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. Author manuscript; available in PMC: 2024 Mar 1.
Published in final edited form as: Addict Behav. 2022 Dec 2;138:107571. doi: 10.1016/j.addbeh.2022.107571

Polysubstance Use among Young Adults and Differences in Negative Alcohol-Related Sexual Experiences

Melissa A Lewis 1,*, Zhengyang Zhou 2, Kathleen A Parks 3, Rebecca Evans-Polce 4, Dana M Litt 1, Anne M Fairlie 5, Femke Geusens 6,7, Cassidy LoParco 1, Sean Esteban McCabe 4
PMCID: PMC9780189  NIHMSID: NIHMS1856639  PMID: 36502745

Abstract

This study aimed to compare negative alcohol-related sexual experiences among individuals who used (1) alcohol only, (2) alcohol plus marijuana, and (3) alcohol plus marijuana and stimulants. Participants in the analytic sample (N=1,015; Mean age=19.16 (SD=0.79); 45.42% male) completed an online baseline survey as part of an intervention study. A hurdle negative binomial model examined the associations between polysubstance use and negative alcohol-related sexual experiences. Models examined if experiences varied by demographic factors. Compared to participants that only used alcohol, those who used alcohol plus marijuana and stimulants reported a higher likelihood and average number of negative alcohol-related sexual experiences in the past 3 months. Participants that used alcohol plus marijuana had a higher likelihood of having a negative alcohol-related sexual experience in the past 3 months compared to those who only used alcohol. These findings suggest the number and risk for negative alcohol-related sexual experiences increases with the number of substances being used.

Keywords: polysubstance use, alcohol-related sexual experiences, sexual risk taking, substance use, alcohol consequences

1. Introduction

Alcohol use among young adults remains a public health concern as 55.1% report using alcohol in the past month and 35% report engaging in heavy episodic drinking (4+/5+ drinks for females/males; SAMHSA, 2019). Among alcohol-related experiences reported by young adults, experiences that involve risky sexual behaviors are common (Cooper, 2002; Orchowski & Barnett, 2012). Consequences of having unprotected sex after engaging in alcohol use can include contracting a sexually transmitted infection and unwanted pregnancy (Orchowski & Barnett, 2012; Satterwhite et al., 2013). Relatedly, alcohol consumption and regretted sex often co-occur (Kypri et al., 2009; Mallett et al., 2006). In addition, nonconsensual sexual activity has routinely been associated with alcohol consumption (Abbey et al., 2014; Bryan et al., 2016). Sexual assault rates are increasing, with up to one in three female college students falling victim (Cantor et al., 2020), indicating that sexual assault continues to be a public health issue. Thus, there are myriad negative alcohol-related sexual experiences reported by young adults.

The present study makes a novel contribution to the literature by investigating whether reports of negative alcohol-related sexual experiences are higher when alcohol is used concurrently with other substances (i.e., use within the same 3-month time period). Research indicates that many young adults who use alcohol also report using other substances including marijuana and nonmedical prescription drugs such as stimulants. Polysubstance use is particularly important to understand in early young adulthood when substance use peaks (SAMSHA, 2019; Schulenberg et al., 2020). Approximately one-third of 19 and 20-year-olds reported use of both alcohol and marijuana in the past 12 months (Patrick et al., 2019) and 12% of college students reported past 12-month use of alcohol and any form of nonmedical prescription drugs (McCabe et al., 2006). The highest rates of nonmedical prescription drug misuse are among young adults ages 18 to 25 (SAMHSA, 2020).

Those who use alcohol and other substances experience more negative consequences compared to those who use alcohol only, including unsafe driving (Terry-McElrath et al., 2014; Subbaraman & Kerr, 2015), greater substance use problems (Keith et al., 2015; Shillington & Clapp, 2006), and academic problems (Jackson et al., 2020). However, less research has examined negative alcohol-related sexual experiences among those who use alcohol only, compared to alcohol plus other substances. Existing research indicates the use of alcohol and other drugs is associated with having experienced negative sexual consequences (Abbey, 2002; Caldeira et al. 2009; Mallett et al., 2008; Parks et al., 2012). One study found the odds of having unplanned sex was nearly two times greater among college students who simultaneously co-ingested alcohol and prescription drugs (McCabe et al., 2006), and similar results were found among young adults who simultaneously co-ingested alcohol and marijuana (Egan et al., 2019). Other work indicates that the range of sexual risk-taking outcomes individuals may experience varies depending on the specific substances used (Fairlie et al., 2018). The current study contributes to this emerging literature by investigating whether young adults experience cumulative effects related to their concurrent polysubstance use, which was defined as use of alcohol and additional substances (marijuana and stimulants) during the past 3 months.

Another way in which this study adds to the literature is by investigating whether the frequency of negative sexual experiences associated with concurrent polysubstance use differs based on important demographic factors including age, biological sex, and sexual orientation. Only a few studies have examined biological sex as it relates to polysubstance use and related sexual experiences (Yurasek et al., 2017). Research indicates that women with low sexual assertiveness refusal are more likely to engage in risky sex on days when they have consumed both alcohol and marijuana prior to the sexual activity (Parks et al., 2012). Regarding age related-differences, research indicates that young adults under age 21 report having more negative alcohol-related experiences, including alcohol-related sexual experiences, compared to older individuals (White & Ray, 2014; Vasilenko et al., 2018). Other research found that rates of sexual assault decreased among women between ages 18–22 (Parks et al., 2008). Thus, it is possible that there may be an interaction between age and biological sex on negative alcohol-related sexual experiences.

Prior research indicates that sexual minority youth appear to have a disproportionate risk for engaging in polysubstance use, especially females, compared to non-sexual minority youth (Dermody, 2018; Kecojevic et al., 2017; Talley et al., 2014). In addition, individuals who identify as sexual minorities are more likely to regularly use substances in sexual contexts (Taggart et al., 2019) and some alcohol-related consequences are more prevalent among bisexual-identified college females than their heterosexual-identified female peers (McCabe et al., 2004). Thus, it is important to examine if individuals who are sexual minorities have higher rates of negative alcohol-related sexual experiences compared to heterosexuals, in conjunction with concurrent polysubstance use.

1.1. The Current Study

We elected to focus on alcohol, marijuana, and prescription stimulants as these are substances with the highest rates of use among young adults in the United States, and use of these substances has been shown to be related to negative consequences. We hypothesized that compared to participants who only used alcohol, those who used alcohol plus marijuana, and those who used alcohol plus marijuana and stimulants would have a significantly higher likelihood of and average number of negative alcohol-related sexual experiences in the past 3 months. Moreover, we expected that compared to participants that used alcohol plus marijuana, those individuals who used alcohol plus marijuana and stimulants would have a significantly higher likelihood of and average number of negative alcohol-related sexual experiences in the past 3 months. Finally, we examined if negative alcohol-related sexual experiences varied by important demographic factors including age, biological sex, and sexual orientation. Taken together, this study will significantly advance our insight into which factors contribute to experiencing negative alcohol-related sexual experiences.

2. Materials and Methods

2.1. Participants and Procedures

Participants were recruited nationally for a larger study evaluating an intervention for reducing risky alcohol-related sexual behavior and completed a 5-minute web-based screening survey to determine if they met inclusion criteria for the longitudinal study1. Recruitment was achieved through various methods including online recruiting (Facebook, Craigslist, etc.), in-print advertisements, flyers, and participant referrals.

Participants who met inclusion criteria (n = 1,144) were sent an invitation to the online baseline survey, where they were presented with a full online consent statement. Of participants invited to the baseline survey, 1,065 (93.1%) completed the survey, all of whom received a $25 gift certificate. All study procedures were conducted in accordance with the Declaration of Helsinki and approved by the University’s Institutional Review Board. No adverse events were reported.

Baseline data were used for the current analyses. Two participants reported alcohol and stimulant use (but no marijuana use). Given there were too few individuals to analyze this group separately, we deleted these two participants from the analytic sample. Participants who had missing responses on the variables included in the analyses were excluded, resulting in an analytic sample of 1,015 (Mage = 19.16, SD = 0.79; 45.42% male; 70.08% White; 74.29% heterosexual; 77.60% currently attending 4-year university). See Table 1 for an overview of the sample demographics.

Table 1.

Demographic overview of the sample

Demographic Variable %
Gender
 Male 45.42
 Female 54.58
Sexual Orientation
 Heterosexual 74.29
 Bisexual 12.51
 Gay/Lesbian 7.88
 Queer 2.27
 Questioning 3.05
Race
 White 70.08
 Asian 10.37
 African American 7.70
 American Indian/Alaska Native 1.09
 Native Hawaiian/Pacific Islander 0.39
 Other/More than one race 10.37
Ethnicity
 Hispanic/Latino 14.48
 Non-Hispanic 85.52
Current Educational Status
 4-year college 77.60
 Community college 7.59
 Technical/vocational college 0.69
 Graduate/professional school 0.49
 High school 1.87
 Not enrolled in any form of schooling 11.52
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Note: Percentages do not total 100 because of rounding

2.2. Measures

2.2.1. Demographic Information

Demographic information included biological sex (1 = male, 0 = female), and education status (1 = currently enrolled in a 4-year university or college, 0 = other). Age ranged from 18 – 21 years at baseline and was coded from 0 to 3. Sexual orientation was treated as a categorical variable with four dummy codes: bisexual, gay/lesbian, queer, and questioning, each with heterosexual as the reference group.

2.2.2. Concurrent Polysubstance Use

Three items were used to assess substance use behaviors in the past 3 months—one item each for alcohol, marijuana, and prescription stimulants. Participants were asked “On average, during the past 3 months, how often have you consumed alcohol?” (Collins et al., 1985). Response options ranged from 0 (Never) to 11 (Every day). Based on an adaptation of this item, participants were asked, “Within the past 3 months, how often have you used marijuana or cannabis?” Response options ranged from 0 (Did not use) to 12 (More than once per day). Frequency of prescription stimulant use was assessed by asking “How many times have you used prescription stimulants (Ritalin, Dexedrine, Adderall, Concerta, methylphenidate) either without a prescription or in a way not prescribed to you in the past 3 months?” Responses used an open-ended format with a limit of 90 times. These three substance use items were recoded to represent alcohol only (past 3 months any alcohol use and no use of marijuana or stimulants), alcohol plus marijuana use (past 3 months any alcohol use plus any marijuana use), and alcohol plus marijuana use and stimulant use (past 3 months any alcohol use plus any marijuana use and plus any stimulant use). Two dummy codes were then created to compare (1) alcohol plus marijuana use and (2) alcohol plus marijuana use and stimulant use to the alcohol-only group (reference).

2.2.3. Typical Number of Drinks per Occasion

Participants were asked “During the past 3 months, when you have consumed alcohol, how many drinks2 on average did you typically consume on a given occasion?” (Collins et al., 1985). Response options ranged from 0 (0 drinks) to 25 (25 or more drinks).

2.2.4. Negative Alcohol-Related Sexual Experiences

To assess negative alcohol-related sexual experiences, 33 items were used to measure a broad range of negative alcohol-related sexual experiences, which have previously demonstrated convergent and divergent validity (Fairlie et al., 2021; Lewis et al., 2019; e.g., “oral sex that I later regretted”). Sexual experiences referred to digital, oral, vaginal, and anal sex. Participants indicated whether or not they had each experience as a result of drinking alcohol in the past 3 months (1 = Yes, 0 = No). A total score was created by summing all items (α = 0.41). Items covered a variety of sexual experiences or behaviors resulting from alcohol such as regretted sexual activity, unprotected sexual activity, sex with someone they just met, and sexual activity they would not have done when sober.

2.3. Analytic Plan

Descriptive statistics and correlations were examined for variables of interest. The outcome variable (i.e., a summed score of negative alcohol-related sexual experiences in the past 3 months) was a count variable with a skewed distribution having many zeros. To account for non-normal distribution and zero-inflation of the outcome, a hurdle negative binomial model was estimated using the “pscl” R package (Zeileis et al., 2008). The hurdle model fits two submodels simultaneously: one submodel is a logistic regression for zero negative alcohol-related sexual experiences versus at least one negative alcohol-related sexual experience, thus measuring the likelihood of any negative alcohol-related sexual experiences. The second submodel is a zero-truncated negative binomial regression for positive numbers of negative alcohol-related sexual experiences, thus measuring the average number of negative alcohol-related sexual experiences, given at least one occurrence of a negative alcohol-related sexual experience. The hurdle negative binomial model included the following variables as predictors: the two concurrent polysubstance use dummy codes, age, biological sex, an age-by-sex interaction, whether the participant was currently enrolled in a 4-year college, the four dummy codes for sexual orientation, and the typical number of drinks per drinking occasion.

3. Results

3.1. Descriptive Information

Table 2 provides the descriptive statistics and correlations. The entire sample reported drinking alcohol and being sexually active during the past 3 months, as these were inclusion criteria for the larger intervention study. The proportions of participants who used alcohol only, alcohol plus marijuana, and alcohol plus marijuana and stimulants in the past 3 months were 17.0%, 64.8%, and 18.1%, respectively. The average frequency of sex in the past 3 months was 10.96 times (SD = 15.19). The average number of negative alcohol-related sexual experiences over the past 3 months was 4.52 (SD = 4.39).

Table 2.

Descriptive Statistics and Correlations

M or % SD Range 1 2 3 4
1. Age 19.16 0.79 18 – 21 -
2. Biological Sex 45.4% Male - 0 – 1 .09** -
3. Current 4-year College 77.6% Yes - 0 – 1 −.03 −.06 -
4. Typical Drinks per Occasion 4.87 2.78 0 – 25 −.04 .20*** .06 -
5. Negative Alcohol-Related Sexual Experiences 4.52 4.39 0 – 22 −.05 −.10* .05 22***
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Note. N = 1,015;

*

p < .05,

**

p < .01,

***

p < .001.

(adjusted for multiple testing); M = Mean; SD = Standard deviation. Only observations with complete cases were used.

3.2. Associations Between Concurrent Polysubstance Use and Negative Alcohol-Related Sexual Experiences

Table 3 shows the results of the hurdle negative binomial model examining the associations between concurrent polysubstance use and negative alcohol-related sexual experiences, controlling for covariates. The top panel of the table describes the results for the likelihood of having any negative alcohol-related sexual experiences in the past 3 months, and the bottom panel describes the results for the average number of negative alcohol-related sexual experiences, given at least one occurrence of a negative alcohol-related sexual experience in the past 3 months.

Table 3.

Negative Alcohol-Related Sexual Experiences in the Past 3 Months

Log OR/Log IRR (SE) OR/IRR OR/IRR 95% CI
Any Negative Alcohol-Related Sexual Experiences (Likelihood)
Intercept 0.24 (0.31) 1.28 (0.69, 2.35)
Age −0.43 (0.13) ** 0.65 (0.50, 0.84)
Male Sex −0.64 (0.29) * 0.53 (0.30, 0.93)
Age-by-Sex Interaction 0.41 (0.20) * 1.51 (1.03, 2.21)
−0.40 (0.22) 0.67 (0.43, 1.03)
−0.53 (0.26) * 0.59 (0.35, 0.98)
Sexual Orientation: Queer vs. Heterosexual 0.37 (0.53) 1.45 (0.51, 4.10)
Sexual Orientation: Questioning vs. Heterosexual 0.10 (0.45) 1.10 (0.46, 2.67)
4-year College 0.19 (0.18) 1.21 (0.86, 1.72)
0.19 (0.04) *** 1.20 (1.12, 1.29)
0.57 (0.19) ** 1.76 (1.21, 2.55)
Polysubstance Use: Alcohol plus marijuana and stimulants vs. Alcohol only 0.98 (0.26) *** 2.68 (1.59, 4.50)
Average Number of Negative Alcohol-Related Sexual Experiences, Given at Least One Occurred (Count)
Intercept 1.41 (0.12) *** 4.09 (3.21, 5.22)
Age 0.06 (0.05) 1.07 (0.97, 1.16)
Male Sex −0.18 (0.10) 0.84 (0.69, 1.02)
Age-by-Sex Interaction −0.09 (0.07) 0.91 (0.80, 1.05)
Sexual Orientation: Bisexual vs. Heterosexual 0.02 (0.09) 1.02 (0.86, 1.21)
−0.03 (0.12) 0.97 (0.77, 1.23)
Sexual Orientation: Queer vs. Heterosexual −0.10 (0.18) 0.90 (0.63, 1.30)
0.19 (0.15) 1.21 (0.89, 1.63)
0.01 (0.07) 1.01 (0.88, 1.15)
Typical Drinks per Occasion 0.05 (0.01) *** 1.05 (1.03, 1.07)
0.11 (0.08) 1.12 (0.95, 1.32)
0.25 (0.10) ** 1.29 (1.06, 1.55)
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Note.

*

p < .05,

**

p < .01,

***

p < .001.

SE = Standard error; OR = odds ratio; IRR = incidence rate ratio; CI = 95% confidence interval. Only observations with complete cases were used. Age was coded as 0 = 18-year-old, 1 = 19 year-old, etc. Biological sex was coded as 0 = Female, 1 = Male. 4-year college was coded as 0 = No, 1 = Yes. Four dummy codes for sexual orientation were included as 1 vs. = Heterosexual.

Compared to participants that only used alcohol, those who used alcohol plus marijuana and stimulants reported a significantly higher likelihood of having any negative alcohol-related sexual experiences and a greater average number of negative alcohol-related sexual experiences in the past 3 months. Similarly, participants that used alcohol plus marijuana had a significantly higher likelihood of negative alcohol-related sexual experiences in the pat 3 months than those who only used alcohol. To compare participants who used alcohol plus marijuana and stimulants to those who used alcohol plus marijuana, a separate analysis was conducted. Results from these post-hoc analyses found that those who used alcohol plus marijuana and stimulants reported a significantly higher average number of negative alcohol-related sexual experiences (IRR = 1.15, 95% CI: 1.00 – 1.31) and a marginally significantly higher likelihood of having at least one negative alcohol-related sexual experience (OR = 1.52, 95% CI: 0.97 – 2.38) in the past 3 months compared to those who used alcohol plus marijuana.

There was no significant association between currently being a 4-year college student and negative alcohol-related sexual experiences, but participants who consumed more drinks on a typical occasion reported a higher likelihood and average number of negative alcohol-related sexual experiences in the past 3 months.

Participants who were older and were male had a lower likelihood of having any negative alcohol-related sexual experiences in the past 3 months. Furthermore, a significant age-by-sex interaction emerged on the likelihood of negative alcohol-related sexual experiences (see Figure 1). Older female participants were less likely to have a negative alcohol-related sexual experience in the past 3 months relative to younger female participants, indicating a protective effect of age. In contrast, age had little effect on the likelihood of having negative alcohol-related sexual experiences for males. Therefore, compared to males, females were more likely to report having negative alcohol-related sexual experiences in the past 3 months at age 18, and the likelihood became lower than males at age 21.

Figure 1.

Figure 1.

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The Interaction Between Age and Biological Sex on the Likelihood of Having A Negative Alcohol-related Sexual Experience.

X-axis: Age (in Years); Y-axis: Predicted probability of having at least one negative alcohol-related sexual experience (Female: black sold line; Male: grey dashed line).

Participants who identified as gay or lesbian had a lower likelihood of having any negative alcohol-related sexual experiences in the past 3 months, compared to participants who identified as heterosexual (p-value < 0.05). A separate analysis was conducted by creating a dummy variable to distinguish between gay and lesbian participants. Post-hoc analyses found that the effect of sexual orientation on negative alcohol-related sexual experiences was mainly driven by the lesbian subgroup, as (1) those participants identifying as lesbian were the only subgroup that was significant (p-value < 0.05), and (2) lesbian participants had a lower proportion of having any negative alcohol-related sexual experiences in the past 3 months, compared to the other sexual orientation subgroups (45.5% vs. 65.6+%; complete results are available upon request).

4. Discussion

This study suggests that concurrent polysubstance use substantially increases the risk for negative alcohol-related sexual experiences above and beyond alcohol-only use. Among a sample of sexually active young adults who use alcohol, the majority (83.0%) reported concurrent polysubstance use (alcohol use and the additional use of marijuana, or the additional use of marijuana and stimulants in the past 3 months). This finding supports research showing that concurrent use of alcohol and marijuana is increasing among young adults (McCabe et al., 2021). The vast majority of young adults in our sample engaged in concurrent polysubstance use of alcohol and marijuana, rather than alcohol-only use in the past 3 months which suggests that a shift is needed in the priority of substance-related practice and research among young adults to look at both concurrent and simultaneous alcohol and other substance use, marijuana in particular (Connor et al., 2014). Studies that assess daily and longitudinal patterns of concurrent and simultaneous polysubstance use and associated negative alcohol-related sexual experiences will be important for developing interventions and policies that should consider substance use beyond alcohol, marijuana and prescription stimulants.

It is important to note that the average number of unique negative alcohol-related sexual experiences was 4.52 (SD = 4.39) over the past 3 months, underscoring that research examining factors contributing to negative sexual experiences should be further investigated. Specifically, it is imperative to determine whether young adults experience particuarly high rates of negative sexual experiences compared to other age groups as well as potential long-term implications related to these consequences.

Specific to study aims, we found that young adults who reported concurrent polysubstance use had a higher likelihood of having negative alcohol-related sexual experiences compared to those who only used alcohol. Moreover, individuals who reported the use of alcohol plus marijuana and stimulants had a significantly higher average number of negative alcohol-related sexual experiences than those who reported the use of alcohol plus marijuana. This suggests that each substance a young adult consumes has the potential to increase the number and risk of negative alcohol-related sexual experiences. Our study results highlight the additional risk that concurrent polysubstance use conveys above and beyond alcohol use for negative alcohol-related sexual experiences, even when controlling for the amount of alcohol consumed.

This finding also indicates the need for additional research focused on concurrent polysubstance use and its role in negative alcohol-related sexual experiences. This study explored a global measure of negative alcohol-related sexual experiences. More nuanced analyses that look at the specific type and severity of negative alcohol-related sexual experiences and their relation to types of polysubstance use (e.g., concurrent or simultaneous) are needed at the event-level. This future research area is important for developing appropriate intervention strategies to reduce the occurrence of negative alcohol-related sexual experiences among young adults.

Interestingly, we found an age-by-sex interaction, such that females were more likely to experience negative sexual experiences than males at age 18, but less likely by age 21. However, the rate of negative alcohol-related sexual experiences did not change for males as they aged. This is in line with other research indicating a decrease in the rates of sexual assault over the same developmental period among college women (Parks et al., 2008). Qualitative findings suggest that women may “learn” from earlier drinking experiences (Parks et al., 2014). Related to student status, our results indicated that being a student enrolled in a 4-year college was not associated with negative alcohol-related sexual experiences.

Of importance, our study suggests few differences among sexual minorities and heterosexuals, with the exception that participants who identified as lesbian reported a lower likelihood of having any negative alcohol-related sexual experiences, compared to participants identifying as heterosexual. Thus, while sexual minorities are at greater risk for polysubstance use (Dermody, 2018; Kecojevic et al., 2017; Talley et al., 2014), the current findings suggest that lesbian participants in this sample were at lower risk than heterosexuals for negative alcohol-related sexual experiences.

Our findings are not generalizable to all young adults who reside in the United States because the sample was not weighted and participants had to meet eligibility criteria at screening. Future studies need to look at additional substances beyond marijuana and stimulants that are likely to be used concurrently and which may increase the risk of negative alcohol-related sexual experiences. The present study did not assess simultaneous substance use (i.e., use at the same time for overlapping effects). Assessment of simultaneous use will be critical for determining synergistic physiological effects of these drugs and their associations with negative sexual experiences.

4.1. Conclusions

We found that a majority of sexually active young adults who use alcohol engage in concurrent polysubstance use. Notably, among those who engage in concurrent polysubstance use, the number and risk for negative alcohol-related sexual experiences increases with the number of substances used. Thus, preventive interventions targeting problematic alcohol and negative sexual experiences use also should address the potential for problematic polysubstance use in this population.

Highlights.

  • Alcohol is frequently used in combination with other substances

  • Polysubstance use is a risk factor for negative alcohol-related sexual experiences

  • Combining alcohol with two substances is riskier than combining it with one

  • Age and gender are risk factors for negative alcohol-related sexual experiences

Role of Funding Source

Data collection and manuscript preparation were supported by NIAAA Grant R01AA021379 awarded to M. A. Lewis. Manuscript preparation was also supported by NIAAA Grant R01AA025684 awarded to S. E. McCabe, and FWO grants V400222N and 1239220N awarded to F. Geusens. The content of this manuscript is solely the responsibility of the author(s) and does not necessarily represent the official views of the National Institute on Alcohol Abuse and Alcoholism or the National Institutes of Health.

Footnotes

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1

Initial eligibility criteria at screening included the following: reside in the U.S.; age 18 – 20 years; provide a birthdate consistent with their age; provide a phone number, first and last name, birth sex, gender, sexual desire, and email address; correctly answer check questions (e.g., select the color blue from a list of colors); not be in a monogamous relationship, or be in a monogamous relationship for less than 3 months and be open to having a sexual relationship with someone other than a monogamous partner; have had sex in the past 3 months; and have had an alcoholic drink at least twice a month on average over the past 3 months.

2

A standard drink was defined as 5 oz. of wine; 12 oz. of beer (10 oz. of Microbrew; 8 oz. of Malt Liquor, Canadian beer or Ice beer; 6 oz. of Ice Malt Liquor); 10 oz. of wine cooler; or 1 Cocktail with 1 oz. of 100 proof liquor or 1 ¼ oz. of 80 proof liquor.

The authors report no relevant disclosures and no conflicts of interest.

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