better clarity on the nature of these relationships. Second, our dichotomous measure of substance/alcohol use did not distinguish between different frequencies or quantities of use. Additionally, with the proliferation of state medical and recreational marijuana laws, it is important to assess for different methods and purposes of cannabis use. For instance, in this current study, we only assessed for smoked cannabis consumption rather than other methods of ingestion, including edible cannabis, which may be more popular among women than men (Friese, Slater, & Battle, 2017), and can differentially impact SRB if women are unsure of the quantity of THC and how it will affect them (Friese, Slater, Annechino, & Battle, 2016). We also did not assess medicinal usage of cannabis which may or may not affect associations with SRB. A recent study using a differences-in-differences approach found the introduction of medical marijuana laws among states to lead to a reduction in contraceptive use conditional on having sex, an increase in number of births, and suggestive evidence on temporary increases in the state-year gonorrhea rate (Baggio, Chong, & Simon, 2020). Further research is needed in this area, particularly among individuals in CJ settings. Despite these limitations, relationships between cannabis and SRB among adult women in community supervision programs is an understudied topic and our findings can be used to help inform sexual risk assessments and the development of sexual risk-reduction interventions incorporating cannabis content for women in CJ settings.

Acknowledgements

We want to thank the women who participated in this study, as well as the community supervision sites that hosted the WORTH intervention study. We also want to thank the case managers and research assistants who facilitated project WORTH.

Funding Statement

Project WORTH was funded by the National Institute of Drug Abuse to Nabila El-Bassel (grant R01DA025878). MNS and KH are supported by the National Institute of Drug Abuse (grant T32DA037801).

Human Participation Protection

Institutional review boards at Columbia University and the Center for Court Innovation approved study protocols prior to implementation of project WORTH. Written informed consent from participants was obtained.

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